Effect of Obesity on Total Ankle Arthroplasty Outcomes

Radiographic soft tissue thickness is not a risk factor for infection after primary total ankle arthroplasty

As the incidence of total ankle arthroplasty (TAA) for the management of end-stage arthritis is on the rise, identification of risk factors for periprosthetic joint infection (PJI) is essential. There has been limited research exploring the use of radiographic soft tissue thickness in TAA despite its predictive value in other forms of arthroplasty. This study evaluated the predictive capabilities of radiographic soft-tissue thickness for PJI following TAA. A retrospective analysis of 323 patients at a single institution who underwent primary TAA from 2003 to 2019 was conducted. Patient demographics, comorbidities, indication for surgery, prosthesis type and tourniquet time were recorded. Tibial-Tissue and Talus-Tissue distances were measured on preoperative lateral radiographic imaging. Logistic regression was utilized to determine the Odds Ratio (OR) of risk factors for the occurrence of PJI. Of the 323 patients, 6 patients (1.86 %) developed a PJI. Average duration of follow-up was 8.42 ± 2.52 years. Neither Tibial-Tissue (OR = 0.975; 95 % CI [0.947 - 1.004]; p = 0.09) nor Talus-Tissue thickness (OR = 0.976; 95 % CI [0.940 - 1.012]; p = 0.18) were significant predictors of PJI. Although not statistically significant, the infected cohort had smaller average Tibial-Tissue (2.20 vs. 2.53 cm; p = 0.05) and Talus-Tissue thickness (2.19 vs. 2.44 cm; p = 0.36) compared to the non-infected cohort. Measurements such as Tibial-Tissue length and Talus-Tissue length were not significant predictors of PJI following primary TAA. These findings underscore the necessity for additional research to identify modifiable risk factors aimed at reducing PJI rates and enhancing patient outcomes. LEVEL OF EVIDENCE: III, Retrospective Comparative Study.

Obesity is highly associated with a non-home discharge following total ankle arthroplasty

Studies have shown that non-home discharge following orthopedic procedures is associated with a higher risk of 30-day complications and significantly increases medical costs. The purpose of this study was to identify risk factors for being discharged to a non-home destination following total ankle arthroplasty (TAA). We included patients undergoing TAA from the American College of Surgeons National Surgical Quality Improvement Program database (NSQIP) between 2014 and 2019. TAA was identified using CPT codes 27702, 27703 and 27704. Logistic regression models were used to assess the association between discharge location (home versus non-home) and a series of exposure variables (e.g., patient demographics, patient health characteristics, and operative factors). A total of 1,704 patients were included, experiencing a 3.6% short term complication rate (61/1,704). 8.5% of the population were discharged to a non-home destination. In the final adjusted model, patients who were older [OR 1.11; 95%CI 1.08, 1.13], female [OR 2.94; 95%CI 2.04, 4.34], obese [OR 1.93; 95%CI 1.29, 2.89], had surgery in an inpatient setting [OR 5.73; 95%CI 1.78, 18.46], and ASA class IV [OR 10.65; 95%CI 1.03, 110.61] were at greater risk for a non-home discharge. People living with obesity experienced a nearly 2x greater likelihood of being discharged to a non-home destination after TAA despite their preoperative functional (e.g., ASA class) and metabolic status (i.e., diabetes). Opportunities to mitigate this risk will be needed to lessen the financial burden of TAA surgery as a growing number of obese patients become eligible for TAA in the US.

The association of ASA score and outcomes following total ankle arthroplasty

BACKGROUND

This study seeks to evaluate the relationship between American Society of Anesthesiologist (ASA) score and postoperative outcomes following TAA.

METHODS

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2007 to 2020 to identify 2210 TAA patients. Patients were stratified into low (n = 1328; healthy/mild systemic disease) or high (n = 881; severe/life-threatening systemic disease) ASA score cohorts.

RESULTS

There was no statistically significant difference in complications, readmission, or reoperation rate based on ASA score. Increased ASA score was significantly associated with longer length of stay (low = 1.69 days, high = 1.98 days; p < .001) and higher rate of adverse discharge (low = 95.3 %, high = 87.4 %; p < .001).

CONCLUSION

Higher ASA scores (3 and 4) were statically significantly associated with increased length of stay and non-home discharge disposition. These findings are valuable for physicians and patients to consider prior to TAA given the increased utilization of resources and cost associated with higher ASA scores.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Association of Radiographic Soft Tissue Thickness With Revision Total Ankle Arthroplasty Following Primary Total Ankle Arthroplasty: A Minimum of 5-year Follow-up

Background

The incidence of primary total ankle arthroplasty (TAA) is rising, with a corresponding increase in revision surgeries. Despite this, research on risk factors for revision TAA following primary TAA remains limited. Radiographic soft tissue thickness has been explored as a potential predictor for outcomes in hip, knee, and shoulder arthroplasty, but its role in TAA has not been assessed. This study aimed to assess the predictive value of radiographic soft tissue thickness for identifying patients at risk of requiring revision surgery following primary TAA.

Methods

A retrospective study was conducted on 323 patients who underwent primary TAA between 2003 and 2019. Radiographic measurements of soft tissue thickness were obtained from preoperative radiographs. Two novel radiographic measures of soft tissue thickness were developed and assessed (tibial tissue thickness and talus tissue thickness). Clinical variables including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, diabetes, smoking status, primary diagnosis, and implant type were recorded. Logistic regression analysis was used to assess the predictive value of soft tissue thickness and BMI for revision TAA.

Results

The rate of revision surgery was 4.3% (14 of 323 patients). Patients requiring revision had significantly greater tibial tissue (3.54 vs 2.48 cm; P = .02) and talus tissue (2.79 vs 2.42 cm; P = .02) thickness compared with those not requiring revision. Both the tibial tissue thickness (odds ratio 1.16 [1.12-1.20]; P < .01) and the talus tissue thickness (odds ratio: 1.10 [1.05-1.15]; P < .01) measurements were significant predictors of revision TAA in multivariable logistic regression models. However, BMI was not a significant predictor of revision TAA. The two metrics demonstrated excellent interrater reliability.

Conclusion

Greater soft tissue thickness was a better predictor of revision TAA compared with BMI. These findings suggest that radiographic soft tissue thickness may be a valuable tool for assessing the risk of the need for revision TAA following primary TAA. Further research is needed to validate and explore the potential impact on clinical practice.

Level of Evidence

Level III, comparative study.

Effect of body mass index on acute postoperative complications following Total Ankle Arthroplasty (TAA)

BACKGROUND

Total ankle arthroplasty (TAA) is an effective treatment for various ankle pathologies, but some concern remains for the high associated complication and failure rates relative to major joint arthroplasty of the hip and knee. Patient body mass index (BMI) is a modifiable and potentially important preoperative variable when evaluating postoperative complications. The purpose of this study is to evaluate the effect of BMI, age and sex on the acute postoperative complication rate after TAA.

METHODS

We retrospectively reviewed adult patients who underwent TAA between 2006 and 2021 from the NSQIP database. Using overweight patients as the reference BMI group, we utilized log-binomial models to estimate risk ratios on outcomes while adjusting for sex and age to investigate whether there were significant adjusted differences in complication rates among the BMI groups.

RESULTS

We found that, relative to overweight patients, there were no statistically significant differences in the risk of acute complications for underweight (BMI < 18.5) (P = .118), healthy weight (18.5≤BMI < 25) (P = .544), obese (30≤BMI < 40) (P = .930), or morbidly obese (BMI < 40) (P = .602) patients who underwent TAA. There were also no statistically significant differences in the risk of acute complications based on age category (P = .482,.824) or sex (P = .440) for TAA. Additionally, there were no significant differences between the BMI groups for either major complications (P = .980) or minor complications (P = .168).

