Analysis of risk factors for failure of arthroscopic ankle fusion in a series of 52 ankles

Tibiotalocalcaneal ankle arthrodesis with posterior approach arthroscopic-assisted hindfoot nailing

PURPOSE

End-stage ankle arthrosis causes severe pain and limited movement. Tibiotalocalcaneal arthrodesis with arthroscopy-assisted hindfoot nailing can be used to achieve a high union rate and low complication rate. We aimed to examine the early- and mid-term results of patients treated with this technique from various perspectives and to evaluate them by comparing them with the current literature.

METHODS

Data were collected from 25 patients who met the established criteria and underwent TTCA with arthroscopic-assisted hindfoot nailing. In addition to the demographic data of the patients, their clinical and pain scores were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS). Additionally, the union time and complication data during the follow-up period were examined.

RESULTS

When the AOFAS and VAS scores of the 25 patients were examined, a significant improvement was observed in the preoperative period and early postoperative period comparisons (p < .001). No significant change was observed between the comparison of the postoperative 12th month and last postoperative control clinical scores. While the union rate of the patients was observed to be 92%, the average union time was 13.1 ± 3.5 weeks. During follow-up, peri-implant fracture, deep infection, and non-union were observed in one patient each (12%).

CONCLUSION

The early- and mid-term postoperative results of patients treated with TTCA surgery with posterior approach arthroscopic-assisted hindfoot nailing show that this technique may be an option with low complication and high union rates for the appropriate group of patients planned for ankle arthrodesis.

A predictive algorithm for perioperative complications and readmission after ankle arthrodesis

PURPOSE

Ankle arthrodesis is a mainstay of surgical management for ankle arthritis. Accurately risk-stratifying patients who undergo ankle arthrodesis would be of great utility. There is a paucity of accurate prediction models that can be used to pre-operatively risk-stratify patients for ankle arthrodesis. We aim to develop a predictive model for major perioperative complication or readmission after ankle arthrodesis.

METHODS

This is a retrospective cohort study of adult patients who underwent ankle arthrodesis at any non-federal California hospital between 2015 and 2017. The primary outcome is readmission within 30 days or major perioperative complication. We build logistic regression and ML models spanning different classes of modeling approaches, assessing discrimination and calibration. We also rank the contribution of the included variables to model performance for prediction of adverse outcomes.

RESULTS

A total of 1084 patients met inclusion criteria for this study. There were 131 patients with major complication or readmission (12.1%). The XGBoost algorithm demonstrates the highest discrimination with an area under the receiver operating characteristic curve of 0.707 and is well-calibrated. The features most important for prediction of adverse outcomes for the XGBoost model include: diabetes, peripheral vascular disease, teaching hospital status, morbid obesity, history of musculoskeletal infection, history of hip fracture, renal failure, implant complication, history of major fracture.

CONCLUSION

We report a well-calibrated algorithm for prediction of major perioperative complications and 30-day readmission after ankle arthrodesis. This tool may help accurately risk-stratify patients and decrease likelihood of major complications.

Characteristics of Nonunion After Arthroscopic Ankle Arthrodesis: A Multicenter Retrospective Cohort Study

Nonunion is a major complication of arthroscopic ankle arthrodesis. However, the characteristics and risk factors of nonunion are not well understood. This retrospective multicenter observational study aimed to clarify the characteristics of nonunion after arthroscopic ankle arthrodesis. We included 154 patients who underwent arthroscopic ankle arthrodesis at any 1 of 5 institutions. Patients were divided into 2 groups: union and nonunion, and the groups were compared. Age, sex, body mass index, diabetes, smoking, corticosteroid use, diagnosis, treatment information, treatment protocol, radiographic evaluation, and patient-reported outcomes were recorded and analyzed. On radiographs, bony union was observed in 142 ankles (91.0%) but not in 12 ankles (9.0%). Postoperative radiographic tibial bony gap (mm) was significantly larger in the nonunion group (medial = 1.98, center = 1.65, anterior = 2.21, middle = 1.72, posterior = 3.01) than in the union group (medial = 1.35, center = 1.13, anterior = 1.28, middle = 1.03, posterior = 2.03). Furthermore, the visual analog score (VAS) of pain and pain-related self-administered foot evaluation questionnaire (SAFE-Q) subscale score significantly worsened in the nonunion group (VAS = 3.83, SAFE-Q subscale score = 69.8) compared to that in the union group (VAS = 1.35, SAFE-Q subscale score = 76.6). A larger radiographic tibiotalar bony gap was observed in the nonunion group. Other measurement outcomes were not associated with nonunion. Additionally, patient-reported outcomes markedly worsened in the nonunion group.

