Comparison of health-related quality of life between patients with end-stage ankle and hip arthrosis

Five-Factor Modified Frailty Index as a Predictor of Complications Following Total Ankle Arthroplasty

INTRODUCTION

Ankle arthritis adversely affects patients' function and quality of life. Treatment options for end-stage ankle arthritis include total ankle arthroplasty (TAA). A 5-item modified frailty index (mFI-5) has predicted adverse outcomes following multiple orthopaedic procedures; this study evaluated its suitability as a risk-stratification tool in patients undergoing TAA.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed for patients undergoing TAA between 2011 and 2017. Bivariate and multivariate statistical analyses were performed to investigate frailty as a possible predictor of postoperative complications.

RESULTS

In total, 1035 patients were identified. When comparing patients with an mFI-5 score of 0 versus ≥2, overall complication rates significantly increased from 5.24% to 19.38%, 30-day readmission rate increased from 0.24% to 3.1%, adverse discharge rate increased from 3.81% to 15.5%, and wound complications increased from 0.24% to 1.55%. After multivariate analysis, mFI-5 score remained significantly associated with patients' risk of developing any complication (P = .03) and 30-day readmission rate (P = .005).

CONCLUSIONS

Frailty is associated with adverse outcomes following TAA. The mFI-5 can help identify patients who are at an elevated risk of sustaining a complication, allowing for improved decision-making and perioperative care when considering TAA.

LEVELS OF EVIDENCE

III, Prognostic.

Total Ankle Arthroplasty for Posttraumatic Fracture Versus Primary Osteoarthritis: An Analysis of Complications, Revisions, and Prosthesis Survival

BACKGROUND

Most outcome studies of total ankle arthroplasty (TAA) do not discriminate by arthritis etiology. The primary purpose of this study was to compare the complications of TAA between posttraumatic fracture osteoarthritis (fracture PTOA) and primary osteoarthritis (POA).

METHODS

Ninety-nine patients who underwent TAA were retrospectively evaluated with a mean follow-up of 3.2 years (range 2 to 7.6 years). 44 patients (44%) had a diagnosis of POA while 55 patients (56%) had a diagnosis of fracture PTOA (40 malleolar fractures [73%], 14 pilon fractures[26%], and 1 talar fracture [1%]). Patient demographics, preoperative coronal plane alignment, postoperative complications, and revision surgery data were collected. Categorical variables were compared with chi square and Fisher exact tests and means with the Student t-test. Survival was assessed with Kaplan-Meier and log-rank analyses.

RESULTS

A higher overall complication rate was associated with fracture PTOA (53%) compared with POA (30%) (P = 0.04). No difference was observed in rates of any specific complication by etiology. Survival, defined as revision surgery with TAA prosthesis retention, was comparable between POA (91%) and fracture PTOA (87%) (P = 0.54). When defined as failure requiring prosthesis explant, POA demonstrated significantly greater survival (100%) as compared with fracture PTOA (89%) (P = 0.03). A higher rate of talar implant subsidence and loosening was noted in TAA with prior pilon (29%) as compared to malleolar fractures (8%) that was not statistically significant (P = 0.07). Fracture PTOA was associated with preoperative valgus deformity (P = 0.04). Compared with varus and normal alignment, preoperative valgus deformity was associated with the need for any revision surgery (P = 0.01) and prosthesis explant (P = 0.02).

CONCLUSIONS

Compared with POA, fracture PTOA was associated with a markedly higher complication rate after TAA and was at higher risk of failure requiring prosthesis explant. Fracture PTOA was markedly associated with preoperative valgus malalignment, an identified risk factor in this series for revision surgery and prosthesis explant. Pilon fractures may represent a group at risk of complications related to talar implant subsidence and loosening compared with malleolar fractures and thus warrants additional investigation.

LEVEL OF EVIDENCE

III.

Risk Factors for the Progression of Varus Ankle Osteoarthritis

Background

With the increase in life expectancy, the prevalence of ankle osteoarthritis (OA) is also expected to increase in the future. Functional disability and diminished quality of life associated with end-stage ankle OA are comparable to those associated with end-stage hip or knee OA. However, there are few reports on the natural history and progression of patients with ankle OA. Hence, this study aimed to evaluate the risk factors for progression in patients with varus ankle OA.

Methods

We evaluated 68 ankles from 58 patients diagnosed with varus ankle OA using radiography performed at intervals over at least 60 months. The mean follow-up period was 99 ± 40 months. Narrowing of the joint space and increasing osteophyte formation were defined as ankle OA progression. Multivariate analysis was performed using logistic regression to predict the odds of progression; the model included 2 clinical variables and 7 radiographic variables.

Results

Of the 68 ankles, 39 (57%) progressed. In multivariable logistic regression analyses, patient's age (odds ratio [OR] 0.92, 95% CI 0.85-0.99, P < .03), and the talar tilt (TT; OR 2.2, 95% CI 1.39-3.42, P = .001) were found to be independent factors for progression. The area under the curve (AUC) of the receiver operating characteristic curve for TT was 0.844, and the cutoff value was 2.0 degrees.

Conclusion

TT was found to be a primary factor associated with varus ankle OA progression. The risk appeared higher in patients with a TT more than 2.0 degrees.

Level of Evidence

Level III, retrospective case control study.

Clinical outcomes of surgical treatment for end-stage ankle osteoarthritis in patients aged ≥ 75 years: a multicenter, retrospective study

BACKGROUND

This study aimed to clarify the clinical outcomes of surgical treatment for end-stage ankle osteoarthritis in patients aged ≥ 75 years and compare these outcomes with those of patients aged < 75 years.

METHODS

A total of 148 patients, including 65 who underwent total ankle arthroplasty and 83 who underwent ankle arthrodesis, were retrospectively surveyed. Clinical outcomes were assessed preoperatively and at the last follow-up using the Japanese Society for Surgery of the Foot Hindfoot Scale and a self-administered foot evaluation questionnaire (SAFE-Q). Patient characteristics, including age, sex, body mass index, radiographic severity, and follow-up period, were also assessed. The patients were divided into older (≥ 75 years) and younger (< 75 years) age groups. Improvements in outcomes were then compared between age groups using univariate analysis and analysis of covariance adjusted for patient characteristics. Total ankle arthroplasty and ankle arthrodesis were analyzed separately.

RESULTS

All clinical outcome scores improved postoperatively in the older age groups for both procedures. Scores for the pain and pain-related subscale of the SAFE-Q improved by 37 points (p < 0.001) in post-total ankle arthroplasty patients and by 35 points in post-ankle arthrodesis patients (p < 0.001). Furthermore, multivariate analysis showed that the improvements observed in all scores were not different between the older and younger age groups for both post-total ankle arthroplasty and post-ankle arthrodesis patients, except for the SAFE-Q physical functioning subscale score for post-ankle arthrodesis patients. The clinical outcomes improved significantly in post-total ankle arthroplasty and post-ankle arthrodesis patients aged ≥ 75 years. Moreover, these improvements were similar to those observed in patients aged < 75 years.

CONCLUSIONS

Surgical treatment of end-stage ankle osteoarthritis can be a viable treatment option, even in elderly patients, and can be expected to improve similarly to younger patients.

Biomechanics and Tribology of Total Ankle Replacement

This article discusses the biomechanics and tribology of total ankle replacements considering the influence of implant design and generation on functional outcome, before discussing the interplay between biomechanics and tribology in the clinical success of total ankle replacement. It reflects on what we know and highlights areas for further research, as well as identifying factors to consider in clinical practice.

Transfibular ankle arthrodesis with use of sagitally split fibula as a biological plate leads to excellent outcome: A retrospective analysis

Background

We studied ankle arthrodesis with a transfibular approach using sagitally spilitted fibula as a biological plate (onlay grafting) as well as other half of fibula as morcellised local interpositional graft (inlay grafting) to achieve bony union.

Material and methods

Retrospective clinico-radiological evaluation of 36 operated cases was done at 3, 6, 12 and 30 months follow-ups. Clinically union was considered once ankle became pain free on full weight bearing. Pain assessment was done by using VAS (visual analogue scale) score and functional evaluation was done by AOFAS (American Orthopaedic Foot & Ankle Society) hind foot score preoperatively and at different follow ups. Radiologically, sagittal plane ankle alignment and fusion status was determined at each follow up.

Results

Mean age of patients was 40.36 ± 10.56 years (range 18-55), who were evaluated for mean duration of 33.32 ± 11.25 months (range 24-65). Thirty-three (91.7%) ankles were fused adequately and mean duration to achieve bony union was 5.09 ± 1.3 months (range 4-9 months). Mean post-operative AOFAS score at final follow up was 76.65 ± 4.87 in comparison to 45.76 ± 3.38, preoperatively. VAS score improved significantly from 7.8 (pre-operative) to 2.3 (final follow-up). Non-union in three patients (8.3%) and ankle malalignment in one patient was observed.

Conclusion

Transfibular ankle arthrodesis achieves excellent bony unions and functional outcomes in severe ankle arthritis. Biologically incompetent fibula that to be judged individually by the operating surgeon to use it as a graft. Patients having inflammatory arthritis have more dissatisfaction than other aetiologies.