CONCLUSION

Ultimately, we found that BMI, age, and sex did not lead to statistically significant differences in the risk of complications within 30 days postoperatively for TAA, even when stratified by major vs minor complications.

LEVEL OF EVIDENCE

Level III.

Effect of Obesity on Patient-Perceived Outcomes After First Metatarsophalangeal Joint Arthrodesis

BACKGROUND

While first metatarsophalangeal joint (MTPJ) arthrodesis is a common and effective procedure, there is a paucity of studies examining obesity's effect on outcomes of 1st MTPJ arthrodesis. This study's purpose was to evaluate patient-reported outcomes following 1st MTPJ arthrodesis in obese versus non-obese patients.

METHODS

A retrospective cohort study of 94 patients undergoing first MTPJ fusion over the age of 18 with a diagnosis of hallux valgus or hallux rigidus was performed. Surgical and postoperative outcomes were examined preoperatively and at 6 and 12 months follow-up via Visual Analog Pain scale (VAS), and Short Form 36 (SF-36) surveys, and data were stratified into 2 patient groups: BMI < 30 (n = 62, mean age 63.9 ± 9.1 and ≥ 30 (n = 32, mean age 61.9 ± 8.4).

RESULTS

Average overall VAS and SF-36 physical component scores improved significantly at 6 months (P < .001, .006) and 1 year postoperative visits (P < .001, .007) with no differences in survey scores, outcomes, or complications between weight groups.

CONCLUSION

Our study showed first MTPJ fusion improves short-term pain and physical quality-of-life in arthritic obese and non-obese patients without differences in nonunion, complications, or patient-reported measures.

LEVEL OF EVIDENCE

Level III, Prognostic, Case-Control Study.

Long-Term Survival Analysis of 5619 Total Ankle Arthroplasty and Patient Risk Factors for Failure

BACKGROUND

Total ankle arthroplasty (TAA) has higher complication and failure rates compared to other surgical joint replacement procedures despite technological advances. This study aimed to find the long-term survivability of the TAA procedure and identify the patient risk factors for failure with one of the largest cohorts of patients in the literature.

METHODS

This retrospective cohort study involving cases between 2007 and 2018 analyzed patients who received an index primary TAA procedure in Korea. A total of 5619 cases were included in the final analysis. The TAA failure was defined as either a case with revision arthroplasty or a case with TAA implant removal and arthrodesis performed after primary TAA.

RESULTS

During the study period, the 5-year survival rate was 95.4% (95% CI, 94.7-96.1%), and the 10-year survival rate was 91.1% (95% CI, 89.1-93.1%). A younger age (<55 years, adjusted hazard ratio [AHR], 1.725; 55-64 years, AHR, 1.812; p < 0.001 for both), chronic pulmonary disease (AHR, 1.476; p = 0.013), diabetes (AHR, 1.443; p = 0.014), and alcohol abuse (AHR, 1.524; p = 0.032) showed a significantly high odds ratio for primary TAA failure in Cox regression analysis.

CONCLUSION

The 10-year TAA survivorship rate was 91.1%. A younger age, chronic pulmonary disease, diabetes, and heavy alcohol consumption are risk factors for TAA.

Obesity and Ankle Prosthesis Revision: A Systematic Review and Meta-analysis

BACKGROUND

The increasing number of total ankle arthroplasties (TAAs) has led to growing evidence on the risk factors for complications after surgery. However, the role of obesity in this patient group has been the subject of much debate. Therefore, this systematic review aimed to investigate the evidence for untoward effects of obesity following TAA.

METHODS

We conducted a comprehensive search on April 28, 2023, in MEDLINE (via PubMed), Embase, and CENTRAL. Eligible observational studies reported on the short- and long-term outcomes of primary TAA, comparing patients with and without obesity (defined as body mass index > 30). Using a random effects model, we calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) from 2 by 2 tables (event and nonevent in the obese and nonobese primary TAA groups).

RESULTS

Nine studies with 10 388 patients were eligible for inclusion in the meta-analysis. We found significantly higher odds of revision in the obese group compared to the nonobese group (OR = 1.68, CI: 1.44-1.95). However, the odds of overall perioperative complications (OR = 1.55, CI: 0.50-4.80) and wound complications (OR = 1.34, CI: 0.29-6.20) were nonsignificantly higher in the obese group.

CONCLUSION

Based on our results, obesity may have affected long-term outcomes following TAA and may have negatively affected the prosthesis's survival.

Racial, Socioeconomic, and Payer Status Disparities in Utilization of Total Ankle Arthroplasty Compared to Ankle Arthrodesis

Total ankle arthroplasty is increasingly being used for the treatment of ankle osteoarthritis when compared to arthrodesis. However, there has been limited investigation into disparities in utilization of these comparable procedures. This study examined racial/ethnic, socioeconomic, and payer status disparities in the likelihood of undergoing total ankle arthroplasty compared with ankle arthrodesis. Patients with a diagnosis of ankle osteoarthritis from 2006 through 2019 were identified in the National Inpatient Sample, then subclassified as undergoing total ankle arthroplasty or arthrodesis. Multivariable logistic regression models, adjusted for hospital location, primary or secondary osteoarthritis diagnosis, and patient characteristics (age, sex, infection, and Elixhauser comorbidities), were used to examine the effect of race/ethnicity, socioeconomic status, and payer status on the likelihood of undergoing total ankle arthroplasty versus arthrodesis. Black and Asian patients were 34% and 41% less likely than White patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Patients in income quartiles 3 and 4 were 22% and 32% more likely, respectively, than patients in quartile 1 to undergo total ankle arthroplasty rather than arthrodesis (p = .001 and p = .01, respectively). In patients <65 years of age, privately insured and Medicare patients were 84% and 37% more likely, respectively, than Medicaid patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Racial/ethnic, socioeconomic, and payer status disparities exist in the likelihood of undergoing total ankle arthroplasty versus arthrodesis for ankle osteoarthritis. More work is needed to establish drivers of these disparities and identify targets for intervention, including improvements in parity in relative procedure utilization.

Midterm Results of AAA Ankle Arthroplasty

BACKGROUND

Outcome reports for Alpha Ankle Arthroplasty (AAA), a third-generation implant relying on a mobile bearing design for total ankle replacement, are sparse. This retrospective study evaluated the midterm survivorship, clinical, and radiologic outcomes after implantation of this implant.

METHODS

For 64 patients who received 65 Triple A ankle implants between 2009 and 2020, implant survival was calculated using the Kaplan-Meier curve. Clinical outcomes were evaluated by measuring the range of motion, stability, Western Ontario and McMaster Universities Osteoarthritis Questionnaire score (WOMAC), and American Orthopaedic Foot & Ankle Society ankle-hindfoot score (AOFAS). The average pain level and satisfaction with the postoperative result were rated on a numeric rating scale (0-10). Additionally, radiologic analysis was performed using anteroposterior and lateral radiographs and tibiotalar alignment was assessed.

RESULTS

The implant-survival rate was 61.5% at a mean follow-up of 8.2 years. Twenty-five patients (38.5%) required revision surgery (average time to revision, 3.1 years, 95% CI 2.1-4.1 years). For patients without revisions, the average range of motion in dorsiflexion and plantarflexion were 3.6 ± 4.2 degrees and 21.9 ± 7.8 degrees, respectively. The mean WOMAC and AOFAS scores were 44.7 ± 47.5 and 75.1 ± 14.0, respectively. The average pain and subjective satisfaction scores were 2.0 ± 1.7 and 8.5 ± 1.9, respectively. Mean alignment values did not differ significantly for patients who required revision surgery.