Association of Preexisting Triple Fusion and Arthroscopic Ankle Arthrodesis nonunion

BACKGROUND

Arthroscopic ankle arthrodesis (AAA) is a successful treatment for end-stage ankle arthritis. A significant early complication of AAA is symptomatic nonunion. Published nonunion rates range from 8% to 13%. Longer term, there is concern that it predisposes to subtalar joint (STJ) fusion. To better understand these risks, we undertook a retrospective investigation of primary AAA.

METHODS

All adult AAA cases conducted at our institution over a 10-year period were reviewed. A total of 284 eligible AAA cases in 271 patients were analyzed. The primary outcome measure was radiographic union. Secondary outcome measures included reoperative rate, postoperative complications and subsequent STJ fusion. Univariate and multivariate logistic regression analysis was performed to identify nonunion risk factors.

RESULTS

The overall nonunion rate was 7.7%. Smoking (odds ratio [OR] 4.76 [1.67, 13.6], P = .004) and previous triple fusion (OR 40.29 [9.46, 171.62], P < .001) were independent risk factors on univariate analysis. Only prior triple fusion persisted as a major risk factor associated with nonunion on multivariate analysis (OR 18.3 [3.4, 99.7], P < .001). Seventy percent of patients with a previous triple fusion went on to develop nonunion compared to 5.5% of those without. Increasing age, obesity, surgical grade, diabetes, postoperative weightbearing plan, steroid use, and inflammatory arthropathy were not significant risk factors. The leading cause of reoperation was hardware removal (18%). There were 5 superficial (1.8%) and 4 deep (1.4%) infections. Eleven (4.2%) required subsequent STJ fusion. The "survivorship" of STJ post AAA was 98%, 85%, and 74% at 2, 5, and 9 years, respectively.

CONCLUSION

As the largest study of AAA in the literature, our findings suggest prior triple fusion is a major independent risk factor for AAA nonunion. These patients should be counseled of this high risk and may benefit from alternative surgical options.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Arthroscopic Ankle Arthrodesis

Despite the increasing popularity of total ankle replacement, ankle arthrodesis remains the gold standard for the treatment of end-stage ankle arthritis. Historically, open techniques have been utilized for ankle arthrodesis. There have been many variations and techniques described, including transfibular, anterior, medial, and miniarthrotomy. Inherent disadvantages to these open techniques include postoperative pain, delayed or nonunion, wound complications, shortening, prolonged healing times, and prolonged hospital stays. Arthroscopic ankle arthrodesis provides the foot and ankle surgeon with an alternative to the traditional open techniques. Arthroscopic ankle arthrodesis has demonstrated faster union rates, decreased complications, reduced postoperative pain, and shorter hospital stays.

Is Ankle Arthrodesis With an Ilizarov External Fixator an Effective Treatment for Septic Ankle Arthritis? A Study With a Minimum of 6 Years of Follow-up

BACKGROUND

Septic ankle arthritis is a devastating clinical problem with a high potential for permanent disability and amputation. Successful treatment of septic ankle arthritis remains a challenge for the surgeon and patient. Ankle arthrodesis combined with radical debridement may be an effective option to eradicate infection and salvage the limb. Although numerous fusion methods have been proposed, there is controversy about the most effective technique.

QUESTIONS/PURPOSES

At a minimum follow-up of 6 years after ankle arthrodesis performed using an Ilizarov external fixator, we asked, (1) In what proportion of patients was bony fusion achieved? (2) What complications were observed, and what reoperations were performed in these patients? (3) How much did patient-reported outcomes improve from before surgery to the most recent follow-up in this group?