Total ankle replacement versus ankle arthrodesis for patients aged 50-85 years with end-stage ankle osteoarthritis: the TARVA RCT

Background

We aimed to compare the clinical effectiveness, cost-effectiveness and complication rates of total ankle replacement with those of arthrodesis (i.e. ankle fusion) in the treatment of end-stage ankle osteoarthritis.

Methods

This was a pragmatic, multicentre, parallel-group, non-blinded randomised controlled trial. Patients with end-stage ankle osteoarthritis who were aged 50-85 years and were suitable for both procedures were recruited from 17 UK hospitals and randomised using minimisation. The primary outcome was the change in the Manchester-Oxford Foot Questionnaire walking/standing domain scores between the preoperative baseline and 52 weeks post surgery.

Results

Between March 2015 and January 2019, 303 participants were randomised using a minimisation algorithm: 152 to total ankle replacement and 151 to ankle fusion. At 52 weeks, the mean (standard deviation) Manchester-Oxford Foot Questionnaire walking/standing domain score was 31.4 (30.4) in the total ankle replacement arm (n = 136) and 36.8 (30.6) in the ankle fusion arm (n = 140); the adjusted difference in the change was -5.6 (95% confidence interval -12.5 to 1.4; p = 0.12) in the intention-to-treat analysis. By week 52, one patient in the total ankle replacement arm required revision. Rates of wound-healing issues (13.4% vs. 5.7%) and nerve injuries (4.2% vs. < 1%) were higher and the rate of thromboembolic events was lower (2.9% vs. 4.9%) in the total ankle replacement arm than in the ankle fusion arm. The bone non-union rate (based on plain radiographs) in the ankle fusion arm was 12.1%, but only 7.1% of patients had symptoms. A post hoc analysis of fixed-bearing total ankle replacement showed a statistically significant improvement over ankle fusion in Manchester-Oxford Foot Questionnaire walking/standing domain score (-11.1, 95% confidence interval -19.3 to -2.9; p = 0.008). We estimate a 69% likelihood that total ankle replacement is cost-effective compared with ankle fusion at the National Institute for Health and Care Excellence's cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained over the patient's lifetime.

Limitations

This initial report contains only 52-week data, which must therefore be interpreted with caution. In addition, the pragmatic nature of the study means that there was heterogeneity between surgical implants and techniques. The trial was run across 17 NHS centres to ensure that decision-making streams reflected the standard of care in the NHS as closely as possible.

Conclusions

Both total ankle replacement and ankle fusion improved patients' quality of life at 1 year, and both appear to be safe. When total ankle replacement was compared with ankle fusion overall, we were unable to show a statistically significant difference between the two arms in terms of our primary outcome measure. The total ankle replacement versus ankle arthrodesis (TARVA) trial is inconclusive in terms of superiority of total ankle replacement, as the 95% confidence interval for the adjusted treatment effect includes both a difference of zero and the minimal important difference of 12, but it can rule out the superiority of ankle fusion. A post hoc analysis comparing fixed-bearing total ankle replacement with ankle fusion showed a statistically significant improvement of total ankle replacement over ankle fusion in Manchester-Oxford Foot Questionnaire walking/standing domain score. Total ankle replacement appears to be cost-effective compared with ankle fusion at the National Institute for Health and Care Excellence's cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained over a patient's lifetime based on long-term economic modelling.

Future work

We recommend long-term follow-up of this important cohort, in particular radiological and clinical progress. We also recommend studies to explore the sensitivity of clinical scores to detect clinically important differences between arms when both have already achieved a significant improvement from baseline.

Trial registration

This trial is registered as ISRCTN60672307 and ClinicalTrials.gov NCT02128555.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 5. See the NIHR Journals Library website for further project information.

Computed Tomography Derived Patient-specific Instrumentation Total Ankle Arthroplasty Survivorship Outcomes

Computed tomography (CT) derived patient-specific total ankle arthroplasty (TAA) systems have been utilized for improved accuracy and reproducible implant alignment. The purpose of the present study was to report the overall implant survivorship as well as radiographic analysis of patients who underwent primary TAA utilizing CT-derived patient-specific instrumentation. A retrospective review of medical charts and radiographs were performed on patients who had undergone primary TAA at a single institution in the Midwest region from March 2013 to October 2020. Radiographic analysis included preoperative, initial postoperative, and final follow-up coronal and sagittal tibiotalar alignment as well as periprosthetic radiolucency. A total of 96 patients with a mean follow-up of 3 years (range, 0.3-7.3 years) were included. Implant survivorship was found to be 92% at median follow-up of 3 years. A total of 8 cases (8.3%) required revision/reoperation, with 6 (6.3%) of these reoperations directly related for failure of one of the metallic implant components. There was significant improvement in both coronal and sagittal tibiotalar alignment from preoperative to initial postoperative follow-up (p < .001). At latest postoperative follow-up, there were 88% of TAAs that remained in a neutral alignment following surgery. A total of 10 cases were found to have radiolucency at latest follow-up. In conclusion, the use of CT derived patient-specific TAA showed high implant survivorship with significant improvement of sagittal and coronal tibiotalar alignment. With better implant alignment and position, it potentially reduces the risk of early implant failure or implant loosening in long-term follow-up.

How long do ankle arthroplasties last?

Despite the increasing numbers of ankle arthroplasties, there are limited studies on their survival and comparisons between different implants. The primary aim of this study was to determine the failure rates of primary ankle arthroplasties commonly used in the UK. A data linkage study combined National Joint Registry (NJR) data and NHS Digital data. The primary outcome of failure was defined as the removal or exchange of any components of the implanted device. Life tables and Kaplan-Meier survival charts were used to illustrate survivorship. Cox proportional hazards regression models were fitted to compare failure rates between 1 April 2010 and 31 December 2018. Overall, 5,562 primary ankle arthroplasties were recorded in the NJR. Linked data show a one-year survivorship of 98.8% (95% confidence interval (CI) 98.4% to 99.0%), five-year survival in 2,725 patients of 90.2% (95% CI 89.2% to 91.1%), and ten-year survival in 199 patients of 86.2% (95% CI 84.6% to 87.6%). The five-year survival for fixed-bearing implants was 94.3% (95% CI 91.3% to 96.3%) compared to 89.4% (95% CI 88.3% to 90.4%) for mobile-bearing implants. A Cox regression model for all implants with over 100 implantations using the implant with the best survivorship (Infinity) as the reference, only the STAR (hazard ratio (HR) 1.60 (95% CI 0.87 to 2.96)) and INBONE (HR 0.38 (95% CI 0.05 to 2.84)) did not demonstrate worse survival at three and five years. Ankle arthroplasties in the UK have a five-year survival rate of 90.2%, which is lower than recorded on the NJR, because we have shown that approximately one-third of ankle arthroplasty failures are not reported to the NJR. There are statistically significant differences in survival between different implants. Fixed-bearing implants appear to demonstrate higher survivorship than mobile-bearing implants.

Outcome measures in clinical studies of ankle osteoarthritis: a systematic review

OBJECTIVE

To explore and describe the outcome measures reported in primary research of ankle osteoarthritis (OA) and to propose aligned health-related domains.

METHODS

Six databases were searched, and studies were screened by two independent reviewers. Studies of participants with ankle OA who were> 18 years of age and reported outcome measure data were included. Non-English, animal, cadaveric, reviews, and studies with< 5 participants were excluded. Outcome measures were examined for content and mapped to health-related domains.

RESULTS

1386 studies were identified, of which 547 met selection criteria - reporting 250 outcome measures. Most commonly reported measures were the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (n = 257 studies), plain radiographs to measure ankle alignment (n = 211), numerical rating scale for pain severity (n = 177) and goniometry to measure ankle range of motion (n = 148). Outcome measures were organised into 19 domains. The most common domains were pain severity (315 (58%) studies), ankle alignment (254 (46%)), ankle motion (181 (33%)), disability (169 (31%)) and health-related quality of life (128 (23%)). These domains fell into the Outcome Measures in Rheumatology (OMERACT) core areas of life impact and pathophysiological manifestations.

CONCLUSION

Many outcome measures are used in ankle OA research, most of which assess joint alignment, pain, and motion. Based on the outcome measures identified, we proposed 19 possible health-related domains, predominantly in the OMERACT core areas of life impact and pathophysiological manifestations of ankle OA. Clinicians and researchers can use this review in guiding selection of outcome measures.

Hybrid-Total Ankle Arthroplasty (H-TAA) for Failed Talar Component in Mobile-Bearing Total Ankle Arthroplasty

INTRODUCTION

Revision Total Ankle Arthroplasty (TAA) surgery due to TAA aseptic loosening is increasing. It is possible to exchange the talar component and inlay to another system for isolated talar component loosening in a primary mobile-bearing TAA: Hybrid-Total Ankle Arthroplasty (H-TAA). The purpose of this study was to analyze the results of the revision surgery of an isolated aseptic talar component loosening in a mobile-bearing three-component TAA with a H-TAA solution.