CONCLUSION

We found a high revision rate with use of the AAA. However, patients who did not require revision surgery had, on average, high satisfaction and good functional outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Updates on Total Ankle Arthroplasty

The newer generation total ankle arthroplasty constructs afford higher levels of long-term survivability, and for the first in the history of ankle arthroplasty procedures, results are comparable to arthrodesis. Much of the success hinges on appropriate patient selection. A comprehensive workup of the patient will allow selection of adjunctive procedures as well as allowing for the determination of single versus 2-stage deformity correction. With the continual addition of implants, it is important to understand the specialization and indications that are assigned to certain models because this will help in selecting the most appropriate implant for any given patient.

Body Mass Index (BMI) Cutoffs and Racial, Ethnic, Sex, or Age Disparities in Patients Treated With Total Ankle Arthroplasty

Background

The rising prevalence of obesity among American adults has disproportionately affected Black adults and women. Furthermore, body mass index (BMI) has historically been used as a relative contraindication to many total joint arthroplasty (TJA) procedures, including total ankle arthroplasty. The purpose of this study was to investigate potential disparities in patient eligibility for total ankle arthroplasty based on race, ethnicity, sex, and age by applying commonly used BMI cutoffs to the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods

Patients in the ACS-NSQIP database who underwent TAA from 2011 to 2020 were retrospectively reviewed in a cross-sectional analysis. BMI cutoffs of <50, <45, <40, and <35 were then applied. The eligibility rate for TAA was examined for each BMI cutoff, and findings were stratified by race, ethnicity, sex, and age. Independent t tests, chi-squared tests, and Fisher exact tests were performed to compare differences at an α = 0.05.

Results

A total of 1215 of 1865 TAA patients (65.1%) were included after applying the exclusion criteria. Black patients had disproportionately lower rates of eligibility at the most stringent BMI cutoff of <35 (P = .004). Hispanic patients had generally lower rates of eligibility across all BMI cutoffs. In contrast, Asian American and Pacific Islander patients had higher rates of eligibility at the BMI cutoffs of <35 (P = .033) and <40 (P = .039), and White non-Hispanic patients had higher rates of eligibility across all BMI cutoffs. Females had lower eligibility rates across all BMI cutoffs. Ineligible patients were also younger compared to eligible patients across all BMI cutoffs.

Conclusion

Stringent BMI cutoffs may disproportionately disqualify Black, female, and younger patients from receiving total ankle arthroplasty.

Level of Evidence

Level III, retrospective cross-sectional study.

Total Ankle Arthroplasty: Does Obesity Matter?

BACKGROUND

There is limited data evaluating the effect of obesity on outcomes following total ankle arthroplasty (TAA), especially in adequate sample sizes to detect impacts on patient-reported outcomes (PROs). The purpose of this study was to assess the effect of obesity on complication rates and PROs.

METHODS

This was a single-institution, retrospective study of 1093 primary TAA performed between 2001 and 2020. Minimum follow-up was 2 years. Patients were stratified by body mass index (BMI) into control (BMI = 18.5-29.9; n = 615), obesity class I (BMI = 30.0-34.9; n = 285), and obesity class II (BMI > 35.0; n = 193) groups. Patient information, intraoperative variables, postoperative complications, and PRO measures were compared between groups using univariable statistics. Multivariable Cox regression was performed to assess risk for implant failure. Mean follow-up was 5.6 years (SD: 3.1).

RESULTS

Compared to control and class I, class II patients had the lowest mean age (P = .001), highest mean ASA score (P < .001), and greatest proportion of female sex (P < .001) and Black/African American race (P = .005). There were no statistically significant differences in postoperative complications (infection, implant failure, or impingement) across the BMI classes (P > .05).Preoperatively, class II had lower (worse) mean scores for Foot and Ankle Outcome Score pain and ADL subscales than controls (post hoc pairwise P < .001 for both). At final follow-up, both class II and class I had lower (worse) mean Short Musculoskeletal Function Assessment (post hoc pairwise P < .001 and P = .030, respectively) and 36-Item Short Form Health Survey scores (post hoc pairwise P < .001 and P = .005, respectively) than controls.

CONCLUSION

At midterm follow-up, obesity was not associated with increased rates of complications after TAA. Patients with obesity reported worse musculoskeletal function and overall quality of life after TAA but there was no differential improvement in PROs across BMI classes. To our knowledge, this is the largest single-institution study to date examining the effect of obesity on outcomes after primary TAA.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Risk Factors for Failure of Total Ankle Replacements: A Data Linkage Study Using the National Joint Registry and NHS Digital

BACKGROUND

Despite the increasing numbers of ankle replacements, there remains debate about which patients should undergo an ankle replacement, and there are limited studies analyzing risk factors for failure of an ankle replacement. The primary aim of this study is to analyze the risk factors for failure of total ankle replacements.

METHODS

A data linkage study combining the National Joint Registry (NJR) Data and NHS (National Health Service) Digital data was performed. The primary outcome of failure is defined as the removal or exchange of any components of the implanted device. Kaplan-Meier survival charts were used to illustrate survivorship. Multivariable Cox proportional hazards regression models were fitted to analyze potential risk factors for failures or ankle replacements.

RESULTS

The overall 5-year survival was 90.2% (95% CI 89.2%-91.1%). In multivariable (adjusted) Cox regression models, only age (hazard ratio [HR] 0.96, 95% CI 0.94-0.97), body mass index (BMI; HR 1.03, 95% CI 1.01-1.06), and underlying etiology (HR 0.88, 95% CI 0.80-0.97) were associated with an increased risk of failure.

CONCLUSION

This study demonstrates that younger patients and those with an increased BMI have an increased risk of failure of a primary ankle replacement. We also show that rheumatoid patients have higher survivorship than those with osteoarthritis.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Republication of "Perspectives in Treatments of End-Stage Ankle Arthritis Among Orthopaedic Surgeons: Analysis of an American Orthopaedic Foot & Ankle Society (AOFAS) Member Survey"

Background

This study aimed to assess the preferred operative treatment for patients over the age of 60 with end-stage ankle arthritis and perspectives on total ankle replacement (TAR) among American Orthopaedic Foot & Ankle Society (AOFAS) members. Associated factors were analyzed for potential contraindications among members with different levels of experience.

Method

A questionnaire containing 6 questions was designed and sent to 2056 members of the AOFAS. Responses were received from 467 orthopaedic surgeons practicing in the United States (76%), Canada (5%), and 26 other countries (20%). Participants were grouped for response comparisons according to country as well as experience level. Differences in contraindications were compared using χ2 tests or exact tests.

Results

Respondents practicing in the United States and surgeons who perform 11 or more TARs per year tended to recommend operative treatments favoring TAR and displayed recognition of its increasing role (P < .05). Overall, respondents felt that 41% of typical patients over 60 years old with end-stage arthritis would be best treated with TAR. Talus avascular necrosis, morbid obesity (body mass index >40 kg/m2), and poorly controlled diabetes with neuropathy were most recognized as the absolute contraindications to TAR. Surgeon's experience affected the consideration of these clinical factors as contraindications.

Conclusions

Total ankle replacement has a substantial and increasing role in the treatment of end-stage ankle arthritis in patients over the age of 60. Absolute and potential contraindications of the procedures were indicated from a cross-sectional survey of AOFAS members. Surgeons more experienced with total ankle replacement felt more comfortable employing it in a wider range of clinical settings.

Level of Evidence

Level III, therapeutic.

