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

Outcomes of Total Ankle Replacement

Total ankle replacement (TAR) is an effective operative treatment of end-stage ankle osteoarthritis (OA) in the appropriate patient, conferring improved kinematic function, decreased stress across adjacent joints, and offering equivalent pain relief in comparison to ankle arthrodesis (AA). It is important to consider patient age, weight, coronal tibiotalar deformity, joint line height, and adjacent joint OA to maximize clinical and patient outcomes. Both mobile-bearing and fixed-bearing implants have demonstrated favorable clinical outcomes, marked improvement in patient-reported outcomes, and good survivorship; however, implant survivorship decreases with longer term follow-up, necessitating constant improvement of primary and revision TAR options.

Ankle osteoarthritis: Toward new understanding and opportunities for prevention and intervention

The ankle infrequently develops primary osteoarthritis (OA), especially when compared to the hip and the knee. Ankle OA instead generally develops only after trauma. The consequences of end-stage ankle OA can nonetheless be extremely debilitating, with impairment comparable to that of end-stage kidney disease or congestive heart failure. Disconcertingly, evidence suggests that ankle OA can develop more often than is generally appreciated after even low-energy rotational ankle fractures and chronic instability associated with recurrent ankle sprains, albeit at a slower rate than after more severe trauma. The mechanisms whereby ankle OA develops after trauma are poorly understood, but mechanical factors are implicated. A better understanding of the prevalence and mechanical etiology of post-traumatic ankle OA can lead to better prevention and mitigation. New surgical and conservative interventions, including improved ligamentous repair strategies and custom carbon fiber bracing, hold promise for advancing treatment that may prevent residual ankle instability and the development of ankle OA. Studies are needed to fill in key knowledge gaps here related to etiology so that the interventions can target key factors. New technologies, including weight bearing CT and biplane fluoroscopy, offer fresh opportunities to better understand the relationships between trauma, ankle alignment, residual ankle instability, OA development, and foot/ankle function. This paper begins by reviewing the epidemiology of post-traumatic ankle OA, presents evidence suggesting that new treatment options might be successful at preventing ankle OA, and then highlights recent technical advances in understanding of the origins of ankle OA to identify directions for future research.

Current concepts in ankle arthrodesis

Ankle osteoarthritis is primarily post traumatic and affects a younger population. It, therefore, not only has a negative effect on the quality of life but also impacts the working life of these patients. A thorough history, clinical examination followed by relevant investigations, radiological and hematological, can provide the necessary information to classify the severity and associated deformity of this condition. This will provide guidance to the necessary and appropriate commencement of treatment. Options include conservative or surgical which can be joint sparing or sacrificing procedures. Ankle arthrodesis, a joint sacrificing procedure, has long been the 'gold standard' and has stood the test of time in providing a pain free plantigrade foot. However, ankle arthroplasty, with newer materials and better understanding, is increasingly being considered for ankle arthritis. In regions with financial constraints and limited accessibility to modern implants ankle arthrodesis should be the preferentially offered surgical procedure. This article will briefly cover the pathophysiology of ankle arthritis, clinical presentation, and its surgical treatment with a focus on ankle arthrodesis.

Total Ankle Arthroplasty Templating: Preoperative Computer Templating Correlates Highly with Intraoperative Component Selection

Proper alignment and sizing are critical to the performance of a successful total ankle arthroplasty. While it is common practice in preoperative planning prior to total knee and total hip arthroplasty, preoperative computer templating has not been well established in the setting of total ankle arthroplasty. A retrospective review of all total ankle arthroplasties performed during a 10-year period by a single fellowship-trained orthopaedic surgeon was conducted. Computer templating was utilized for all preoperative Anterior to Posterior (AP) and lateral standing radiographs, and templated component sizes were compared to the operative reports and postoperative radiographs to determine the precision of the available templates. Statistical analysis was performed with Interclass Correlation Coefficients (ICC) and descriptive statistical tests. Seventy patients with a mean age of 64.8 years (range, 48-87) and mean BMI of 30.34 (range, 19.1-55.6) were included. The ICC demonstrated that both the AP (ICC 0.80 - 95% CI 0.679-0.876) and lateral (ICC 0.786 - 95% CI 0.655-0.867) radiographs provided accurate tibial total ankle arthroplasty component templating. Similarly, the AP (ICC 0.842 - 95% CI 0.745-0.902) and lateral (ICC 0.809 - 95% CI 0.692-0.881) radiographs provided accurate talar templating. No differences were observed when comparing AP to lateral radiographs in percentage of correct component templating: tibial AP 61.4% vs lateral 58.6%, p = .119 and talar component AP 57.1% vs lateral 45.7%, p = .176. These study findings demonstrate that preoperative templating for total ankle arthroplasties is accurate in determining appropriate implant sizing. Accurate templating is an absolute necessity for future templating studies.