METHODS

Between April 2010 to March 2015, we treated 59 patients for septic ankle arthritis. Of those, we considered patients who were at least 18 years of age with irreversible destruction of the joint as potentially eligible. During that time period, all patients met the prespecified criteria and were treated with ankle arthrodesis using an Ilizarov external fixator. Two percent (one of 59) of patients were excluded because they died in the second year after surgery for reasons unrelated to the procedure, and another 7% (four of 59) of patients were excluded because they were lost before the minimum study follow-up interval of 6 years. Finally, 92% (54 of 59) of patients were analyzed at a mean follow-up time of 9 ± 1 years. A total of 61% (33 of 54) were men, and they had a mean age of 48 ± 12 years. Forty-six percent (25 of 54) of patients were smokers, and 13% (seven of 54) of patients had Type 2 diabetes mellitus. All patients received radical debridement and primary arthrodesis with an Ilizarov external fixator, followed by antibiotic therapy. Postoperatively, patients were instructed to perform lower extremity functional exercises and external fixator care; weightbearing ambulation as tolerated was encouraged as early as possible. Fusion was assessed with a radiographic review that was performed by an individual who was not involved in the surgical care of these patients. We defined bony fusion as continuous trabeculae and complete cortical bridging in the fusion interface achieved before 9 months; delayed union was defined as fusion achieved by 9 to 12 months; and nonunion was defined as patients in whom fusion was not achieved by 12 months. Complications and reoperations were tallied through a record review that was performed by an individual who was not involved in the surgical care of these patients. We defined complications as any deviation from the expected postoperative course. We used the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the VAS active pain score, and the SF-12 questionnaire (including the physical component summary [PCS] score and mental component summary [MCS] score) to assess patient-reported outcomes. The minimum clinically important difference (MCID) for the AOFAS score was 30 points of 100, the MCID for the VAS active pain score was 2 points of 10, and the MCID of PCS and MCS scores was 7 points and 9 points, respectively.

RESULTS

Primary bony fusion was achieved in 94% (51 of 54) of patients. Delayed union was found in 2% (one of 54) of patients. Nonunion was found in 6% (three of 54); one of these patients underwent autologous bone grafting during revision, and bony fusion was ultimately achieved. Final bony fusion was achieved in 96% (52 of 54) of patients. Recurrent infection was found in 2% (one of 54). The median (range) AOFAS score improved from 28 points (8 to 59) before surgery to 80 points (52 to 86) at the most recent follow-up (median difference 52; p < 0.001). The median (range) VAS active pain score decreased from 8 points (6 to 9) before surgery to 2 points (0 to 5) at the most recent follow-up (median difference -6; p < 0.001). For the Short Form 12-item score, the median (range) PCS score improved from 0 points (0 to 30) before surgery to 70 points (40 to 95) at the most recent follow-up (median difference 70; p < 0.001), and the median (range) MCS score improved from 46 points (21 to 75) before surgery to 75 points (50 to 92) at the most recent follow-up (median difference 29; p < 0.001).

CONCLUSION

Ankle arthrodesis with Ilizarov external fixation might eradicate an infection and restore foot function in patients with septic ankle arthritis. However, patients should be fully informed of the complications related to the external fixator, such as pin-tract infections, recurrent infection, and nonunion. Standardized and professional pin care is important. Additionally, because Ilizarov external fixators can be inconvenient to the patients' daily lives, future studies should explore how psychologic support affects patients who undergo ankle arthrodesis with these devices.

LEVEL OF EVIDENCE

Level IV, therapeutic 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.

Risk Factors for Nonunion Following Ankle Arthrodesis: A Systematic Review and Meta-analysis

BACKGROUND

Nonunion is a postoperative complication after ankle arthrodesis (AA), which leads to increased morbidity and revision rates. Previous studies have identified risk factors for nonunion following AA, but no meta-analysis has been performed to stratify risk factors based on strength of evidence.

METHODS

Abstracts and full-text articles were screened by 2 independent reviewers. Relevant data were extracted from the included studies. Random effects meta-analyses were summarized as forest plots of individual study and pooled random effect results.

RESULTS

Database search yielded 13 studies involving 987 patients were included, and 37 potential risk factors for nonunion. Meta-analysis found 5 significant risk factors for nonunion post-AA. Strong evidence supports male gender (OR: 1.96; 95% CI: 1.13-3.41), smoking (OR: 2.89; 95% CI: 1.23-6.76), and history of operative site infection prior to arthrodesis (OR: 2.40; 95% CI: 1.13-5.09) as predictors for nonunion following AA. There was moderate evidence supporting history of open injury (OR: 5.95; 95% CI: 2.31-15.38) and limited evidence for preoperative avascular necrosis (OR: 13.16; 95% CI: 2.17-79.61) as possible risk factors for nonunion.