METHODS

In this prospective case study, nine patients (six women, three men; mean age 59.8 years; range 41-80 years) with symptomatic isolated aseptic loosening of the talar component of a mobile-bearing TAA were treated with an isolated talar component and inlay substitution. In all nine cases, a hybrid TAA revision surgery was performed by implanting a VANTAGE TAA talar and insert component (Flatcut talar component: six cases, standard talar component: three cases). The patients were reviewed with the pain score (VAS Pain Score 0-10), Dorsiflexion/Plantarflexion (DF/PF) Range of Motion (ROM; degrees), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle/Hindfoot Score (0-100 points), Sports Frequency Score (Level 0-4), and subjective Patients' Satisfaction Score (0-10 points).

RESULTS

The average Pain score improved significantly from preoperative 6.7 points to postoperative 1.1 points (p < 0.001). Average Dorsiflexion/Plantarflexion ROM values increased significantly post-surgery: 21.7° preoperative to 45.6° postoperative (p < 0.001). The postoperative AOFAS scores were significantly greater than the preoperative values: 47.7 points preoperative, 92.3 points postoperative (p < 0.001). The sports activity improved from preoperative to postoperative where, preoperative, none of the patients were able to perform sports. Postoperative, eight patients were able to be sports-active again. The overall average postoperative level of sports activity was 1.4. The postoperative average patient's satisfaction was 9.3 points.

CONCLUSIONS

In painful talar component aseptic loosening of a three-component mobile-bearing TAA, H-TAA is a good surgical solution for reducing pain, restoring ankle function, and improving patients' life quality.

Correction of ankle varus deformity using patient-specific dome-shaped osteotomy guides designed on weight-bearing CT: a pilot study

BACKGROUND

Dome-shaped supramalleolar osteotomies are a well-established treatment option for correcting ankle deformity. However, the procedure remains technically demanding and is limited by a two-dimensional (2D) radiographic planning of a three-dimensional (3D) deformity. Therefore, we implemented a weight-bearing CT (WBCT) to plan a 3D deformity correction using patient-specific guides.

METHODS

A 3D-guided dome-shaped supramalleolar osteotomy was performed to correct ankle varus deformity in a case series of five patients with a mean age of 53.8 years (range 47-58). WBCT images were obtained to generate 3D models, which enabled a deformity correction using patient-specific guides. These technical steps are outlined and associated with a retrospective analysis of the clinical outcome using the EFAS score, Foot and Ankle Outcome Score (FAOS) and visual analog pain scale (VAS). Radiographic assessment was performed using the tibial anterior surface angle (TAS), tibiotalar angle (TTS), talar tilt angle (TTA), hindfoot angle (HA), tibial lateral surface angle (TLS) and tibial rotation angle (TRA).

RESULTS

The mean follow-up was 40.8 months (range 8-65) and all patients showed improvements in the EFAS score, FAOS and VAS (p < 0.05). A 3-month postoperative WBCT confirmed healing of the osteotomy site and radiographic improvement of the TAS, TTS and HA (p < 0.05), but the TTA and TRA did not change significantly (p > 0.05).

CONCLUSION

Dome-shaped supramalleolar osteotomies using 3D-printed guides designed on WBCT are a valuable option in correcting ankle varus deformity and have the potential to mitigate the technical drawbacks of free-hand osteotomies.

LEVEL OF EVIDENCE

Level 5 case series.

[Update: endoprosthetics on the ankle joint]

The ankle joint has to bear the entire body weight on a relatively small joint surface. Incongruities, instabilities and deformities lead to painful arthrosis and considerable restrictions in everyday life. For many years, arthrodesis has proven to be the gold standard for end stage arthrosis; however, considering modern endoprostheses for the ankle joint it is no longer appropriate to offer only arthrodesis. The very good results of the 3rd generation 3‑component prostheses and the 4th generation 2‑component prostheses show how much the surgical treatment options for the ankle joint are currently changing. The simplified implantation techniques enable access to arthroplasty of the ankle joint for a broader spectrum of surgeons and explain the increasing implantation rates in recent years. Decisive for postoperative success are correct planning with knowledge of the leg axes and foot position, correct patient selection and exact surgical placement of the components.

Age-, sex-, and subregion-specific properties of distal fibular microarchitecture and strength: An ex vivo HR-pQCT study

Despite its clinical relevance in the context of ankle fractures, little is known about the bone microarchitecture and strength of the distal fibula, especially regarding age-, sex-, and subregion-specific effects. To address this gap of knowledge, we obtained fibulae from 30 skeletally intact donors at autopsy (each 15 male and female), which were analyzed by high-resolution peripheral quantitative computed tomography including micro-finite element analysis. Scans were performed in a 7-cm volume of interest and evaluated in three subregions according to the Danis-Weber fracture classification. Group comparisons and linear regression analyses were applied to evaluate the effects of age, sex, and subregion. From distal to proximal, we observed an increase of cortical parameters and a decrease of trabecular parameters. Age was primarily associated with a cortical decrease in all subregions (Danis-Weber type A, B, and C) in women. While women showed a greater magnitude of decline, men also exhibited an age-associated decrease for some parameters, including cortical area and cortical thickness in the type C subregion. Stiffness and failure load were highest in the type C subregion in both women and men. A critical age-related decline in bone strength parameters in the type B subregion was observed in women, providing an explanation for the increased incidence of low-traumatic type B fractures in the elderly. Together, these findings extend the current understanding of distal fibular microarchitecture, likely explaining the epidemiologic features of distal fibula fractures and emphasizing the need for age-adapted treatment algorithms.

Short-term Results of Hemiarthroplasty of the Ankle Joint for Talar-Sided Cartilage Loss

Background

Ankle hemiarthroplasty is a 1-piece implant system replacing the talar side of the tibiotalar joint. Hemiarthroplasty offers limited bone resection and may provide easier revision options than joint-ablating procedures.

Methods

Prospective, multicenter, noncomparative, nonrandomized clinical study with short term follow-up on patients undergoing hemiarthroplasty of the ankle. Radiologic and functional outcomes (Foot and Ankle Outcome Score FAOS, Foot and Ankle Ability Measure [FAAM], Short Form-36 Health Survey [SF-36], Short Musculoskeletal Functional Assessment [SMFA], and visual analog scale [VAS] pain scores) were obtained at 3 and 12 months and the 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. Pain VAS scores improved on average from 6.8 to 4.8 (P = .044) of the remaining 7 at a mean of 31.9 months' follow-up. For these 7 in the Survival Group, we found that SF-36 physical health component improved from 25.03 to 42.25 (P = .030), SMFA dysfunction and bother indexes improved from 46.36 to 32.28 (P = .001), and from 55.21 to 30.14 (P = .002) in the Survival Group, and FAAM sports improved from 12.5 to 34.5 (P = .023).

Conclusion

Patients undergoing hemiarthroplasty of the ankle joint for talar-sided lesions had a 30% failure rate by 18 months. Those who did not have an early failure exhibited modest pain reduction, functional improvements, and better quality of life in short-term follow-up. This procedure offers a possible alternative for isolated talar ankle cartilage cases.

Level of Evidence

Level IV, prospective case series.

Management of Periprosthetic Bone Cysts After Total Ankle Arthroplasty

Modern improvements in total ankle arthroplasty (TAA) have increased the performance of this procedure for treatment of end-stage ankle arthritis. A common finding after TAA is the formation of periprosthetic bone cysts, which can be clinically silent or result in TAA failure. The exact cause of periprosthetic bones cysts has not been established, but major theories are related to osteolysis secondary to implant wear, micromotion, and stress shielding. Treatment can be nonoperative with clinical observation for small, asymptomatic cysts. Large, progressive, and symptomatic cysts often merit surgical treatment with debridement and grafting, revision TAA, or salvage arthrodesis.

Early Clinical Outcomes and Complications of Transfibular Total Ankle Arthroplasty: The Australian Experience

BACKGROUND

We report the short-term outcomes of a retrospective cohort of Trabecular Metal total ankle arthroplasties (TAAs) via a transfibular approach from a single, nondesigner surgeon in Australia.

METHODS

This was a retrospective cohort study. Demographic, clinical, and patient-reported outcome measures (PROMs) were collected. The primary outcome was the Foot and Ankle Outcome Score (FAOS), and secondary outcomes included patient satisfaction, the EuroQol-5 Dimension (EQ5D), and complications including revision rates.

RESULTS

Between 2016 and 2019, 84 trabecular metal prostheses were implanted in 84 patients. Mean age (SD) at time of surgery was 68 (7.8) years, and 46 (55%) were male. Mean follow-up (SD) was 26.1 (13) months. There were significant (P < .001) improvements in the FAOS in the subscales of pain (47.9 to 79.1), activities of daily living (59.5 to 83.7), and quality of life (25.5 to 60.2) and EQ-5D (0.55 to 0.75) (P < .001), and overall satisfaction was 69.6%. The commonest complications were wound infection or breakdown (11.9%, n=10), fibular nonunion (3.5%), plate irritation (3.5%), and tibial nerve neuropathy (3.5%). There were no thromboembolic complications. Implant survivorship was 100%, with Trabecular Metal components retained in all patients. Two patients developed deep infection, with 1 requiring debridement and polyethylene exchange. No patients experienced implant loosening.