Implications of obesity in patients with foot and ankle pathology

Obesity is a growing problem defined as a body mass index of greater than 30 kg/m². It is predicted that by 2030, 48.9% of adults will be classified as obese which expands surgical risk factors to a broad population while increasing healthcare costs at the same time in different socioeconomic groups. This specific population has been widely studied in multiple surgical fields and published studies have shown the implications in each of these fields. The impact of obesity on orthopedic surgical outcomes has been previously reported in several total hip and knee arthroscopy studies, with evidence indicating that obesity is strongly associated with an increased risk of post operative complications together with higher revision rates. In line with increasing interest on the impact of obesity in orthopedics, there has been a similar output of publications in the foot and ankle literature. This review article evaluates several foot and ankle pathologies, their risk factors associated with obesity and subsequent management. It provides an updated, comprehensive analysis of the effects of obesity on foot and ankle surgical outcomes, with the ultimate aim of educating both surgeons and allied health professionals about the risks, benefits, and modifiable factors of operating on obese patients.

Systemic medical complications following joint replacement: a review of the evidence

INTRODUCTION

Arthroplasty procedures are commonly performed in the UK. Informed consent is required for each procedure. To obtain informed consent the patient and their surgeon should discuss the risks and benefits of the proposed operation. This discussion should include both regional and systemic complication rates. Regional complications of arthroplasty are generally well documented in the literature. Systemic medical complications are less well described. This lack of accurate data could make it difficult for the treating surgeon to obtain valid consent. The aim of this paper was to review and compare the literature regarding the rate of systemic medical complications after common arthroplasty procedures.

METHODS

A literature search was conducted using the PubMed, Cochrane Library and MEDLINE databases. Studies regarding the systemic medical complications and mortality rate of joint replacement were included.

FINDINGS

We found that systemic complications were more frequent than regional complications following arthroplasty. The systemic complication rates were: hip, 5.1%; knee, 6.9%; ankle, 3.0%; shoulder, 11.2%; elbow, 8.5%; and wrist, 0%. Mortality rates for arthroplasty procedures were: hip, 0.3%; knee, 0.2%; ankle, 0.3%; shoulder, 0.3%; elbow, 0.2%; and wrist, 0%.

CONCLUSIONS

The most common systemic medical complication following arthroplasty was venous thromboembolism. Preoperative comorbidity was the most important risk factor for both postoperative mortality and systemic medical complications following arthroplasty procedures. We recommend that to obtain informed consent the given rates of systemic medical complications of joint replacement should be discussed and documented.

Midterm Outcomes of the INBONETM II Total Ankle Arthroplasty

As the number of total ankle arthroplasties (TAA) performed continues to increase, understanding midterm outcomes can guide both implant selection and preoperative patient counseling. The purpose of this study was to investigate midterm results including the survival rate and reasons for revision for the INBONE^TM II TAA. Patients undergoing a primary TAA with the study implant and minimum of 4.6 years postoperative follow-up were reviewed from a prospectively collected database. The primary outcome was implant survival. Secondary outcomes included coronal plane radiographic alignment, evaluation for cysts and osteolysis, and failure mode when applicable. Patients were eligible for inclusion in this study if they had a minimum of 4.6-year follow-up TAA with the study implant. Eighty-five TAAs in 83 patients were eligible for inclusion; 75 TAA in 73 patients were included in the study. The mean duration of follow up was 6.2 ± 0.9 years (range 4.7-8.1 years). Thirty-six percent of the TAAs had a preoperative coronal plane deformity of at least 10^°, and 12% of the TAAs had at least 20^°. There were 6 (8%) implant failures that occurred at a mean 2.0 ± 1.4 years postoperatively. Eighty-one percent of the TAAs had no reoperation events in the follow-up period. Midterm outcomes at a minimum of 4.6 years postoperatively in patients undergoing a TAA using this implant demonstrates acceptable implant survival, an approximately 20% reoperation rate, and maintenance of coronal plane alignment.

Fast-Track for Total Ankle Replacement: A Novel Enhanced Recovery Protocol for Select Patients

BACKGROUND

Enhanced recovery after surgery programs, also called fast-track protocols, were developed and successfully applied in the last decade for hip and knee reconstruction. Specific fast-track protocols have not yet been applied to ankle prostheses. The aim of the study was to develop and validate an enhanced recovery protocol for total ankle replacement (TAR) evaluating the clinical and radiographic results. We hypothesize that on the basis of well-defined pre- and postoperative characteristics, the current knowledge on ankle replacement, and referring to hip and knee reconstruction, it is possible to identify a "patient type" to be safely eligible to a Fast-Track Protocol with at least comparable results and without increasing the complications risk.

METHODS

We identified 8 predictive variables that might affect the outcome of TAR. Those variables were the body mass index, the state of anxiety or depression, the functional preoperative status, ankle equinus, the coronal malalignment, the surgical time, the surgical accessory procedures, and the bone quality. These characteristics were evaluated for each patient with almost validated outcome tools attributing a specific score. Based on the score obtained, the patients were divided into 2 groups: the Standard Protocol group (Control Group) and the Fast-Track Protocol group (Study Group). The main difference between treatment of the 2 groups relates to the use of postoperative plaster casts: in the Fast-Track group the cast was removed the first day after surgery and walking was allowed in sports shoes assisted with crutches, whereas in the Standard Protocol group, the cast was removed after 3 weeks. Clinical and radiographic evaluation was performed for all patients preoperatively and postoperatively every 6 months.

RESULTS

A total of 163 patients received a score between 1 and 5 and were included in the control group (Standard Protocol); 47 patients received a score of 0 and were allocated to the study group (Fast-Track Protocol). Clinically, except for the preoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score, no statistically significant differences were recorded in the multiple comparisons between the 2 groups. No significant differences were found regarding complications.

CONCLUSION

In selected patients, it is possible to apply an enhanced recovery protocol of rehabilitation, focused on immediate weightbearing and mobilization without any plaster or boot.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Systemic medical complications following total ankle arthroplasty: A review of the evidence

BACKGROUND

Total Ankle Arthroplasty (TAA) is increasingly undertaken for the treatment of end-stage ankle arthritis. For each TAA procedure informed consent is required. The consent process should include discussion of the relevant complications, both systemic and regional. There is a lack of data regarding the systemic complications of TAA. This might cause problems in obtaining valid informed consent.

METHODS

We reviewed and summarised the literature regarding the systemic complications and mortality rate of TAA.

RESULTS

The average rate of systemic medical complications after TAA was 3% (range: 0-7%). The average mortality rate following TAA was 0.3% (range: 0-0.72%). The following were risk factors for systemic medical complications: obesity, diabetes, systemic co-morbidities, preoperative blood transfusion, revision procedures, and long anaesthetic duration.

CONCLUSIONS

When obtaining informed consent for TAA a systemic complication rate of 3% and a mortality rate of 0.3% ought to be included and documented.

Soft-Tissue Reconstruction of Complicated Total Ankle Arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) is a popular modality to treat end-stage arthritis or internal ankle derangement. Unfortunately, failure rates remain undesirably high, with severe complications, including prosthesis failure, ankle fusion, and amputation. The importance of a stable soft-tissue envelope for coverage of implant compromise has been previously described, but the predictive factors for successful salvage of complicated TAA remain poorly understood.

METHODS

A retrospective review was conducted of patients requiring soft-tissue reconstruction following TAA wound complications. Patient demographics, history, microbiological data, reconstructive approach, and outcomes data were collected. Statistical analysis was used to abstract factors associated with unsuccessful prosthetic salvage.