CONCLUSION

The results of our meta-analysis suggest that male gender, smoking, and history of operative site infection have strong evidence and that history of open injury and avascular necrosis also have evidence as risk factors for nonunion. Surgeons should be cognizant of these risks when performing AA and closely follow up with patients with the aforementioned risk factors to ensure postoperative success.

LEVELS OF EVIDENCE

Level V: Systematic review of cohort and case-control studies.

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

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

Do degree of coronal plane deformity and patient related factors affect union and outcome of Arthroscopic versus Open Ankle Arthrodesis?

BACKGROUND

This study aimed to analyse if union and outcome of Arthroscopic Ankle Arthrodesis (AAA) versus Open Ankle Arthrodesis (OAA) were influenced by the extent of coronal plane deformity and to report if patient related factors influence union.

METHODS

A total of 122 ankle arthrodesis procedures were included in the study. These were divided into two groups; Group A (n = 99) with deformity less than 15° and Group B (n = 23) with deformity greater than or equal to 15°. Data was collected on patient demographics, medical comorbidities (smoking, diabetes, obesity) and time to union. Patient reported outcome measures (PROMs) evaluated were Manchester Oxford Foot Questionnaire, EuroQol-5D and EuroQol visual analogue health thermometer (EQ-VAS).

RESULTS

The mean follow-up in Group A and B was 74.87 and 89.17 months respectively. The average deformity in Group A was 4.9° for AAA and 5.8° for OAA. In Group B it was 18.9° (maximum 28° varus) for AAA and 22.1° (maximum 41° valgus) for OAA. The overall union rate was 95% in Group A (AAA-94%; OAA-100%; [p = 0.20]) and 87% in Group B (AAA-100%; OAA-67%; [p = 0.02]). Mean time to union was 13.2 weeks in Group A (AAA-13.3 weeks; OAA-12.8 weeks; [p = 0.73]) compared to 12.4 weeks for Group B (AAA-12.9 weeks; OAA-11.8 weeks; [p = 0.56]). Irrespective of the extent of deformity and type of surgery, smokers had a 10 times higher likelihood of non-union (p = 0.03). In Group A, none of the PROMs showed significant difference between AAA and OAA. In Group B, EQ-VAS score reached statistical significance (p = 0.03) in favour of AAA whereas other PROMs showed no difference.

CONCLUSION

AAA is reproducible in achieving union in end stage ankle arthritis and good PROMs can be expected even in ankles with larger deformities. Regardless of the type of surgery and extent of deformity, smoking is a significant risk factor for non-union.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Arthroscopic Ankle Arthrodesis

End-stage ankle arthritis typically affects an active younger patient population as compared with hip and knee arthritis. The optimal surgical treatment depends on several patient-specific factors. Open ankle arthrodesis has achieved reliable outcomes for this condition over years; however, arthroscopic techniques seem to be advantageous and feasible even in cases with significant intraarticular deformity. This article describes the surgical technique of arthroscopic ankle arthrodesis and discusses the outcome compared with that of open ankle fusion and total ankle replacement.

Sex Differences in End-Stage Ankle Arthritis and Following Total Ankle Replacement or Ankle Arthrodesis

BACKGROUND

We investigated the influence of sex on patient-reported outcomes preoperatively and following total ankle replacement and ankle arthrodesis.

METHODS

Patients who had undergone total ankle replacement or ankle arthrodesis for the treatment of end-stage ankle arthritis and who had ≥2 years of follow-up were identified from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database. Standard surgical techniques and implantation methods were followed, and STAR, Hintegra, Mobility, and Agility prostheses were used. Data were collected on patient demographics, revisions, secondary procedures, complications, Ankle Osteoarthritis Scale (AOS) scores, Short Form-36 (SF-36) scores, and expectations and satisfaction. Statistical analyses included 3-way repeated-measures analysis of variance (ANOVA) and multiple linear regression models controlling for inflammatory arthritis, age, preoperative scores, and surgery type.