CONCLUSION

Our results demonstrate that the trabecular metal survival rates are comparable with other total ankle implants in the Australian Orthopaedic Association National Joint Replacement Registry and as published in other international literature. Overall patient satisfaction was high, as were PROMs. However, the data highlight potential complications uniquely associated with this implant. The authors believe that these figures support TAA via a transfibular approach as a viable option in the treatment of ankle arthritis.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial

BACKGROUND

End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF).

OBJECTIVE

To determine which treatment is superior in terms of clinical scores and adverse events.

DESIGN

A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307).

SETTING

17 National Health Service trusts across the United Kingdom.

PATIENTS

Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure.

INTERVENTION

Patients were randomly assigned to TAR or AF surgical treatment.

MEASUREMENTS

The primary outcome was change in Manchester-Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible.

RESULTS

Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was -5.6 (95% CI, -12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (-11.1 [CI, -19.3 to -2.9]).

LIMITATION

Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques.

CONCLUSION

Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%.

PRIMARY FUNDING SOURCE

National Institute for Health and Care Research Heath Technology Assessment Programme.

Intermediate to long-term clinical outcomes and survival analysis of the Salto Mobile Bearing total ankle prothesis

INTRODUCTION

Osteoarthritis of the ankle is a major burden to affected patients. While tibio-talar arthrodesis has been the gold-standard regarding the treatment of osteoarthritis of the ankle joint for many years, at present total ankle arthroplasty (TAA) provides appealing clinical outcomes and is continually gaining popularity. The aim of this study was to evaluate the intermediate- to long-term clinical outcome including the survival rate of Salto Mobile Bearing TAA (Tonier SA, Saint Ismier, France).

MATERIAL AND METHODS

In this retrospective study intermediate- to long-term outcomes measures [Ankle Range of Motion (ROM), American Orthopaedic Foot and Ankle Score (AOFAS score) and survival rate] of 171 consecutive TAA were analysed and compared before and after surgery. Revision was defined as secondary surgery with prothesis component removal, while reoperation was defined as a non-revisional secondary surgery involving the ankle.

RESULTS

At a mean follow-up (FU) period of 7.2 ± 2.7 years (range 2.0 to 14.1 years) there was a significant improvement in ankle ROM (total ROM improved from 25.0° ± 15.0° to 28.7° ± 11.3°, p = 0.015; plantarflexion improved from 18.4° ± 11.7° to 20.6° ± 8.2°, p = 0.044; dorsiflexion improved from 6.6° ± 5.7° to 8.1° ± 4.9°, p = 0.011). AOFAS score increased significantly by 41 ± 15 points after surgery (43.3 ± 11.1 before and 84.3 ± 12.0 after surgery, p < 0.001). Overall survival rate within the FU was 81.3% (95% CI 75.3% to 87.3%) with any secondary surgery, 89.9% (95% CI 84.1% to 93.6%) with revision and 93.6% (95% CI 89.8% to 97.3%) with reoperation as endpoint.

CONCLUSION

This study endorses the previously reported appealing intermediate- to long-term outcomes of the Salto Mobile Bearing TAA. There was a significant increase in ROM and AOFAS score as well as decent implant survival at final FU.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 1: Epidemiology, Pathophysiology, and Current Imaging Approaches

This first of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey the state of scientific knowledge related to incidence, diagnosis, pathologic mechanisms, and injection treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 3, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Part 1 overviews areas of epidemiology and pathophysiology, current approaches in imaging, diagnostic and therapeutic injections, and genetics. Opportunities for future research are discussed. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the needs of patients that suffer from arthritis of foot and ankle. The foot and ankle contain a myriad of interrelated joints and tissues that together provide a critical functionality. When this functionality is compromised by OA, significant disability results, yet the foot and ankle are generally understudied by the research community. Level of Evidence: Level V - Review Article/Expert Opinion.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 2: Treatment Options

This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non-joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research.

LEVEL OF EVIDENCE

Level V, review article/expert opinion.

Usefulness of preoperative Short Form-36 Mental Component Score as a prognostic factor in patients who underwent decompression surgery for degenerative lumbar spinal stenosis

Physical factors such as frequency of low back pain, sensory abnormalities in the lower extremities, smoking history before surgery, and preoperative mental health status as predictors of operative outcomes have been growing as areas of interest in the field of degenerative lumbar spinal stenosis (DLSS). This study aimed to investigate the correlation between the preoperative Short Form-36 Mental Component Score (SF-36 MCS) and long-term prognosis after decompression surgery for DLSS. In total, 198 patients were enrolled in this study. The Oswestry Disability Index (ODI) and Rolland Morris Disability Questionnaire (RMDQ) were used to evaluate spinal functional outcomes. The SF-36 questionnaire was used and analyzed by classifying it into physical component score (PCS) and mental component score (MCS). The SF-36 MCS was divided into role limitations caused by emotional problems, social functioning, vitality, and emotional well-being. In the correlation between preoperative MCS and ODI improvement, the r value was -0.595 (P < .05) at 12 months postoperatively. ODI improvement at 12 months after decompression surgery showed a statistically significant and strong negative correlation with preoperative MCS. In the correlation between preoperative MCS and RMDQ improvement, the r value was -0.544 (P < .05) at 12 months postoperatively. Therefore, RMDQ improvement 12 months after decompression surgery showed a strong negative correlation with preoperative MCS. Regarding the correlation between preoperative MCS and SF-36 PCS improvement, the r values were 0.321 (P < .05) at 6 months postoperatively and 0.343 (P < .05) at 12 months postoperatively. Therefore, SF-36 PCS improvement at 6 and 12 months after decompression surgery showed a strong positive correlation with preoperative SF-36 MCS scores. Preoperative SF-36 MCS is a factor that can predict the prognosis of patients who underwent decompression surgery for lumbar spinal stenosis for at least 1 year postoperatively.

Mobile-Bearing Total Ankle Replacement In Vivo Kinematic Assessment: A Prospective Study Protocol

Total ankle prosthesis as a surgical solution in the case of end-stage osteoarthritis has seen a considerable increase in the last two decades. This study protocol arises from the need to understand the in vivo kinematics of mobile-bearing, flat tibial component total ankle replacement, evaluating the real range of motion and the reciprocal relationships between the components during normal motor tasks through the use of model-based radio-stereometric analysis (MB-RSA). In addition, pre- and post-operative evaluation of walking kinematics with inertial motion sensors, proprioception through a dedicated workstation, and clinical outcomes are discussed. We expect that based on our study protocol researchers will be able to improve future prosthetic designs and validate the setup of MB-RSA, as well as to understand "how an ankle prosthesis moves" once implanted in the patient.

Reconstructive Surgery and Joint-Sparing Surgery in Valgus and Varus Ankle Deformities: A Comprehensive Review

Osteoarthritis (OA) of the ankle affects about 1% of the world’s adult population, causing an important impact on patient lives and health systems. Most patients with ankle OA can show an asymmetrical wear pattern with a predominant degeneration of the medial or the lateral portion of the joint. To avoid more invasive ankle joint sacrificing procedures, joint realignment surgery has been developed to restore the anatomy of the joints with asymmetric early OA and to improve the joint biomechanics and symptoms of the patients. This narrative, comprehensive, all-embracing review of the literature has the aim to describe the current concepts of joint preserving and reconstructive surgery in the treatment of the valgus and varus ankle early OA, through an original iconography and clear indications and technical notes.

Protocol for the development of a core domain set for individuals with ankle osteoarthritis

Background

Ankle osteoarthritis (OA) is a debilitating health condition that is increasing in prevalence. Currently, there are no evidence-based guidelines for managing ankle OA. One of the current challenges to establishing guidelines is the lack of a widely agreed-upon set of outcome measures that are consistently used in ankle OA research. Without a set of agreed-upon outcome measures, it is difficult to synthesise clinical trial outcomes through meta-analysis—an essential element of evidence-informed practice. In order to develop an appropriate set of outcome measures for ankle OA, it is important first to develop a core domain set. In this protocol, we describe the methodological approach that we will use to develop such a core domain set for ankle OA.

Methods

We established an international steering committee to guide the development of a core domain set for ankle OA. The core domain set development will follow a multi-staged approach consisting of three phases, involving participation by patients and clinicians/healthcare professionals. In phase 1, a list of candidate domains will be gleaned from (a) a scoping review of outcome measures used in ankle OA research, (b) qualitative interviews with individuals with ankle OA, and (c) qualitative interviews with healthcare professionals with expertise in ankle OA. In phase 2, the steering committee will review and generate a list of candidate domains from those gleaned in phase 1. In phase 3, this list of candidate domains will be considered in a Delphi process to reach a consensus on a core domain set. We anticipated this will involve 3 rounds of surveys.

Conclusion

This protocol describes the methods that will be used to develop a core domain set of health-related aspects for ankle OA. Importantly, it will include both healthcare professional and patient involvement. This is a prerequisite step to developing a core outcome set for ankle OA that should be reported in all clinical trials for ankle OA. The findings will be widely disseminated across peer-refereed publication(s) and national and international conferences, as well as via relevant professional societies, patient support group organisations, and social media platforms.