Ankle Osteoarthritis

Ankle osteoarthritis (OA) is less common than knee and hip OA, and 75% to 80% of all presentations are posttraumatic in nature, resulting from either ligamentous or bony injury to the ankle. While the ankle joint cartilage demonstrates capacity for self-restoration, the ankle joint is sensitive to aberrancies in biomechanics and the inflammatory milieu after an injury is thought to contribute to the onset of posttraumatic ankle OA. Conservative care for ankle OA is currently centered on pain reduction, and derivatives that may delay the progression of ankle OA are the subject of ongoing investigation. Surgical management for end-stage ankle OA currently focuses on ankle arthrodesis and total ankle arthroplasty. Specific indication for one procedure over the other is the topic of much debate. While total ankle arthroplasty has become more frequently used with the advent of newer generation systems, ankle arthrodesis may still be favored in younger patients with high-demand occupations.

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.

Efficacy of Maitland Mobilization and Myofascial Release as Preoperative Care in Ankle Arthritis With Severe Equinus Deformity: A Rare Case Report

Advanced post-traumatic ankle osteoarthritis (PTAO) is a severe condition that affects less than one percent of the population, with rare incidence. It accounts for less than 5% of all osteoarthritis (OA) cases. Physiotherapy enhances functionality by strengthening the dynamic stabilizers of the ankle, such as the calf, soleus, tibialis anterior, and peroneal muscles, and by improving proprioception, which aids in balance and coordination. As OA progresses, individuals may experience early losses in their ability to perform everyday activities and job tasks. Occupational therapy and cardiovascular exercises are crucial for conserving energy while walking and improving posture at work. This case report involves a 39-year-old male who presented to the hospital with pain, swelling, difficulty walking, and an equinus deformity. After diagnosing him with ankle arthritis, the orthopedic specialist recommended an X-ray. Medication and physical therapy were administered to educate and rehabilitate the patient, aiming to improve pain, range of motion (ROM), strength, and walking capacity. A four-week treatment plan, along with medication, resulted in significant improvements in pain reduction, ROM, strength, and walking ability. This case report also underscores the importance of focusing on preoperative care to ensure that post-surgery, the hip and knee ranges are normal, and the patient experiences less difficulty walking. Future studies are needed to explore this condition further and to evaluate the effectiveness of ultrasound therapy in such cases, as it was not effective in reducing pain in this instance.

Concerns beyond ankle symptoms predominate healthcare professionals' views of patients with ankle osteoarthritis: A qualitative study

OBJECTIVES

Explore healthcare professionals' perspectives on the main problems that their patients with ankle osteoarthritis experience and to propose health-related domains.

METHODS

A qualitative study using semi-structured interviews was conducted with an international multidisciplinary group of healthcare professionals identified as ankle experts. Eligibility criteria were aged ≥18 years, and a certified healthcare professional with ≥ 5-year experience post-qualification in working with ankle osteoarthritis and/or chronic ankle pain. Interviews were recorded, transcribed verbatim and thematically analysed.

RESULTS

Twenty-one healthcare professionals (20 males; mean (range) age 49 (34-72) years) from four professions (orthopaedic surgeons (n = 9), athletic trainers (n = 5), physiotherapists (n = 4) and podiatrists (n = 3)) were interviewed. Four main themes were identified: 1) people with ankle osteoarthritis have difficulty with weight-bearing activities; 2) symptoms of pain and stiffness predominate, alongside swelling, instability, weakness and poor balance; 3) chronic pain in ankle osteoarthritis has psychosocial consequences; and 4) the loss of activities of daily living and independence compromises quality of life. We proposed 15 health-related domains that emerge from the interview data.