RESULTS

The study included 872 patients: 629 who had undergone total ankle replacement (316 men, 313 women) and 243 who had undergone ankle arthrodesis (154 men, 89 women). The mean duration of follow-up (and standard deviation) was 4.9 ± 2.4 and 4.0 ± 1.9 years for the total ankle replacement and ankle arthrodesis groups, respectively. Men were older than women (p ≤ 0.001). In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS pain scores (i.e., more pain) than men preoperatively (p < 0.05). Pain was reduced significantly in both sexes postoperatively (p < 0.05), with no significant difference between sexes. In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS disability scores (i.e., more disability) and lower SF-36 Physical Component Summary (PCS) scores (i.e., worse function) than men both preoperatively and postoperatively (p < 0.001). Postoperatively, AOS disability and SF-36 PCS scores improved significantly from baseline in both sexes (p < 0.001). After controlling for covariates, sex was not a significant predictor of postoperative SF-36 MCS (Mental Component Summary), AOS pain, or AOS disability scores (p > 0.05) but explained 0.5% of variance in SF-36 PCS scores (p = 0.03). Sex did not significantly influence preoperative expectations or postoperative satisfaction. When patients with inflammatory arthritis were excluded, preoperative and postoperative outcome measures, expectations, and satisfaction were similar.

CONCLUSIONS

Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. Small differences in pain and function between men and women undergoing total ankle replacement and ankle arthrodesis mostly disappeared when controlling for potential confounding variables. Both total ankle replacement and ankle arthrodesis remain good options for men and women with end-stage ankle arthritis.

LEVEL OF EVIDENCE

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

Modern total ankle arthroplasty versus ankle arthrodesis: A systematic review and meta-analysis

The controversy in surgical management of end-stage tibiotalar arthritis with Total Ankle Arthroplasty (TAA) versus Ankle Arthrodesis (AA) has grown in parallel with the evolution of both procedures. No randomized controlled trials exist due to the vast differences in surgical goals, patient expectations, and complication profiles between the two procedures. This makes high quality systematic reviews necessary to compare outcomes between these two treatment options. The aim of this study was to provide a systematic review with meta-analysis of publications reporting outcomes, complications, and revision data following third-generation TAA and/or modern AA published in the past decade. Thirtyfive articles met eligibility criteria, which included 4312 TAA and 1091 AA procedures. This review reports data from a mean follow-up of 4.9 years in the TAA cohort and 4.0 years in the AA cohort. There was no significant difference in overall complication rate following TAA compared to AA (23.6% and 25.7% respectively, P-value 0.31). Similarly, there was no significant difference in revision rate following TAA compared to AA (7.2% and 6.3% respectively, P-value 0.65). Successful treatment of end-stage tibiotalar arthritis requires an understanding of a patients’ goals and expectations, coupled with appropriate patient selection for the chosen procedure. The decision to proceed with TAA or AA should be made on a case-by-case basis following an informed discussion with the patient regarding the different goals and complication profiles for each procedure.

Arthroscopic Ankle Arthrodesis Provides Similarly Satisfactory Surgical Outcomes in Ankles With Severe Deformity Compared With Mild Deformity in Elderly Patients

PURPOSE

To evaluate the surgical outcome in terms of radiographic measurements, functional outcomes, and complications following arthroscopic ankle arthrodesis (AAA) in patients 60 years of age or older, and to compare the results of patients with mildly deformed ankle with those of patients with severely deformed ankle.

METHODS

We retrospectively reviewed patients who underwent AAA with 3 cannulated screws between January 2008 and December 2017 and followed postoperatively for at least 24 months. All included patients were 60 years of age or older. Demographic data and radiographic and functional outcomes were compared between patients with coronal deformity of less than 15° (group I) and those with a deformity equal to or greater than 15 degrees (group II).

RESULTS

A total of 41 patients with a mean age of 70.6 years were included (group I, n = 26; group II, n = 15) and mean follow-up was 51.4 months. Group II had significantly more severe preoperative coronal deformity of tibiotalar angle than group I (20.1 ± 2.9 vs 6.6 ± 4.1°, P < .01). Near-normal tibiotalar alignment was achieved postoperatively in both groups (group I, 3.4 ± 3.3 vs group II, 4.7 ± 3.1°, P = .227). Union was achieved in 39 (95.1%) patients with 2 cases in group I experiencing non-union. Union rate, mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and visual analog scale pain scores were not significantly different between the 2 groups at final follow-up.