Project registration

This project is registered with the Core Outcome Measures in Effectiveness Trials (COMET) database on 17 March 2021. https://www.comet-initiative.org/Studies/Details/1837.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06692-0.

Supramalleolar Osteotomy vs Arthrodesis for the Treatment of Takakura 3B Ankle Osteoarthritis

BACKGROUND

To compare the clinical/functional outcomes of supramalleolar osteotomy (SMOT) and ankle arthrodesis (AA) for the treatment of modified Takakura stage 3B ankle osteoarthritis.

METHODS

Outcomes of 28 SMOT patients and 30 AA patients were reviewed at an average of 50 and 51 months, respectively. The baseline characteristics of the 2 groups were similar. The preoperative tibial articular surface angle and talar tilt angle in the SMOT group were 82.6 and 10 degrees and in the AA group, 83.9 and 9.1 degrees, respectively. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score, 12-item Short-Form Health Survey (SF-12) mental component summary (MCS) and physical component summary (PCS) scores, range of motion (ROM), radiologic parameters, and complications were compared.

RESULTS

The AOFAS, VAS, and SF-12 MCS and PCS scores improved significantly postoperatively in both groups (P < .001). The VAS and SF-12 PCS scores indicate marginally better improvement in the AA group (P < .05). The patient satisfaction value (P = .028) and the possibility of repeated surgery value (P = .012) were also significantly higher in the AA group. The early (P = .905) and late (P = .181) complications did not significantly differ between the 2 groups. The reoperation rate was significantly higher in the SMOT group (P = .038).

CONCLUSION

Both SMOT and AA showed improvements in function, pain, alignment, and quality of life after surgery. Patients in the AA group reported better pain relief, had a lower reoperation rate, and better hindfoot alignment during a short- to mid-term follow-up time.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Long-Term Clinical Outcomes and Implant Survivorship of 151 Total Ankle Arthroplasties Using the HINTEGRA Prosthesis: A Minimum 10-Year Follow-up

BACKGROUND

Few studies have investigated long-term clinical outcomes of a mobile-bearing total ankle arthroplasty (TAA) system. This study analyzed long-term outcomes of TAA using the HINTEGRA prosthesis at a single, non-developer center.

METHODS

Primary TAAs were performed on 213 ankles in 194 patients, and 151 consecutive ankles [71%] in 136 patients with a minimum follow-up of 10 years after the primary TAA were included in this study. Clinical results were assessed using a visual analog scale (VAS) pain score, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale score, the Ankle Osteoarthritis Scale (AOS) pain and disability subscores, and ankle range of motion. Prosthesis survivorship, reoperations, and risk factors were also evaluated.

RESULTS

The mean follow-up was 135.5 months (range, 120.0 to 204.0 months). All clinical scores and ankle range of motion improved significantly from preoperatively to 2 years, 4 to 6 years, and ≥10 years after TAA (p < 0.001). A total of 43 ankles (28.5%) required revision procedures, with the most common reason being periprosthetic osteolysis (32 ankles [21.2%]). The overall implant survivorship was 93.5% in Kaplan-Meier survival analysis at the mean follow-up of 11.3 years after the TAA.

CONCLUSIONS

TAA using the HINTEGRA prosthesis with careful follow-up observation and appropriate adjunct procedures for the treatment of end-stage ankle arthritis produced satisfactory clinical results, which were maintained at a follow-up of ≥10 years, and resulted in 93.5% of implant survivorship.

LEVEL OF EVIDENCE

Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

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

BACKGROUND

Patients undergoing total ankle replacement (TAR) often have symptomatic adjacent joint arthritis and deformity. Subtalar arthrodesis can effectively address a degenerative and/or malaligned hindfoot, but there is concern that it places abnormal stresses on the TAR and adjacent joints of the foot, potentially leading to early TAR failure. This study hypothesized that ankle and talonavicular joint kinematics would be altered after subtalar arthrodesis in the setting of TAR.

METHODS

Thirteen mid-tibia cadaveric specimens with neutral alignment were tested in a robotic gait simulator. To simulate gait, each specimen was secured to a static mounting fixture about a 6-degree of freedom robotic platform, and a force plate moves relative to the stationary specimen based on standardized gait parameters. Specimens were tested sequentially in TAR and TAR with subtalar arthrodesis (TAR-ST_fuse). Kinematics and range of motion of the ankle and talonavicular joint were compared between TAR and TAR-ST_fuse.

RESULTS

There were significant differences in kinematics and range of motion between TAR and TAR-ST_fuse groups. At the ankle joint, TAR-ST_fuse had less internal rotation in early-mid stance (P < .05), with decreased range of motion in the sagittal (-2.7 degrees, P = .008) and axial (-1.8 degrees, P = .002) planes in early stance, and increased range of motion in the coronal plane in middle (+1.2 degrees, P < .001) and late (+2.5 degrees, P = .012) stance. At the talonavicular joint, there were significant differences in axial and coronal kinematics in early and late stance (P < .05). Subtalar arthrodesis resulted in significantly decreased talonavicular range of motion in all planes in early and late stance (P < .003).

CONCLUSION

In ankles implanted with the TAR design used in this study, kinematics of the ankle and talonavicular joint were found to be altered after subtalar arthrodesis. Aberrant motion may reflect altered contact mechanics at the prosthesis and increased stress at the bone-implant interface, and affect the progression of adjacent joint arthritis in the talonavicular joint.

CLINICAL RELEVANCE

These findings may provide a correlate to clinical studies that have cited hindfoot arthrodesis as a risk factor for TAR failure.

Knee Kinetics and Kinematics in Patients With Ankle Arthroplasty and Ankle Arthrodesis

Background: Previous literature suggests that patients treated with total ankle arthroplasty (TAA) versus ankle arthrodesis (AA) may have better function and lower risk for adjacent joint arthritis in the foot. Little is known on how these interventions affect proximal joints such as the knee. Questions: We sought to assess whether patients with TAA and AA exhibited altered biomechanics linked to the onset and progression of knee osteoarthritis (KOA). We used the knee adduction moment (KAM), a surrogate measure for the mechanical load experienced at the medial tibiofemoral compartment, because it is linked with the onset and progression of KOA. Methods: At a minimum of 2 years postoperatively, instrumented 3-dimensional walking gait was recorded in 10 TAA and 10 AA patients at self-selected walking speeds. TAA patients had either a Salto Talaris or INBONE prosthesis. Average first and second peak KAMs (Nm/kg), KAM impulse (Nm-s/kg), and range-of-motion (ROM, °) were calculated on both the affected and unaffected limbs for each patient. Results: There were no significant differences in the KAM's first and second peaks, impulse, or knee ROM in any plane between the unaffected and affected limbs, or between TAA and AA. Conclusion: TAA and AA may not meaningfully affect ipsilateral knee kinetics and KAMs in short-term follow-up. This study highlights the importance of continuing to study these parameters in larger cohorts of patients with longer follow-up to determine how our treatment of end-stage ankle arthritis may affect the incidence or progression of ipsilateral KOA.

Simultaneous Total Ankle Replacement and Contralateral Ankle Arthrodesis for Bilateral Ankle Osteoarthritis: A Retrospective Study Focused on Clinical Outcomes and Cost-effectiveness

Objective

Total ankle replacement (TAR) and ankle arthrodesis (AA) are two common surgical treatment options for end‐stage ankle osteoarthritis. However, few reports compare the outcomes of simultaneous TAR and contralateral AA for bilateral ankle osteoarthritis. The aim of this study was to assess changes in pain, joint range of movement (ROM), functional outcomes, patient satisfaction, and cost‐effectiveness following simultaneous TAR and contralateral AA.

Methods

A retrospective study was conducted on 12 patients with bilateral end‐stage ankle osteoarthritis who underwent simultaneous TAR and contralateral AA in our institution between May 2016 and August 2018, and who had a minimum of two‐year follow‐up data. Clinical and radiological follow‐up data for all patients were collected after 4 months, 1 year and 2 years. The results were assessed clinically on a visual analogue scale (VAS) and included ROM, American Orthopedic Foot and Ankle Society (AOFAS) ankle hindfoot score, and satisfaction questionnaire. The total hospital costs of patients were also recorded. Independent sample t tests were conducted to compare continuous variables between groups. Paired sample t‐tests were conducted to compare changes from the preoperative to postoperative evaluations within each group.

Results

Both surgical groups presented with pain reduction (P < 0.001) at the one‐year postoperative session, which was generally consistent until the two‐year follow‐up. There was a significant increase (P < 0.001) in the mean AOFAS score postoperatively in both ankles. The functional outcomes at the one‐ and two‐year follow‐up were significantly better in patients in the TAR group than in those in the AA group (P < 0.001). Joint ROM differences were observed between the two groups after surgery (decreased ankle ROM in arthrodesis, P < 0.001; increased ankle ROM in arthroplasty, P < 0.001). The mean satisfaction score was 2 (range, 1–4) for the TAR group and 3 (range, 1–5) for the AA group. A significant difference in the satisfaction score was observed between the two groups (P = 0.036). Simultaneous TAR and contralateral AA was 34.1% less expensive than simultaneous bilateral TAR. No intraoperative complications were noted in either group. Wound healing occurred without problems within 2 weeks after surgery. No symptomatic deep venous thrombosis was found during follow‐up.