RESULTS

In all, 13 patients met inclusion criteria: 8 (61.5%) achieved prosthetic salvage, and 5 (38.5%) failed. The majority (90.9%) of patients presented with infected joints. Reconstructive techniques included skin grafts, dermal substitutes, locoregional flaps, and free tissue transfer. Successful prosthetic salvage was associated with shorter time intervals between wound diagnosis and index reconstructive surgical intervention (median: 20 days for salvage vs 804 days for failure; P = .014). Additionally, salvage was associated with reduced time from the index orthopaedic/podiatric surgical intervention to the index reconstructive surgery procedure (12 vs 727 days; P = .027).

CONCLUSION

The prognosis of complicated TAA requiring soft-tissue reconstruction remains poor, especially in patients who present with infected joints. Several reconstructive techniques, ranging from simple skin grafts to complex free tissue transfers, can be used successfully. Early intervention to achieve soft-tissue coverage is crucial in maximizing salvage rates in the setting of complicated and infected TAA.

LEVEL OF EVIDENCE

Level IV.

Risk Factors for Complications, Longer Hospital Stay, and Readmission After Total Ankle Arthroplasty

BACKGROUND

Studies have shown conflicting results regarding associations of preoperative comorbidities with outcomes after total ankle arthroplasty (TAA). Our aim was to analyze preoperative risk factors for complications, longer hospital stay, and readmission within 30 days after TAA.

METHODS

We conducted a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database. We included 294 patients who underwent TAA from 2009 through 2012. We used multivariate logistic regression to identify risk factors for complications, longer hospital stay, and hospital readmission.

RESULTS

Surgical site infection was the most common complication. Diabetes was associated with greater odds of complications as was current smoker status. Notably, obesity was not associated with greater odds of complications. Age, chronic obstructive pulmonary disease, and diabetes mellitus were associated with longer hospital stays. Surgical site infection was the most common reason for hospital readmission.

CONCLUSIONS

TAA has a low complication rate, with surgical site infection being the most common complication and the most common reason for hospital readmission. Patients with diabetes have greater odds of poor outcomes and prolonged hospital stays after TAA than patients without diabetes. Obesity was not associated with poor outcomes after TAA.

LEVELS OF EVIDENCE

Level III.

Investigation on the contour and bone mineral density of the distal tibial cutting surface used for total ankle arthroplasty

PURPOSE

This study was designed to investigate (1) the contour of the distal tibial cutting surface, and (2) the bone mineral density (BMD) of the distal tibial cutting surface used during total ankle arthroplasty (TAA).

METHODS

Eight-four distal tibial models were created using foot and ankle computerized tomographic (CT) images taken from normal people. The distal tibial cutting surface for TAA was determined to be 10 mm proximal to the tibial plafond. The bony contour and BMD values were determined from the CT image at that level. A bounding box was made on the contour and the width and length of the contour was measured. Regional BMD was evaluated by Hounsfield units (HU) value measurement, with 7 regions of interest (ROI) on 8 different directions for all the 84 CT images. Two different observers made independent measurements and mean HU values for all the 56 ROIs were calculated.

RESULTS

Great variations were found among the contours of the cutting surface especially in term of the shape of the anterior and posterior tibial tubercle, and the fibular notch. These variations could be grouped into six categories. For the BMD of the cutting surface, the medial border of the cutting surface did not included cortical bone. The HU value of seven ROIs, which included cortical bone, were significantly greater than all the other ROIs. Few statistical differences were found by multiple comparisons among HU value of all the 49 ROIs without cortex.

CONCLUSIONS

Great variability existed in the shape and the BMD of the distal tibial cutting surface.

Early Failure of Total Ankle Arthroplasty in a Patient with Ipsilateral Varus Knee Deformity

Multiple risk factors such as age, body mass index (BMI), preoperative diagnosis, smoking, diabetes mellitus, malalignment of an implant, and presence of ipsilateral hindfoot fusion have been shown to contribute to failure of total ankle arthroplasty (TAA). However, the exact causes of TAA failure remain uncertain, and various causes can lead to a need for revision surgery. We report a case of early aseptic loosening of the implant following TAA in a patient with severe varus deformity of the ipsilateral knee.

Risk factors associated with failure of total ankle arthroplasty: a nationwide cohort study

We conducted a nationwide population-based cohort study to identify the risk factors associated with failure of total ankle arthroplasty (TAA). We included 2,914 subjects who underwent primary TAA between January 1, 2010, and December 31, 2016, utilizing the database of the Korean National Health Insurance Service. Failure of TAA was defined as revision TAA or arthrodesis procedures. An increased risk of TAA failure was observed in the < 65 age group versus the ≥ 75 age group [adjusted hazard ratios (aHR) 2.273, 95% confidence interval (CI) 1.223-4.226 in the 60-64 age group; aHR 2.697, 95% CI 1.405-5.178 in the 55-59 age group; aHR 2.281, 95% CI 1.145-4.543 in the 50-54 age group; aHR 2.851, 95% CI 1.311-6.203 in the < 50 age group]. Conversely, the ≥ 65 age group displayed no increase in the risk of TAA failure. The risk of TAA failure was increased in the severely obese group with body mass index (BMI) of ≥ 30 kg/m² versus the normal BMI group (aHR 1.632; 95% CI 1.036-2.570). This population-based longitudinal study demonstrated that age < 65 years and BMI of ≥ 30 kg/m² were associated with increased risk of TAA failure.

Analysis of early failure rate and its risk factor with 2157 total ankle replacements

The failure rate of TAA is still higher than that of other joint replacement procedures. This study aimed to calculate the early failure rate and identify associated patient factors. Data from the Korean Health Insurance Review and Assessment Service database from 2009 to 2017 were collected. We evaluated patients who had TAA as a primary surgical procedure. Early failure was defined as conversion to revision TAA or arthrodesis after primary TAA within five years. Patients with early failure after primary TAA were designated as the "Failure group". Patients without early failure and who were followed up unremarkably for at least five years after primary TAA were designated as the "No failure group". Overall, 2157 TAA participants were included. During the study period, 197 patients developed failure within five years postoperatively, for an overall failure rate of 9.1%. Significant risk factors for early failure were history of chronic pulmonary disease, diabetes, peripheral vascular disease, hyperlipidemia, dementia, and alcohol abuse. A significant increase of odds ratio was found in patients with a history of dementia, chronic pulmonary disease, and diabetes. Surgical indications and preoperative patient counseling should consider these factors.

Economic Analysis and Clinical Outcomes of Short-Stay Versus Inpatient Total Ankle Replacement Surgery

BACKGROUND

We aimed to perform an economic analysis and compare the clinical outcomes between inpatient and short-stay designation total ankle replacement (TAR).

METHODS

We performed a retrospective study on 178 consecutive patients undergoing primary inpatient versus short-stay designation TAR during the 2016 and 2017 fiscal years. Patient demographics, concomitant procedures, perioperative complications, patient-reported outcomes, and perioperative costs were collected.

RESULTS

The mean age of our cohort was 62.5 ± 9.6 years (range, 30-88 years), with a significant difference in age (64.1 vs 58.5 years) (P = .005) and Charlson Comorbidity Index (3.3 ± 1.9 vs 2.3 ± 1.4; P = .002) for the inpatient and short-stay designation groups, respectively. At a mean follow-up of 29.6 ± 11.8 months (range, 12-52.3 months), there was no difference in complications between groups (P = .97). The inpatient designation TAR group had a worse baseline Short Musculoskeletal Functional Assessment (SMFA) function score (76.1; 95% CI, 70.5-81.6) than the short-stay designation TAR group (63.9; 95% CI, 52.5-75.3) while achieving similar final postoperative SMFA function scores for the inpatient (55.2; 95% CI, 51.1-59.2) and short-stay (56.2; 95% CI, 48.2-64.2) designation TAR groups (P > .05). However, the inpatient designation TAR group showed a significantly greater mean improvement in SMFA function score (20.9; 95% CI, 19.4-22.4) compared with the short-stay designation TAR group (7.7; 95% CI, 3.7-11.1) (P = .0442). The total direct cost was significantly higher for the inpatient designation group ($15 340) than the short-stay designation group ($13 002) (P < .001).