CONCLUSIONS

AAA is a reliable procedure for end-stage ankle arthritis in patients 60 years of age or older resulting in a high union rate, encouraging radiographic and functional outcomes, and a low complication rate, even in cases with severe preoperative deformity. In addition, arthroscopic intra-articular malleolar osteotomy was a useful technique for correcting severe coronal deformity in our series.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Agonizing and Expensive: A Review of Institutional Costs of Ankle Fusion Nonunions

Nonunion after ankle arthrodesis requiring revision is a challenging operative complication, and bone graft substitutes are costly. This study sought to summarize all institutional expenditures related to the revision of an ankle fusion nonunion, presuming that cost and skin-to-skin time would exceed those of the index surgery. The electronic records from 2 foot and ankle centers were reviewed, leading to a list of patients with 2 or more entries for tibiotalar fusions being generated. A total of 24 cases were found to match the criteria. Demographic factors and skin-to-skin time of the remaining patients were compiled. This cohort included 24 patients (6 female and 18 male) with a mean age of 64 years and body mass index of 30.4 kg/m². Supplemental clinic visits and investigations were included either after computed tomography to assess union or 365 days after index surgery. Total cost of the revision was calculated from billing codes, length of operation, and period of hospitalization. Postrevision outpatient fees were included as well. The revisions were performed open in all cases, and 21 patients received autograft and/or bone substitute. Mean postoperative hospitalization was 3 days. The additional costs (in US dollars) associated with nonunion were $1061 for imaging, $627 for prerevision visits, $3026 for the revision, $3432 for the hospital stay, and $1754 for postrevision follow-up. The total mean amount was $9683, equivalent to 9 nights of acute inpatient stay. Mean index skin-to-skin time was 114 minutes, being 126 minutes for revisions (P=.26). Additional care related to ankle fusion nonunion represents a financial burden equivalent to 9 nights of acute inpatient stay. The use of an orthobiologic would need to be less than $436 to be cost saving. Revision surgery is not significantly longer intraoperatively than index surgery. [Orthopedics. 2020;43(4):e219-e224.].

Arthroscopic ankle fusion only has a limited advantage over the open operation if osseous operation type is the same: a retrospective comparative study

Background

A great deal of research suggests that arthroscopic ankle fusion (AAF) has advantages over open ankle fusion (OAF), but these outcomes would be imprecise because of a selection bias. The purpose of this study is to verify which is better for ankle fusion, AAF or OAF. We regrouped the OAF group into two subgroups according to whether the osseous operation type is the same as AAF group. The goal is to minimize the impact of disease severity, thereby reducing selection bias to some extent.

Methods

We retrospectively analyzed the data of ankle fusion in our hospital between July 2015 and October 2018. Forty-three patients were enrolled and divided into AAF group (n = 17) and OAF group (n = 26). In order to eliminate selection bias, we divided OAF group into complex osseous operation subgroup (COO subgroup) (n = 15) and simple osseous operation subgroup (SOO subgroup) (n = 11). The osseous operation type of SOO subgroup is the same as AAF group. Then, we compared the differences between these groups. All patients were followed up at least 1 year after operation. We analyzed data, including etiology composition, surgical time, intra-op blood loss, reduction of albumin, total hospital stays, union time, fusion situation, complications, radiological examination, functional score, and questionnaire survey. Then we performed statistical analyses.

Results

We found that the etiological components of AAF group and OAF group were different; the etiological components of AAF group and SOO subgroup were similar. We found that AAF group has advantages over OAF group and COO subgroup in general. However, except in terms of surgical trauma, hospital stays, and short-term complications occurred, the AAF group has not obvious advantages over SOO subgroup, including intra-op blood loss, fusion condition, postoperative function score, and postoperative patient satisfaction; and AAF group need more surgical time than the SOO subgroup.

Conclusions

The arthroscopic ankle fusion can bring a good curative effect; however, if the osseous operation type is the same, the arthroscopic ankle fusion only has a limited advantage over the traditional open operation in perioperative soft tissue protection and enhanced recovery after surgery.

Physical Performance and Quality of Life after Ankle Fusion

INTRODUCTION

Ankle fusion is still considered as an established therapy for end-stage ankle osteoarthritis. To determine exact description of postoperative functioning, it is necessary to consult a variety of functional scores and quality of life questionnaires.