Conclusion

TAR had better patient‐perceived post‐operative function and preserves more anatomic sagittal plane motion compared to ankles undergoing AA. In addition, simultaneous TAR and contralateral AA are more cost‐effective than simultaneous bilateral TAR, with lower costs for the average patient.

Arthroscopic Versus Open Ankle Arthrodesis: A 5-Year Follow Up

BACKGROUND

End-stage ankle arthritis has long been managed surgically with open ankle arthrodesis (OAA). Since the first published report in 1983, arthroscopic ankle arthrodesis (AAA) has been thought to be associated with improved patient-reported outcome measures (PROMs) and fewer complications. The purpose of the present study was to compare the long-term PROMs, major complications, and reoperations for these 2 approaches at up to 15 years of follow-up.

METHODS

This longitudinal cohort study included patients at our institution who underwent primary ankle arthrodesis for the treatment of end-stage arthritis. Demographic data and preoperative COFAS (Canadian Orthopaedic Foot and Ankle Society) ankle arthritis type were collected for all patients. PROMs were completed preoperatively, at 6 months, and annually thereafter to 5 years. PROMs were compared at all time points with use of a mixed-effects regression model that adjusted for preoperative variables and scores. Major complications and reoperations at the site of the ankle arthrodesis were also compared.

RESULTS

Of 1,294 patients who were screened for inclusion, 351 who had undergone ankle arthrodesis between 2003 and 2019 were eligible for the study. Of those, 223 had undergone AAA and 128 had undergone OAA. The 2 groups were similar preoperatively with respect to demographics, but COFAS Type-4 arthritis was relatively more common in the OAA group and Type-1 arthritis was relatively more common in the AAA group. In addition, the Ankle Osteoarthritis Scale (AOS) score and Ankle Arthritis Score (AAS) were better in the AAA group. In the mixed-effects model analysis, the differences in postoperative outcome scores between the groups were not significant. The risk of revision due to malunion or nonunion was similar in both groups (6% in the AAA group, compared with 4% in the OAA group). Deep infection and wound complications did not occur in the arthroscopic group but occurred in 4% of the patients in the OAA group.

CONCLUSIONS

After adjustment for baseline patient characteristics, there were no differences in PROMs between the 2 techniques. Ankle arthrodeses done arthroscopically had a similar revision rate but lower infection rate compared with those done with the open technique.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Demineralized Bone Matrix Affect the Nonunion Rate in Arthroscopic Ankle Arthrodesis?

Demineralized bone matrix (DBM) has been shown to have positive effects on union rates in many orthopedic subspecialties; however, minimal evidence exists about bone graft substitutes in foot and ankle surgery. The purpose of this study is to compare nonunion rates in arthroscopic ankle arthrodesis in patients receiving DBM with those without. We hypothesized DBM to be associated with a decreased risk of nonunion. This retrospective review includes 516 consecutive ankle arthrodesis cases from March 2002 to May 2016. Of these, 58 ankles (56 patients) that underwent primary arthroscopic ankle arthrodesis met the inclusion criteria, and 31 of these ankles received DBM, while 27 did not. Nonunion was assessed by clinical examination and routine postoperative radiographs. If nonunion was suspected, a computed tomography (CT) scan was performed. The primary outcome measure was nonunion rate. Secondary outcome measures included wound complications, return to operating room (OR), and rate of postoperative deep vein thrombosis (DVT) or pulmonary embolism (PE). From the study cases, 58 were available for final follow-up. The average age was 55.9 years (±17.4), and mean follow-up was 43.0 months (range 6.3–119.4). There was no difference in nonunion rate in patients who received DBM (4/31, 12.9%) versus those who did not (4/27, 14.8%) (p = 0.83). Similarly, when comparing the two groups, there were no statistically significant differences in superficial wound complications (6.5% vs. 3.7%, p = 1.0) or rate of return to OR (29% or 0.037/person-years vs. 37% or 0.099/person-years; p = 0.20). No major complications including deep wound infections, DVTs, or PEs occurred. This is the largest study to directly compare nonunion rates and complications for patients receiving DBM versus those who did not in primary arthroscopic ankle arthrodesis. No significant association was found between DBM usage and risk of nonunion, wound complications, return to OR, or postoperative DVT or PE development.

Ankle osteoarthritis: comprehensive review and treatment algorithm proposal

Ankle osteoarthritis (OA) is much less frequent than knee or hip OA, but it can be equally disabling, greatly affecting the quality of life of the patients.

Approximately 80% of ankle OA is post-traumatic, mainly secondary to malleolar fractures, being another of the main causes untreated in chronic instability. The average age of the patient affected by ankle OA is around 50 years, being therefore active patients and in working age who seek to maintain mobility and remain active.

The authors conducted a comprehensive review of the conservative, medical, and surgical treatment of ankle OA.

Initial conservative treatment is effective and should be attempted in any stage of OA. From a pharmacological point of view, non-steroidal anti-inflammatory drugs (NSAIDs) and intra-articular infiltrations can produce temporary relief of symptoms.

After the failure of conservative-medical treatment, two large groups of surgical treatment have been described: joint-preserving and joint-sacrificing procedures.

In the early stages, only periarticular osteotomies have enough evidence to recommend in ankle OA with malalignment. Both ankle arthrodesis and ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of the disease.

Finally, the authors propose a global treatment algorithm that can aid in the decision-making process.

Preliminary Report of a Hybrid Total Ankle Arthroplasty Combining a Stemmed Intramedullary Tibial Component With Chamfer-Cut Talar Dome

Total ankle arthroplasty (TAA) is a viable treatment for end-stage ankle arthritis. In our experience, a stemmed intramedullary tibial component combined with a chamfer-cut talar component provides the most stable construct for TAA. We present our technique for placement of this hybrid prosthesis utilizing the INBONE tibial component in combination with the INFINITY talar component. This technique differs from the standard protocol by minimizing use of both patient-specific and standard intraoperative guides. The primary aim of this study is to report our preliminary outcomes with our novel technique. Secondarily, we aim to demonstrate that placement of this hybrid prosthesis is radiographically reproducible and accurate. The first 10 patients undergoing this technique with at least 1 year of follow-up were retrospectively reviewed. Average visual analog pain scale decreased from 7.4 preoperatively to 0.5 at 1 year postoperatively. The average time to weightbearing was 6.4 weeks. Complications were minimal, and no implant-related complications were encountered. First weightbearing ankle radiographs postoperatively were evaluated by 3 reviewers to determine accuracy of the tibial intramedullary stem in relation to the anatomical axis of the tibia. We found that the deviation of the tibial implant from the anatomic axis was on average 0.9°± 0.5° in the coronal plane, and 2.2°± 2.7° in the sagittal plane. Inter-rater reliability was 83%. We conclude that this hybrid technique utilizing a stemmed intramedullary tibial component in combination with a chamfer-cut talar component for TAA is reproducible, accurate, and safe.

Effects of Patient-Specific Instrumentation and Ancillary Surgery Performed in Conjunction With Total Ankle Implant Arthroplasty: Postoperative Radiographic Findings

Accuracy and reproducibility when performing total ankle implant arthroplasty (TAA) are essential for longevity of the implant, maintaining relative stability of the joint, and theoretically reducing the formation of adjacent joint arthritis in the subtalar and knee joints. Studies have helped to illustrate the accuracy of implantation when using patient-specific instrumentation in both knee and ankle implant arthroplasty. Despite the findings of these studies, few have gone on to evaluate the effects of ancillary procedures on TAA; particularly their effects on postoperative implant congruity when performed simultaneously with joint replacement surgery. In this study, preoperative plans on implant alignment based on patient-specific computed tomography images were compared with the alignment observed on immediate postoperative radiographs. Additionally, postoperative joint congruity was measured, and operative reports were assessed to determine if concomitant procedures performed with total ankle replacement had a significant effect on overall alignment. In our population, 46/47 implants were within 1.5° of their anticipated placement in the coronal plane, and 100% were within 2° of anticipated placement in the sagittal plane. Using a spearman's rank-order correlation, our data failed to show any significant relationship between conducting additional procedures in conjunction with TAA (rho = 0.178; p value = .232) and postoperative congruency of the implant. These findings help support the accuracy of ankle implantation using patient-specific instrumentation, while also supporting the appropriate use of indicated procedures in conjunction with total ankle replacement to help obtain a congruent joint postoperatively.

Effect of four combined procedures to achieve inframalleolar correction for advanced varus ankle arthritis

A man in his early 60s with Takakura stage IIIB varus ankle arthritis underwent four combined procedures (Dwyer's osteotomy with lateral displacement, superficial/deep deltoid ligament release, anterior talofibular ligament/calcaneofibular ligament reconstruction with suture tape augmentation and posterior tibial tendon lengthening). Decreased talar tilt and talar centre lateral shifting and improved hindfoot varus were observed 2 years postoperatively. Also, excellent clinical outcome could be achieved.

Evaluating the Association between Anesthesia Type and Postoperative Complications for Patients Receiving Total Ankle Arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) is performed for ankle arthritis and there has been interest investigating which anesthetic method is the best choice in order to optimize perioperative outcomes. In this study, we compared postoperative complications after TAA for patients receiving either 1) general anesthesia alone or 2) general anesthesia plus regional anesthesia.