CONCLUSION

While inpatient designation TARs were more comorbid, short-stay designation TARs were associated with a 15.5% reduction in perioperative costs, comparable complication rates, and similar final postoperative patient-reported outcome scores compared with inpatient TARs.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Overall Health and the Influence of Physical Therapy on Physical Function Following Total Ankle Arthroplasty

BACKGROUND

The overall health and the importance of physical therapy for people following total ankle arthroplasty (TAA) have been understudied. Our purpose was to characterize the overall health of patients following TAA, and explore the frequency, influence, and patient-perceived value of physical therapy.

METHODS

People who received a TAA participated in this retrospective cohort online survey study. The survey included medical history questions and items from the Patient-Reported Outcomes Measurement Information System (PROMIS) Short Forms. Seven PROMIS domains, reflecting the biopsychosocial model of care (physical, mental, social), were included to examine participant overall health status in comparison to the general population. Items regarding physical therapy participation (yes/no), number of visits, and perceived value (scale 0-10; 10 = extremely helpful) were also included. Descriptive statistics were generated for participant characteristics, PROMIS domain T scores, and physical therapy questions. The influence of participant characteristics or physical therapy visits on PROMIS domain T scores that scored below the population mean were examined with multiple linear regression or ordinal regression.

RESULTS

The response rate was 61% (n=95). Average postoperative time was approximately 3 years (mean [SD]: 40.0 [35.3] months). Physical function and ability to participate in social roles and activities domain T scores were at least 1 SD below the population mean. Most patients received physical therapy (86%; 17.1 [11.0] visits) and found it helpful (7.2 [3.0]). Participant characteristics were minimally predictive of physical function and social participation T scores. Number of physical therapy visits predicted physical function T scores (P = .03).

CONCLUSIONS

Most health domain scores approached the population mean. Physical therapy was perceived to have a high value, and greater visits were related to greater physical function. However, lower physical function and social participation scores suggest that postoperative care directed toward these domains could improve the value of TAA and promote overall health.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Risk factors for periprosthetic joint infection following total ankle replacement

BACKGROUND

Identifying preoperative patient characteristics that correlate with an increased risk of periprosthetic joint infection (PJI) following total ankle replacement (TAR) is of great interest to orthopaedic surgeons, as this may assist with appropriate patient selection. The purpose of this study is to systematically review the literature to identify risk factors that are associated with PJI following TAR.

METHODS

Utilizing the terms "(risk factor OR risk OR risks) AND (infection OR infected) AND (ankle replacement OR ankle arthroplasty)" we searched the PubMed/MEDLINE electronic databases. The quality of the included studies was then assessed using the AAOS Clinical Practice Guideline and Systematic Review Methodology. Recommendations were made using the overall strength of evidence.

RESULTS

Eight studies met the inclusion criteria. A limited strength of recommendation can be made that the following preoperative patient characteristics correlate with an increased risk of PJI following TAR: inflammatory arthritis, prior ankle surgery, age less than 65 years, body mass index less than 19, peripheral vascular disease, chronic lung disease, hypothyroidism, and low preoperative AOFAS hindfoot scores. There is conflicting evidence in the literature regarding the effect of obesity, tobacco use, diabetes, and duration of surgery.

CONCLUSIONS

Several risk factors were identified as having an association with PJI following TAR. These factors may alert surgeons that a higher rate of PJI is possible. However, because of the low level of evidence of reported studies, only a limited strength of recommendation can be ascribed to regard these as risk factors for PJI at this time.

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

BACKGROUND

Wound complications after total ankle arthroplasty (TAA) are a common postoperative complication occurring in 14% to 66% of all surgeries. Soft tissue breakdown along the anterior incision can cause exposure of anterior tendons and implant, and adhesions of the extensor tendons of the foot. Recent publications have advocated for the implantation of dehydrated human amniotic membrane (DHAM) allograft during closure of anterior ankle incisions during TAA. The goal of this study was to determine whether implantation of DHAM allograft in TAAs decreased overall postoperative wound complications.

METHODS

One hundred seventy patients with end-stage ankle arthritis refractory to conservative management underwent TAA with a standard anterior approach by 1 of 3 board-certified foot and ankle orthopedic surgeons. Ninety-one patients underwent closure of the anterior incision with addition of DHAM, whereas 79 patients served as the control (no addition of DHAM). The primary endpoints considered were postoperative complications and reoperation. Included in the postoperative complications was return to the operating room, postoperative plastic surgery intervention, wound communication with the implant, removal of the implant, neurolysis, tendon debridement, and extensor hallucis longus contracture/adhesions.

RESULTS

In the analysis of our demographically homogenous cohorts, there was no statistically significant difference in any postoperative complications between patients closed with DHAM and controls. Return to the operating room occurred in 8.9% of controls and 15.4% of the DHAM group (P = .291). Similarly, there was no statistically significant difference in postoperative plastic surgery, wound communication with the implant, implant removal, neurolysis, and tendon debridement between the control and DHAM groups.

CONCLUSION

The application of DHAM theoretically acts to decrease overall wound complications in TAA. The use of DHAM preceding wound closure in TAA did not show a statistically significant reduction in overall wound complications in our retrospective analysis. Further study, including prospective randomized studies, is needed to further investigate the effectiveness of DHAM in reducing wound complications in TAAs.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Current concepts in the management of ankle arthritis

Ankle arthritis is a common condition. It causes a significant socioeconomic burden, and is associated with significant morbidity. Patients with ankle arthritis are either elderly with significant co-morbidities, or young adults who have previously suffered with ankle injuries, resulting in post-traumatic arthritis. There is a wide variation in the management of these patients with ankle arthritis. We therefore present an overview of the current evidence based management of patients with symptomatic ankle arthritis.

Incidence and predictors of early complications following primary and revision total ankle arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) offers an effective option for end-stage osteoarthritis. The incidence and preoperative risk factors for early adverse events (AEs) following primary and revision TAA may be useful information for providers.

METHODS

A large database was queried from 2010 to 2016 to identify 905 patients of whom 818 underwent primary TAA (90.4%) and 87 underwent revision TAA (9.6%). Data on patient demographics, comorbidities, and hospital length of stay were analyzed as risk factors for reported 30-day AEs.

RESULTS

The overall AE rate was 5.5% (50/905) for the entire cohort. AEs occurred more frequently for revision TAA (9/87) than primary TAA (41/818) cases (OR 2.43, p=0.022). Age (OR 1.03, p=0.045), BMI (OR 1.04, p=0.046), and revision TAA (OR 2.56, p=0.002) were independent risk factors for 30-day AEs in multivariate analysis.

CONCLUSIONS

Older age, higher BMI, and revision cases are associated with a higher risk of AEs.