METHODS/PATIENTS

34 patients with 34 ankle fusions were investigated on average 5.9 years postoperatively by functional tests and health-related quality of life questionnaires (AOFAS hindfoot score [AOFAS: American Orthopaedic Foot/Ankle Society], Foot Function Index [FFI], Lower Extremity Functional Scale [LEFS], Lower Extremity Activity Scale [LEAS], Visual Analogue Scale Foot/Ankle Surgery [VAS FA], Short Form 36 [SF-36], EuroQol 5D [EQ-5D]).

RESULTS

After ankle fusion: the majority of cases gain pain reduction, but residual symptoms may persist; the maximum walking distance (subjectively more than objectively) will be extended; rarely walking without any aids can be achieved; in most cases, the gait pattern is only slightly changed; the re-entry into working life is often possible; climbing stairs without any restrictions is not always possible; the psychological situation will be equalized with that of healthy people.

CONCLUSION

The results of the study confirm the success rates of ankle fusions in the majority of cases. Well defined limitations and residual symptoms can be named on the basis of the available data.

Postoperative weightbearing following ankle arthrodesis

Aims

Postoperative rehabilitation regimens following ankle arthrodesis vary considerably. A systematic review was conducted to determine the evidence for weightbearing recommendations following ankle arthrodesis, and to compare outcomes between different regimens.

Patients and Methods

MEDLINE, Web of Science, Embase, and Scopus databases were searched for studies reporting outcomes following ankle arthrodesis, in which standardized postoperative rehabilitation regimens were employed. Eligible studies were grouped according to duration of postoperative nonweightbearing: zero to one weeks (group A), two to three weeks (group B), four to five weeks (group C), or six weeks or more (group D). Outcome data were pooled and compared between groups. Outcomes analyzed included union rates, time to union, clinical scores, and complication rates.

Results

A total of 60 studies (2426 ankles) were included. Mean union rates for groups A to D were 93.2%, 95.5%, 93.0%, and 93.0%, respectively. Mean time to union was 10.4 weeks, 14.5 weeks, 12.4 weeks, and 14.4 weeks for groups A to D, respectively. Mean complication rates were 22.3%, 23.0%, 27.1%, and 28.7% for groups A to D, respectively. Reporting of outcome scores was insufficient to conduct meaningful analysis.

Conclusion

Outcomes following ankle arthrodesis appear to be similar regardless of the duration of postoperative nonweightbearing, although the existing literature is insufficient to make definitive conclusions. Cite this article: Bone Joint J 2019;101-B:1256–1262

Effect of Cigarette Smoking on Patient-Reported Outcomes in Hip Arthroscopic Surgery: A Matched-Pair Controlled Study With a Minimum 2-Year Follow-up

Background

The rate of hip arthroscopic surgery has recently increased; however, there is limited literature examining patient-reported outcomes (PROs) in cigarette smokers.

Purpose/Hypothesis

The purpose of this study was to evaluate whether smoking status for patients undergoing hip arthroscopic surgery affects clinical findings and PRO scores. We hypothesized that patients who smoke and undergo primary hip arthroscopic surgery will have similar clinical examination findings and preoperative and postoperative PRO scores compared with nonsmoking patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

Data were collected on all patients who underwent primary hip arthroscopic surgery from February 2008 to July 2015. A retrospective analysis of the data was then conducted to identify patients who reported cigarette use at the time of the index procedure. Patients were matched 1:2 (smoking:nonsmoking) based on sex, age within 5 years, labral treatment (repair vs reconstruction vs debridement), workers' compensation status, and body mass index within 5 kg/m². All patients were assessed preoperatively and postoperatively using 4 PRO measures: the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12 (iHOT-12). Pain was estimated using a visual analog scale. Satisfaction was measured on a scale from 0 to 10. Significance was set at P < .05.

Results

A total of 75 hips were included in the smoking group, and 150 hips were included in the control group. Preoperatively, the smoking group had significantly lower PRO scores compared with the control group for the mHHS, NAHS, and HOS-SSS. Both groups demonstrated significant improvement from preoperative levels. A minimum 2-year follow-up was achieved, with a mean of 42.5 months for the smoking group and 47.6 months for the control group (P = .07). At the latest follow-up, the smoking group reported inferior results for all outcome measures compared with controls. The improvement in PRO scores and rates of treatment failure, revision arthroscopic surgery, and complications was not statistically different between the groups.