METHODS

Patients undergoing primary TAA from 2007 to 2018 were identified in a national database. Patients were stratified into 2 cohorts: general anesthesia and general anesthesia combined with regional anesthesia. In this analysis, 30-day wound, cardiac, pulmonary, renal, thromboembolic, and sepsis complications, as well mortality, postoperative transfusion, urinary tract infection, extended length of stay, and reoperation were assessed. Bivariate analyses and multivariable logistical regression were performed.

RESULTS

Of 1,084 total patients undergoing TAA, 878 patients (81.0%) had general anesthesia and 206 (19.0%) had general anesthesia combined with regional anesthesia. Following adjustment, there were no increased risk of postoperative complications in the combined general and regional anesthesia group compared to those who only underwent general anesthesia.

CONCLUSION

Compared to general anesthesia alone, the addition of regional anesthesia to general anesthesia for TAA is not associated with increased risk of complications in the perioperative period. Level of Evidence: III.

The Impact of Concomitant Ipsilateral Knee Pain on Functional Outcomes in Total Ankle Arthroplasty

In end-stage ankle arthritis, little is known about the impact of concomitant knee pathology, including the impact of ipsilateral knee pain on total ankle arthroplasty (TAA) outcomes. The aim of this study was to determine the prevalence of ipsilateral preoperative knee pain in patients undergoing TAA and analyze its impact on patient-reported functional outcome measures (PROMs). A retrospective review was performed on the Vancouver End Stage Ankle Arthritis Database at a single institution. In total, 114 patients were studied, with patient demographics collected preoperatively, including the presence or absence of knee pain. Postoperative follow-up was performed at 5 years, primarily analyzing disease-specific PROMs, including the Ankle Osteoarthritis Score (AOS) and Ankle Arthritis Score (AAS). Multivariate mixed-effects linear regression models compared the scores between the groups. In total, 31 patients (27.2%) presented with concomitant ipsilateral knee pain. Despite more females in the knee pain group (64.5% vs 36.1%) there were no other significant differences at baseline between the knee pain and no knee pain groups in terms of demographics or baseline primary disease specific PROMs. At 5 years, the patients with knee pain had significantly worse AAS (37.9 ± 23.8 vs 21.2 ± 16.3, P = .004) and AOS total scores (38.1 ± 24.1 vs 21.9 ± 15.5, P = .005) compared with the no-knee pain group. Both groups improved significantly from baseline across all outcome measures; however, the magnitude of improvement was less in the knee pain group. Our study demonstrated that over one-quarter of patients with end-stage ankle arthritis undergoing TAA present with ipsilateral concomitant knee pain. If present, it is associated with worse functional outcomes at the 5-year mark. Further studies are needed to evaluate if knee pain influences complications, implant failure rates, and survival.Levels of Evidence: Level III.

Total Ankle Arthroplasty Survivorship, Complication, and Revision Rates in Patients Younger Than 55 Years

Total ankle replacement has become a viable alternative to ankle arthrodesis in the surgical management of advanced ankle arthritis. Total ankle replacement has generally been reserved for patients who are older and for those who will have a lower demand on the replacement. The purpose of the current study is to review patient outcomes, complications, and implant survival in patients younger than 55 years who underwent total ankle replacement at a single institution. A single-center chart and radiographic review was performed of consecutive patients who underwent total ankle replacement for treatment of end-stage ankle arthritis. All surgeries were performed by 1 of 5 fellowship-trained foot and ankle surgeons at a single institution. A total of 51 patients met inclusion criteria with a mean follow-up of 31.2 months (SD = 16.2). Implant survival was 94%, There were 7 major complications (13%) requiring an unplanned return to the operating room and 8 minor complications (15%) that resolved with conservative care. The results of this study show that total ankle replacement is a viable treatment option for patients younger than 55 years.Levels of Evidence: A retrospective case series.

Nationwide Analysis of Total Ankle Replacement and Ankle Arthrodesis in Medicare Patients: Trends, Complications, and Cost

BACKGROUND

Surgical management of end-stage ankle arthritis consists of either ankle arthrodesis (AA) or total ankle replacement (TAR). The purpose of this study was to evaluate utilization trends in TAR and AA and compare cost and complications.

METHODS

Medicare patients with the diagnosis of ankle arthritis were reviewed. Patients undergoing surgical intervention were split into AA and TAR groups, which were evaluated for trends as well as postoperative complications, revision rates, and procedure cost.

RESULTS

A total of 673 789 patients were identified with ankle arthritis. A total of 19 120 patients underwent AA and 9059 underwent TAR. While rates of AA remained relatively constant, even decreasing, with 2080 performed in 2005 and 1823 performed in 2014, TAR rates nearly quadrupled. Average cost associated with TAR was $12559.12 compared with $6962.99 for AA (P < .001). Overall complication rates were 24.9% in the AA group with a 16.5% revision rate compared with 15.1% and 11.0%, respectively, in the TAR group (P < .001). Patients younger than 65 years had both higher complication and revision rates.

DISCUSSION

TAR has become an increasingly popular option for the management of end-stage ankle arthritis. In our study, TAR demonstrated both lower revision and complication rates than AA. However, TAR represents a more expensive treatment option.

LEVELS OF EVIDENCE

Level III: Retrospective comparative study.

High Pain Catastrophizing Scale Predicts Lower Patient-Reported Outcome Measures in the Foot and Ankle Patient

BACKGROUND

Postoperative outcomes may be affected by the patient's preoperative morbidity. It is hypothesized that patient's pain catastrophization prior to foot and ankle surgery may affect their patient-reported outcomes. Methods: This study prospectively assessed a consecutive cohort of 46 patients undergoing foot and ankle reconstruction to describe the relationship between Pain Catastrophizing Scale (PCS) and patient-reported outcomes measured by 12-item Short Form Health Survey and Foot and Ankle Outcome Score (FAOS).

RESULTS

The 1-year postoperative FAOS pain, activities of daily living, and quality of life scores correlated significantly with all baseline PCS subcategories. We found that the mental domain of the SF-12 had a statistically significant correlation with the rumination and helplessness PCS subcategories.

CONCLUSION

This study showed a significant association between a high preoperative PCS and a worse 1-year FAOS. As such, catastrophization could be screened for and potentially treated preoperatively to improve patient-reported outcomes in elective foot and ankle surgery.

LEVEL OF EVIDENCE

Therapeutic, Level III Evidence.

Long-Term Survival of HINTEGRA Total Ankle Replacement in 683 Patients: A Concise 20-Year Follow-up of a Previous Report

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparisons between ankle distraction arthroplasty and supramalleolar osteotomy for treatment of post-traumatic varus ankle osteoarthritis

BACKGROUND

Ankle distraction arthroplasty and supramalleolar osteotomy were both options for post-traumatic varus ankle arthritis (VAA), but their comparative effectiveness was scarcely reported. This study aimed to compare the outcomes of two operative methods for treatment of Takakura-Tanaka stage 3 post-traumatic VAA.

METHODS

This was a retrospective study, comprising 73 consecutive patients who presented with Takakura-Tanaka stage 3 post-traumatic VAA treated by either ankle distraction arthroplasty (n = 32) or supramalleolar osteotomy (n = 41) from January 2016 to December 2019. All patients had a minimum 24-month follow-up assessments. The outcome measures were visual analog scale (VAS), the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores, complications, patient-rated overall satisfaction and ankle function.

RESULTS

At an average of 32 months (range, 24-52 months) follow-up, significant improvement was observed for VAS, AOFAS, range of motion (ROM) and most radiographic parameters (except for TAS and TLS for ankle distraction arthroplasty group) compared to preoperative baselines (p < 0.05) for both groups. However, both groups did not differ significantly in terms of VAS or AOFAS, excellent and good rate (78.1% versus 85.4%, p = 0.422), overall rate of postoperative complications (28.1% vs. 17.1%, p = 0.257), or various radiographic parameters (e.g. tibial anterior surface angle, talar tilt angle and tibial lateral surface angle) (all p > 0.05). The ankle distraction arthroplasty group had a better postoperative ankle motion than did the supramalleolar osteotomy group, in terms of plantarflexion (37.8 ± 4.2 vs. 30.4 ± 3.6, p = 0.006), dorsiflexion (36.5 ± 6.4 vs. 28.3 ± 5.5, p = 0.004), varus (32.1 ± 4.5 vs. 27.1 ± 3.1, p = 0.017) and valgus (28.4 ± 3.7 vs. 25.2 ± 2.8, p = 0.046).

CONCLUSIONS

Both operative treatments are effective for Takakura-Tanaka stage 3 post-traumatic VAA. In practice, individualized treatment option tailored to the ankle condition and patients' specific need should be considered.

LEVEL OF EVIDENCE

 III, retrospective comparative series.