CONCLUSION

Healthcare professionals recognise that ankle osteoarthritis patients have difficulty in physical, sporting, and occupational weight-bearing activities, and they live with persistent ankle pain, stiffness and other symptoms that have physical and psychosocial consequences. The health-related domains derived from interviews with expert healthcare professionals will contribute to the development of a core domain set for ankle osteoarthritis.

Estimating three-dimensional foot bone kinematics from skin markers using a deep learning neural network model

The human foot is a complex structure comprising 26 bones, whose coordinated movements facilitate proper deformation of the foot, ensuring stable and efficient locomotion. Despite their critical role, the kinematics of foot bones during movement remain largely unexplored, primarily due to the absence of non-invasive methods for measuring foot bone kinematics. This study addresses this gap by proposing a neural network model for estimating foot bone movements using surface markers. To establish a mapping between the positions and orientations of the foot bones and 41 skin markers attached on the human foot, computed tomography scans of the foot with the markers were obtained with eleven healthy adults and thirteen cadaver specimens in different foot postures. The neural network architecture comprises four layers, with input and output layers containing the 41 marker positions and the positions and orientations of the nine foot bones, respectively. The mean errors between estimated and true foot bone position and orientation were 0.5 mm and 0.6 degrees, respectively, indicating that the neural network can provide 3D kinematics of the foot bones with sufficient accuracy in a non-invasive manner, thereby contributing to a better understanding of foot function and the pathogenetic mechanisms underlying foot disorders.

The INVISION Talar Component in Revision Total Ankle Arthroplasty: Analysis of Early Outcomes

INTRODUCTION

Launched in 2018 for revision total ankle arthroplasty (rTAA), the INVISION talar component addresses subsidence when poor talar bone stock is present. Due to the recency of the market-availability of the INVISION, studies evaluating its efficacy are lacking. This study presents the first analysis of early-term outcomes of patients undergoing rTAA with the INVISION talar component.

METHODS

This was a single-center, retrospective review of 28 patients undergoing rTAA with the INVISION talar component and INBONE II tibial component performed between 2018 and 2022. Data on preoperative characteristics, postoperative complications, secondary procedures, and survivorship were collected. The primary outcome measures were rates of major complications, re-operation, and implant failure. Secondary outcomes included post-operative changes in varus and valgus alignment of the tibia and talus.

RESULTS

The most common secondary procedures performed with rTAA were medial malleolus fixation (n = 22, 78.6%) and gastrocnemius recession (n = 14, 50%). Overall, 10.7% (n = 3) of patients underwent reoperation and 14.3% (n = 4) suffered major complications. Incidence of implant failure was 10.7% (n = 3). All reoperations were caused by infection. Mean varus alignment of the tibia and talus improved from 4.07 degrees and 4.83 degrees to 1.67 degrees and 1.23 degrees, respectively. Mean valgus alignment of the tibia and talus improved from 3.67 degrees and 4.22 degrees to 2.00 degrees and 2.32 degrees, respectively.

CONCLUSIONS

In a series of 28 patients undergoing rTAA with the INVISION talar component, we discovered comparatively low rates of reoperation, major complication, and implant failure (10.7%, 14.3%, and 10.7%). The INVISION system appears to have a reasonable safety profile, but further studies evaluating long-term outcomes are required to assess the efficacy of the INVISION system.

Development of a core domain set for ankle osteoarthritis: An international consensus study of patients and health professionals

OBJECTIVES

To develop an internationally agreed-upon core domain set for ankle osteoarthritis (OA).

METHODS

In a three-part Delphi process, a group of multidisciplinary health professionals with expertise in ankle OA and people with ankle OA responded to online questionnaires. The questionnaires proposed a list of 29 candidate domains derived from a systematic review of ankle OA research, and interviews with people with ankle OA and health professionals. Consensus was defined a priori as ≥70% agreement in people with ankle OA and health professionals whether a domain should or should not be included in a core domain set. An online consensus meeting was held to discuss and resolve undecided candidate domains.