Conclusion

Patients who smoke had lower PRO scores preoperatively and at the latest follow-up compared with nonsmokers. Both groups demonstrated significant improvement in all PRO scores. These results show that while hip arthroscopic surgery may still yield clinical benefit in smokers, these patients may ultimately achieve an inferior functional status. To optimize results, physicians should advise patients to cease smoking before undergoing hip arthroscopic surgery.

Re-arthrodesis after primary ankle fusion: 134/1,716 cases from the Swedish Ankle Registry

Background and purpose - Arthrodesis is the most common treatment of severe ankle arthritis. Large studies on the occurrence of re-arthrodesis are few, especially with information in terms of risk. We used the National Swedish Ankle Registry to assess incidence and risk factors for re-arthrodesis. Patients and methods - In the Registry, we examined the occurrence of re-arthrodesis in 1,716 patients with a primary ankle arthrodesis. We also analyzed associations between the re-arthrodesis risk and sex, diagnosis, and surgical method. Results - The risk of first re-arthrodesis at 2.5 years was 7.4% and the rate at 9 years 7.8%. The risk following arthroscopic surgery with fixation by screws was 15%, which is statistically significantly higher than the 8% following the gold standard technique with open screw fixation, the 5% following fixation by intramedullary nailing, and the 3% following fixation by plate and screws. Patients with either idiopathic osteoarthritis or posttraumatic arthritis had a higher risk of re-arthrodesis than patients with rheumatoid arthritis. We could not find that the risk of re-arthrodesis was associated with sex. Interpretation - In Sweden, the re-arthrodesis risk varied by primary technique and was especially high after arthroscopic surgery. Reasons are unknown but poor surgical technique and/or surgeon inexperience may contribute, as may patient selection.

Fibular Intra-articular Resection During Arthroscopic Ankle Arthrodesis: The Surgical Technique

Ankle arthrodesis is still considered the gold standard in the treatment of advanced painful ankle osteoarthritis. More than 3 decades ago, it was performed under arthroscopy; thereafter, many authors have reported excellent results and a low complication rate. Despite the significant improvements in surgical techniques, nonunion remains a problematic and relatively frequent event. This is one of the reasons the research is constantly active in this field. Ten years ago, a fibular resection during ankle arthrodesis was, for the first time, described in the literature as a means to correct malalignment in varus cases. Nowadays, we perform a similar technique during all arthroscopic ankle arthrodeses, regardless of the kind of preoperative deformity (varus, valgus, or normal alignment). In this article, we describe the arthroscopic technique to perform a fibular intra-articular resection during arthroscopic ankle arthrodesis, joining the benefits of arthroscopic minimal invasiveness to the full joint contact gained after such a fibular osteotomy. In our opinion, this would be the only way through which full contact between the talar and tibial surfaces may be achieved.

Results of Arthroscopic Ankle Arthrodesis with Fixation Using Two Parallel Headless Compression Screws in a Heterogenic Group of Patients

BACKGROUND

As orthopedic surgeons become skilled in ankle arthroscopy technique and evidence -based data is supporting its use, arthroscopic ankle arthrodesis (AAA) will likely continue to increase, but stabilization methods have not been described clearly. We present a technique for two parallel 7.3-mm headless compression screws fixation (HCSs) for AAA in cases of ankle arthritis with different etiology, both traumatic and non-traumatic, including neuromuscular and inflammatory patients.

MATERIALS AND METHODS

We retrospectively verified 24 consecutive patients (25 ankles) who underwent AAA between 2011 and 2015. The average follow-up was 26 months (range 18 to 52 months). Arthrodesis was performed in 16 patients due to posttraumatic arthritis (in 5 as a sequela of pilon, 6 ankles, 3 tibia fractures, and 2 had arthritis due to chronic instability after lateral ligament injury), in 4 patients due to neuromuscular ankle joint deformities, and in 4 patients due to rheumatoid arthritis.

RESULTS

Fusion occurred in 23 joints (92%) over an average of 12 weeks (range 6 to 18 weeks). Ankle arthrodesis was not achieved in 2 joints (8%), both in post-pilon fracture patients. The correct foot alignment was not achieved in 4 feet (16%). None of the treated patients required hardware removal.

CONCLUSION

The presented technique was effective in achieving a high fusion rate in a variety of diseases, decreasing intra- and post-operative hardware complications while maintaining adequate bone stability.