Relationship Between Body Mass Index and Complications in Total Ankle Arthroplasty: A Single Surgeon's Experience in Ninety-Seven Replacements

The purpose of this study was to compare complication rates of total ankle replacement in 2 groups of patients based on their body mass index (BMI). The total cohort was divided into 2 groups based on BMI. Group 1 included patients with a BMI ≤30 kg/m². Group 2 included patients with a BMI >30 kg/m². Available charts were reviewed for patients who underwent primary total ankle arthroplasty. Patient demographics, BMI, prosthesis used, concomitant procedures, and intraoperative and postoperative complications were recorded. Ninety-seven patients met the inclusion criteria and underwent total ankle replacement between March 2012 and July 2016. Mean follow-up was 26.3 (range 12 to 62) months. Mean age was 66.4 (range 23 to 85) years. Mean BMI was 29.6 (range 20.6 to 49.5) kg/m². Forty-three males and 54 females were included. There were 53 patients in group 1 (BMI ≤30 kg/m²) and 44 patients in group 2 (BMI >30 kg/m²). Total complication rates for group 1 and 2 were 18.9% (10 of 53) and 11.4% (5 of 44), respectively. There were a total of 10 minor complications and 5 major complications. There was no statistical difference between the groups (p = .308) in terms of complication rates. All patients underwent at least 1 concomitant procedure at the time of the index ankle replacement. We found that total ankle replacement can be safely utilized in patients with a BMI >30 kg/m². In the present study, there was no statistical significance in complication rates in the 2 groups.

Risk Factors for Failure of Total Ankle Arthroplasty With a Minimum Five Years of Follow-up

BACKGROUND:

As the popularity of total ankle arthroplasty (TAA) increases and indications expand, surgeons require a better understanding of which patient factors are associated with implant failure. In this study, we aimed to use a large total ankle database to identify independent risk factors for implant failure at mid- to long-term follow-up.

METHODS:

A prospectively collected database was used to identify all patients who underwent primary TAA with a minimum 5 years' follow-up. The primary outcome was revision, defined as removal of one or both metal components; failures due to infection were excluded. Patient and clinical factors analyzed included age, sex, body mass index (BMI), smoking status, presence of diabetes, indication for TAA, implant, tourniquet time, and presence of ipsilateral hindfoot fusion. Preoperative coronal deformity and sagittal talar translation were assessed, as were postoperative coronal and sagittal tibial component alignment. Univariable and multivariable analyses were performed to identify predictors of implant failure. After excluding 5 ankles that failed because of deep infection, 533 ankles with a mean 7 (range, 5-11) years of follow-up met the inclusion criteria. Four implants were used: INBONE I, INBONE II, STAR, and Salto-Talaris.

RESULTS:

Thirty-four ankles (6.4%) were revised or removed a mean 4 (range, 1-9) years postoperatively. The only independent predictors of failure were the INBONE I prosthesis and ipsilateral hindfoot fusion ( P = .006 and P = .023, respectively).

CONCLUSIONS:

This is among the largest studies to analyze the relationship between TAA failure rates and multiple different patient, operative, and radiographic factors. Of note, age, BMI, and amount of deformity were not associated with higher failure rates. Only patients with ipsilateral hindfoot fusion or who received the INBONE I prosthesis were at significantly higher risk of implant failure.

LEVEL OF EVIDENCE:

Level III, retrospective cohort study.

The Effect of Patient Characteristics on 1 to 2-Year and Minimum 5-Year Outcomes After Total Ankle Arthroplasty

BACKGROUND

Total ankle arthroplasty has shown durable improvements in patient-reported outcomes. However, the impact of common comorbidities and patient factors has not been fully characterized. The purpose of this study was to identify patient comorbidities and characteristics that impact outcomes after total ankle arthroplasty.

METHODS

Patients who underwent a total ankle arthroplasty between January 2007 and December 2016 were enrolled into a prospective study at a single academic center. Patients completed outcome measures before the surgical procedure and at the time of follow-up: a visual analog scale (VAS) for pain, the 36-item Short Form Survey (SF-36), and the Short Musculoskeletal Function Assessment (SMFA). Patient and operative factors, along with prevalent preoperative comorbidities, were analyzed for association with preoperative to postoperative changes in 1 to 2-year and minimum 5-year outcomes. Comorbidities that met a significance threshold of p < 0.05 in adjusted analyses were incorporated into multivariable outcome models.

RESULTS

A total of 668 patients with a mean 1 to 2-year follow-up (and standard deviation) of 1.6 ± 0.5 years (range, 10 months to 2 years and 2 months) were included. Patients' pain and function significantly improved across all outcomes (p < 0.05). However, depression, staged bilateral ankle arthroplasty, increased length of stay, a prior surgical procedure, increased American Society of Anesthesiologists (ASA) score, and particular implant types were associated with significantly smaller improvements in at least 1 patient-reported outcome after total ankle arthroplasty in the 1 to 2-year follow-up, although the effects were relatively small. At a minimum 5-year follow-up, smoking, depression, implant type, and staged bilateral ankle arthroplasty were associated with worse outcomes, and a prior surgical procedure, a simultaneous bilateral surgical procedure, and obesity were associated with improved outcomes.

CONCLUSIONS

Patients who underwent total ankle arthroplasty had significant improvement in patient-reported outcomes, although several factors were associated with a small, but significant, negative impact on improvement, including depression, increased ASA score, current smoking, increased length of stay, a prior surgical procedure, and staged bilateral total ankle arthroplasty. Current smoking, obesity, and depression are potentially modifiable risk factors that could be improved prior to total ankle arthroplasty. Patients with these characteristics should be counseled on their risk of limited improvement in ankle pain and disability after total ankle arthroplasty.

LEVEL OF EVIDENCE

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

Increased Early Revision Rate With the INFINITY Total Ankle Prosthesis

BACKGROUND:

A number of new 2-component total ankle arthroplasty systems that emphasize minimal bone resection have been introduced for which few clinical outcomes reports are available. Our aim was to identify the rate of early revision among patients receiving the 2-component INFINITY prosthesis.

METHODS:

Patients from 2 prospectively collected databases at the authors' institution were screened for inclusion in the present study. All patients who underwent a primary total ankle arthroplasty (TAA) with the INFINITY prosthesis and who were at least 1 year postoperative were included. A total of 159 ankles with a mean 20 months of follow up (range, 12-37) met these criteria. All surgeries were performed by 1 of 2 orthopedic foot and ankle surgeons with extensive experience in TAA. The primary outcome was the need for revision surgery, defined as removal of 1 or both metal components. Peri-implant lucency at most recent follow-up was a secondary outcome. Weightbearing radiographs at most recent follow-up were graded for lucency independently by 2 reviewers.

RESULTS:

Sixteen ankles (10%) underwent revision at a mean 13 months postoperatively. The most common reasons for revision were symptomatic tibial component loosening and deep infection (6 patients each, 3.8%). Of the 108 ankles with retained components and at least 1 year of radiographic follow-up, 8 (7.4%) had global lucency around the tibial component suggestive of loosening at most recent follow-up.

CONCLUSIONS:

Our initial review of patients undergoing TAA with this new 2-component prosthesis demonstrates an elevated early revision rate due to tibial component loosening compared to other implant systems.

LEVEL OF EVIDENCE:

Level IV, case series.