RESULTS

A total of 100 people (75 health professionals and 25 people with ankle OA) from 18 countries (4 continents) participated in this study. Five domains reached consensus for inclusion in a core domain set for ankle OA - pain severity, health-related quality of life, function, disability and ankle range of motion. Twenty-one candidate domains reached agreement not to be included in the core domain set, and three domains remained undecided (ankle instability, physical capacity, and mental health).

CONCLUSION

This international consensus study, which included people with ankle OA and health professionals, has established a core domain set for ankle OA with five domains that should be measured and reported in all ankle OA trials - pain severity, health-related quality of life, function, disability and ankle range of motion. This core domain set will guide the reporting of outcomes in clinical trials on ankle OA. Future research should determine which outcome measurement instruments should be used to measure each of the core domains.

Predictive Factors of Postoperative Pain in Patients With Tibiotalocalcaneal Arthrodesis With an Intramedullary Nail: A Retrospective Review

Tibiotalocalcaneal arthrodesis has been shown in literature to have good results in regards to low complication rates and deformity correction. While previous studies have investigated functional outcomes and complication rates, no large-scale studies have looked at pain outcomes. The present study performed a retrospective review of 154 extremities to analyze how a patient's comorbidities and characteristics influence pain outcomes following a tibiotalocalcaneal arthrodesis. The present study found an average change of pain from 7.1 to 3.0 in at least a 6 month follow up. We found that a diagnosis of chronic pain and tobacco use had statistically significant less pain improvement compared to patients without chronic pain or current tobacco use. We determined no statistically significant difference in pain outcomes for patients with or without Charcot deformity. Lastly, we found that with older patients there was more pain improvement observed. We physicians can educate current tobacco users of the improved pain outcomes with tobacco cessation prior to surgery. We recommend a multidisciplinary approach for pain in patients with a pre-operative diagnosis of chronic pain and to educate patients on realistic postoperative pain outcomes.

Static posture weightbearing joint angle differences in patients with varus ankle osteoarthritis

BACKGROUND

Advanced varus ankle osteoarthritis is a debilitating disease that can present with limited physical function, severe pain, and diminished quality of life. Weightbearing computed tomography enables submillimeter 3-dimensional visualization, computational analyses, and enhanced diagnoses in reporting complex degenerative changes more accurately.

RESEARCH QUESTION

This study set to compare static posture weightbearing joint angle differences in healthy and varus ankle osteoarthritis patients (compensated and non-compensated).

METHODS

Our retrospective assessment included 70 individuals, 44 of whom were diagnosed with advanced varus ankle osteoarthritis, and the remaining 26 were healthy participants to serve as controls. An automatic anatomic coordinate system was applied to each patient's 3-dimensional talus and calcaneus bone reconstructions from weightbearing computed tomography scans. Subtalar and midtarsal joint angles were calculated using Euler angles.

RESULTS

We report statistical differences between the healthy group and both advanced varus osteoarthritis groups for midtarsal inversion/eversion. Specifically, both osteoarthritis groups' midtarsal joints were more inverted and plantarflexed as compared to healthy participants. Compensated and non-compensated subtalar joints were statistically different with respect to inversion/eversion. Non-compensated ankles exhibited a similar mean to healthy ankles who were both less inverted than compensated ankles.

SIGNIFICANCE

Our study helps physicians to better understand underlying mechanisms of peritalar compensation in varus ankle osteoarthritis. Patients featuring hindfoot compensation on average had a greater subtalar joint angle indicating greater inversion than healthy and non-compensated patients.

Change of Segmental Motion Following Total Ankle Arthroplasty Using a 3-Dimensional Multi-segment Foot Model

Background

Total ankle arthroplasty (TAA) enhances patients' subjective outcomes with respect to pain and function. The aim of this study was to analyze the biomechanical changes of the affected limb following TAA using gait analysis with a 3-dimensional multi-segment foot model (3D MFM).