Risk Stratification for Revision Surgery Following Total Ankle Replacement

As a result of improved implants total ankle replacement (TAR) is becoming a more reliable option for end stage ankle arthritis. As with any surgery there are numerous complications that can occur intraoperatively and postoperatively with TAR. The primary aim of this study is to use recent data on implants currently on the market to develop a well-defined and comprehensive complication classification system which stratifies risk of subsequent surgery for TAR. A systematic review of studies on TARs from 2013 to 2018 was performed. Inclusion criteria were studies published between 2013 and August 2018, studies having at least 20 patients, data with at least 1-year follow-up and use of implants currently on the market. Studies were excluded if they involved revision cases, case reports, basic science articles and studies published in non-peer-reviewed journals. Sixteen studies fit inclusion criteria involving 3,305 implants. Overall survival of all implants was found to be 93% with a pooled complication rate of 75.6% using criteria for classifying complications by Glazebrook et al. Previously published classification systems did not clearly define complication categories leading to inconsistency in complication reporting and inaccurate complication rates. There are also several complications that are unclassifiable with the classifications developed by Gadd et al and Glazebrook et al. Our proposed updated classification system provides more inclusive tier profiles to capture the complications that can occur with implants currently on the market. Furthermore, this system provides a stratification of risk that these complications pose to ultimate procedure success.

Pain catastrophising, body mass index and depressive symptoms are associated with pain severity in tertiary referral orthopaedic foot/ankle patients

Introduction

Patients with chronic foot/ankle pain are often referred for orthopaedic assessment. Psychological vulnerabilities influence pain states (including foot and ankle), therefore this study aimed to establish the prevalence and relative importance of compromised psychological health to perceived foot/ankle pain severity in people referred to an orthopaedic foot and ankle clinic with non-urgent presentations.

Methods

Patients with triaged non-urgent foot/ankle referrals to the Department of Orthopaedics at Gold Coast University Hospital were recruited over a 12-month period and completed the Manchester-Oxford Foot and Ankle Questionnaire which was the primary measure. Participants also completed questionnaires assessing their anthropometric, demographic and health characteristics (Self-Administered Comorbidity Questionnaire) as well as measures of health-related quality of life (EuroQol-5-Dimensions-5-Level Questionnaire and EQ Visual Analogue Scale) and psychological health (Center for Epidemiological Studies-Depression scale, Pain Catastrophizing Scale and Central Sensitization Inventory). Descriptive statistics were used to summarise participant characteristics and a hierarchical multiple linear regression was employed to establish the extent to which psychological variables explain additional variance in foot/ankle pain severity beyond the effects of participant characteristics (age, sex, body mass index (BMI)).

Results

One hundred and seventy-two adults were recruited ((64.0% female), median (IQR) age 60.9 (17.7) years and BMI 27.6 (7.5) kg/m²). Specific psychological comorbidities were prevalent including depressive symptoms (48%), central sensitisation (38%) and pain catastrophising (24%). Age, sex and BMI accounted for 11.7% of the variance in MOXFQ-index and psychological variables accounted for an additional 28.2%. Pain catastrophising was the most significant independent predictor of foot/ankle pain severity (accounting for 14.4% of variance), followed by BMI (10.7%) and depressive symptoms (2.3%).

Conclusions

This study demonstrated that specific psychological comorbidities and increased BMI are common in this cohort and that these factors are associated with the symptoms for which patients are seeking orthopaedic assessment. This knowledge should prompt clinicians to routinely consider the psychosocial components of patient presentations and develop non-operative and pre-operative treatment strategies which consider these factors with the goal of improving overall patient outcomes.

Midterm Survivorship of the INBONE II Total Ankle Arthroplasty

BACKGROUND

The use of total ankle arthroplasty (TAA) in the treatment of ankle arthritis has grown substantially as advancements are made in design and surgical technique. Among the criteria guiding the choice between arthroplasty and arthrodesis, the long-term survival and postoperative outcomes are of crucial importance. Although outcomes of the INBONE I have been published, there is limited midterm survival data for the INBONE II. The purpose of this study was to determine the radiographic and patient-reported outcomes, and survivorship of this prosthesis in patients with a minimum 5-year follow-up.

METHODS

We retrospectively identified 51 ankles (46 patients) from 2010 to 2015 who underwent TAA with the INBONE II prosthesis at our institution. Of these, 44 cases had minimum clinical follow-up of 5 years (mean, 6.4; range 5-9). Median age was 66 years (range 42-81) and median BMI was 27.5 (range 20.1-33.0). A chart review was performed to record the incidence of revision and reoperation. Preoperative and postoperative radiographs were analyzed to assess the coronal tibiotalar alignment (TTA), the talar inclination angle, and the presence of periprosthetic lucencies and cyst formation. Preoperative and minimum 5-year postoperative Foot and Ankle Outcome Score (FAOS) subscales were compared. Survivorship was determined by incidence of revision, defined as removal of a metallic component.

RESULTS

The survivorship at 5 years was 98% and the rate of reoperation was 7.8% (n = 4); 2 patients underwent irrigation and debridement for infection, 1 patient underwent a medializing calcaneal osteotomy, and 1 patient underwent open gutter debridement, 1 patient underwent a revision of a subsided talar component at 3.2 years after index surgery. Average postoperative TTA was 88.6 degrees, with 42 rated as neutral (85-95 degrees), 2 varus (<85 degrees), and no valgus (>95 degrees) ankles. At final follow-up, asymptomatic periprosthetic cysts were observed in 8 patients. All FAOS domain scores improved between preoperative and final follow-up.

CONCLUSION

At midterm follow-up, we observed significant improvement in radiographic alignment and patient-reported outcome scores for the INBONE II total ankle prosthesis. In addition, this cohort has had a relatively low reoperation rate and high survivorship.

LEVEL OF EVIDENCE

Level IV, case series.

CT Scan Assessment and Functional Outcome of Periprosthetic Bone Grafting After Total Ankle Arthroplasty at Medium-term Follow-up

BACKGROUND

Periprosthetic cysts can occur in up to 95% of total ankle arthroplasties (TAA) and have been correlated with implant failure. The aim of this study was to determine the clinical and radiologic outcomes, using computed tomographic (CT) scan, after periprosthetic cyst bone grafting and assess for the minimum cyst size that should be grafted.

METHODS

A retrospective review was performed of all TAA procedures performed between 2007 and 2014 (n=93). A CT scan was done to assess cyst size and operative planning. Eight patients with 9 periprosthetic cysts larger than 1.75 cm³ were grafted and specimens sent for histology. The mean time to bone grafting was 7.3 (3.8-9.5) years. Functional outcome was assessed using the American Orthopaedic Foot & Ankle Society ankle score, visual analog scale, and Self-reported Foot and Ankle Score. A CT scan was performed at follow-up to assess graft incorporation and cyst size progression. The mean time to CT scan post grafting was 3.0 (0.7-4.7) years.

RESULTS

There was no implant malalignment identified and no differences in the pre- and postoperative functional scores. Preoperatively cysts had a mean volume of 8.16 (2.04-14.03) cm³. The mean percentage incorporation was 89% (69%-100%). Eight of the grafted cysts were considered successful on CT, with the ninth having 69% incorporation. Five cysts were not grafted, as they were below 1.75 cm³, and remained the same size or had minimal enlargement.

CONCLUSION

The satisfactory results in this small cohort suggests that prophylactic bone grafting may extend implant survival. We recommend that periprosthetic cysts greater than 1.75 cm³ be prophylactically bone grafted, and that cysts smaller than 1.75 cm³ be monitored for progression in size.

LEVEL OF EVIDENCE

Level IV, Case Series.

Accuracy and quality of the British Orthopaedic Foot and Ankle Society (BOFAS) Registry - Ankle Arthrodesis Pathway

BACKGROUND

This study investigated the completeness, accuracy, quality and clinical outcomes of the British Orthopaedic Foot and Ankle Society (BOFAS) registry - Ankle Arthrodesis pathway.

METHODS

An observational study using retrospective data derived from the BOFAS registry. Adults aged ≥18 years with a record of undergoing ankle arthrodesis in the UK from 2014 to 31/10/2019 were included. Accuracy of data capture and completeness were explored using means, SD, medians and IQR for continuous variables and frequencies for categorical variables. The pre and post treatment pathway was evaluated by analysing Patient Reported Outcome Measures (PROMs) including MOXF-FQ scores for pain/walking/standing/social interaction; NRS pain; EQ-5D-5L; and EQ-5D-5L-Health VAS at baseline, 6 months, and 12 months.

RESULTS

Mean age of the study population (n = 186) was 62.3 (±12.9) years and 65% of the study cohort were male. Completeness of data collection was disappointing but variables such as BMI (62.4%) smoking status (82.3%) were reasonably well recorded. PROMs scores were well recorded at baseline but rapidly declined at 6 and 12-months intervals. Reductions in MOXFQ and NRS pain scores by 12 months following surgery were statistically significant (p = 0.001 and p = 0.008), illustrating that most patients demonstrated reductions in pain intensity, improved walking/standing ability, and social interaction.

CONCLUSION

These findings illustrate the potential effectiveness of surgery on all outcomes following ankle arthrodesis that merits evaluation in a clinical trial; but also demonstrated the difficulties in obtaining representative data sets. The analyses strongly suggest that with the improvements in data quality greater resources would bring, the BOFAS registry would become a valuable tool.