Effects of Cryopreserved Amniotic Membrane-Umbilical Cord Allograft on Total Ankle Arthroplasty Wound Healing

Relatively high rates of wound healing complications continue to be reported with a total ankle arthroplasty (TAA) anterior incision. The amniotic membrane-umbilical cord (AM-UC) allograft is a regenerative orthobiologic adjunct that modulates wound healing by down-regulating inflammation, enhancing local healing and antimicrobial factors, and reducing scar formation. The purpose of this study was to determine whether local application of a cryopreserved AM-UC allograft enhances soft tissue healing after TAA. A total of 104 patients with symptomatic ankle arthritis who failed conservative management underwent standard TAA. At skin closure, patients were allocated to either the treatment (local application of AM-UC) or control (no allograft) group. Demographic data, patient comorbidities, and radiographic findings were collected. The primary outcome was a major complication necessitating reoperation. Secondary outcomes were time to healing, minor complications (i.e., skin dehiscence, local wound care, use of antibiotics), and patient scar assessment. Local application of an AM-UC allograft significantly decreased the overall time to skin healing (28.5 days vs 40 days; p = .03). Two patients required a reoperation for soft tissue wound complications, with no difference (p = 1.00) between the groups. No statistically significant difference was detected in terms of skin dehiscence, local wound care, or antibiotic prescriptions in the 2 groups. Regenerative technology using local application of a cryopreserved AM-UC allograft may enhance TAA outcomes by decreasing the time to healing. Larger randomized controlled trials are needed to determine whether an AM-UC allograft enhances soft tissue wound healing and ultimately reduces the incidence of devastating soft tissue complications.

Effect of Obesity on Total Ankle Arthroplasty: A Systematic Review of Postoperative Complications Requiring Surgical Revision

Total ankle arthroplasty has become an increasingly used alternative to ankle arthrodesis for the treatment of end-stage ankle arthritis. However, despite progressive technological advances and the advent of multiple commercial implant systems, some concern remains for the relatively high complication and failure rates. The objective of the present investigation was to perform a systematic review of the incidence of complications in obese patients undergoing total ankle arthroplasty. We performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses, and prospective clinical trials with ≥15 total participants, a mean follow-up period of ≥12 months, ≥1 defined cohort with a body mass index of ≥30 kg/m², and a reported incidence rate of complications requiring revisional surgery at the final follow-up point. Four studies met our inclusion criteria, with a total of 400 implants analyzed. Of these, ≥71 (17.8%) developed a complication requiring a revisional surgical procedure. The most commonly reported surgeries were revision of the metallic components and ankle gutter debridement. It is our hope that our investigation will allow foot and ankle surgeons to more effectively communicate the perioperative risk to their patients during the education and consent process.

[Recent progress in foot and ankle surgery]

The article focuses on the recent progress in foot and ankle surgery, including the diagnosis of disease, treatment protocols, outcomes, and evaluation tools as well as other innovations. New and accurate diagnostic modalities and measurements have undergone a breakthrough. Diagnostic modalities tend to be simpler and less expensive. Measurement tools also change to simpler and more accurate. The accuracy and efficacy of surgery and the minimally invasive method have become more popular and important. New treatments and basic research have also made breakthroughs.

Obesity in Elective Foot and Ankle Surgery

Obesity is a global health problem with significant economic and health consequences. There is very little literature in regards to obesity and its effect on foot and ankle surgery, and to the author's knowledge, there has been no consolidated review on this subject to date. The purpose of this article is to provide a comprehensive review as it pertains to foot and ankle surgery, with hopes of improving surgeon decision making, mitigating risk, and providing better outcomes for patients. A better understanding of the effects of obesity also allows for improved prognostic performance.

The Influence of Obesity on Total Elbow Arthroplasty

Total elbow arthroplasty (TEA) has undergone a significant evolution in indications and outcomes in the past decade. Although rheumatoid patients once had the overwhelming number of TEAs, now TEAs for the sequelae of trauma predominate. Furthermore, as obesity has mirrored the increase in the posttraumatic population, TEA complications have increased whereas the durability of implants under these loads has decreased. Solutions are urgently needed to address the complications and revision burden related to posttraumatic deformity and obesity.

Perspectives in Treatments of End-Stage Ankle Arthritis Among Orthopaedic Surgeons

Background:

This study aimed to assess the preferred operative treatment for patients over the age of 60 with end-stage ankle arthritis and perspectives on total ankle replacement (TAR) among American Orthopaedic Foot & Ankle Society (AOFAS) members. Associated factors were analyzed for potential contraindications among members with different levels of experience.

Method:

A questionnaire containing 6 questions was designed and sent to 2056 members of the AOFAS. Responses were received from 467 orthopaedic surgeons practicing in the United States (76%), Canada (5%), and 26 other countries (20%). Participants were grouped for response comparisons according to country as well as experience level. Differences in contraindications were compared using χ2 tests or exact tests.

Results:

Respondents practicing in the United States and surgeons who perform 11 or more TARs per year tended to recommend operative treatments favoring TAR and displayed recognition of its increasing role ( P < .05). Overall, respondents felt that 41% of typical patients over 60 years old with end-stage arthritis would be best treated with TAR. Talus avascular necrosis, morbid obesity (body mass index >40 kg/m2), and poorly controlled diabetes with neuropathy were most recognized as the absolute contraindications to TAR. Surgeon’s experience affected the consideration of these clinical factors as contraindications.

Conclusions:

Total ankle replacement has a substantial and increasing role in the treatment of end-stage ankle arthritis in patients over the age of 60. Absolute and potential contraindications of the procedures were indicated from a cross-sectional survey of AOFAS members. Surgeons more experienced with total ankle replacement felt more comfortable employing it in a wider range of clinical settings.

Level of Evidence:

Level III, therapeutic.

The Effect of Obesity on Surgical Treatment of Achilles Tendon Ruptures

INTRODUCTION

We conducted a retrospective comparison of surgical treatment outcomes for acute Achilles tendon ruptures in nonobese and obese patients.

METHODS

Between October 2006 and April 2014, we studied 76 patients with acute midsubstance Achilles tendon rupture: 44 nonobese and 32 obese (body mass index >30 kg/m). Preoperative and postoperative function and pain were graded with the Foot and Ankle Ability Measure (FAAM) Sports subscale and the visual analog scale for pain, respectively.

RESULTS

All 76 patients presented for follow-up. On a scale of 100, the mean FAAM score for the nonobese patients increased from 38.1 preoperatively to 90.2 at final visit, and on a scale of 10, the mean pain score decreased from 7.1 preoperatively to 1.6 at latest follow-up. For obese patients, the mean FAAM score increased from 34.2 preoperatively to 83.3 at final visit, and the mean pain score decreased from 6.2 preoperatively to 1.9 at the latest follow-up. The postoperative scores of the two groups were not significantly different (P > 0.05). Postoperative wound complications developed in six nonobese patients and one obese patient (13.6% and 3.1%, respectively; P < 0.05).

DISCUSSION

To our knowledge, comparing outcomes from surgically treated acute Achilles ruptures in nonobese and obese patients has not been previously reported. We found that both obese and nonobese patients can achieve improved Achilles tendon function and pain as a result of surgery.

CONCLUSIONS

The findings of this study demonstrate that both nonobese and obese patients can achieve a high rate of improvement in ankle function and pain relief after surgical repair of the Achilles tendon.

Patient selection for total ankle arthroplasty

Total ankle arthroplasty is a treatment option for end-stage osteoarthritis of the ankle, as is ankle arthrodesis. Many variables, including patient characteristics, are thought to influence clinical outcome and survival. As with any surgery, but especially with total ankle replacement (TAR), patient selection is considered critical for good (long-term) outcome. In this review, we summarize the available scientific evidence regarding patient characteristics and its influence on the results of TAR.

Malalignment Correction of the Lower Limb Before, During, and After Total Ankle Arthroplasty

One of the main challenges in ankle replacement is correction of any deformities in the operative limb. Deformity can be found proximal and distal to the ankle joint as well as in the ankle joint. There are static and dynamic deformities that can create unbalanced ankle joints causing early and often catastrophic failure. Surgeons must recognize the deformities that are present and use sound judgment to balance the ankle joint with procedures before, during, or after total ankle implantation. This article helps clinicians to identify deformity and provides a basic template to consider how to address each challenge.