Methods

We reviewed medical records, simple radiographs, and gait analyses using a 3D MFM of patients who underwent TAA for severe varus ankle arthritis. Preoperative and postoperative gait data of 24 patients were compared. Postoperative gait analyses were done at least 1 year after surgery.

Results

TAA significantly increased stride length (p = 0.024). The total range of motion of all planes in the hindfoot and forefoot showed no significant changes between preoperative and postoperative states. Hindfoot was significantly plantarflexed and pronated after TAA, while forefoot was significantly supinated in all phases. After appropriate calculations, the genuine coronal motion of the hindfoot showed no changes after TAA in all phases.

Conclusions

TAA did not result in biomechanical improvements of segmental motions in the forefoot and hindfoot, except for changes to the bony structures. Therefore, it is important to point out to patients that TAA will not result in significant improvement of ankle function and range of motion. Clinicians can consider this information during preoperative counseling.

Contemporary modern total ankle arthroplasty (TAA): A systematic review and meta-analysis of indications, survivorship and complication rates

BACKGROUND

This study evaluates the clinical outcomes of contemporary total ankle arthroplasty (TAAs) to primarily establish the current benefits and risks to facilitate informed decision making to secondarily establish if improvements are seen between subsequent generations of implants, bearing philosophy, and associated surgical technique.

METHODS

A systematic review and meta-analysis of published data from January 2000 to January 2020 was conducted following PRISMA guidelines.

INCLUSION CRITERIA

English language papers, adult population, ≥20 ankles with a minimum follow up ≥24 months, pre- and post-operative functional scores available. Ankle implants were characterised by generations, which were determined from the original studies and confirmed based on literature set definitions.

RESULTS

A total of 4642 TAAs in 4487 patients from 51 studies were included. The mean age was 61.9-years and follow up 57.8-months. Overall, 10-year survivorship rates were 77.63 %, with mobile bearing designs showing a small but significant advantage. Improved survivorship favoured the most modern implants at both two (p < 0.05), and 10-years (p < 0.01). The relative risk of a complication occurring improved with the evolution of implants e.g., nerve injury, and post-operative complications such as fracture, wound complications (e.g., dehiscence or heamatoma) and radiological abnormalities (e.g., radiolucencies, heterotopic bone formation and aseptic loosening). However, surgical site infection, and intra-operative fracture rates remain implant independent.

CONCLUSIONS

Modern TAA offers improved survivorship, even with a trend to lower mean implantation age, similar complexity and ever changing indications. It would appear that implant evolution has reduced risks, especially those associated with revision, without affecting functional outcomes.

Does anxiety influence outcome measurements in ankle replacement patients?

BACKGROUND

Total ankle arthroplasty (TAA) is increasingly used to treat end-stage ankle arthritis to restore ankle functional outcomes and alleviate pain. This treatment outcome may be influenced by pre-morbid patient anxiety.

METHODS

Twenty-five Infinity TAA implants were prospectively followed post-operatively with a mean follow-up time of 34.18 months. Demographic, clinical, and functional outcomes were assessed. Analysis was performed on the effect of anxiety, reported by the HADS, on patient-perceived postoperative pain, functioning, and quality of life.

RESULTS

Postoperative the PROMs and Range of Motion (ROM) improved significantly. Linear regression analysis and Pearson correlation showed a significant negative effect of anxiety on the postoperative patient-reported outcome measurements (EQ-5D-5L, VAS, and MOxFQ) at the end of follow-up.

CONCLUSION

Good functional, clinical, and radiographic results were observed in this prospective cohort study. Anxiety had a negative influence on the outcome of the patient-reported outcome measurements (EQ-5D-5L and MOxFQ) postoperatively.

LEVEL OF EVIDENCE

Level III, prospective cohort study.

Hindfoot motion according to subtalar compensation and ankle osteoarthritis stage analyzed by a multi-segment foot model

BACKGROUND

The biomechanics of the hindfoot in ankle osteoarthritis (OA) are not yet fully understood. Here, we aimed to identify hindfoot motion in a gait analysis using a multi-segment foot model (MFM) according to ankle OA stage and the presence of subtalar compensation defined by hindfoot alignment.

METHODS

We retrospectively reviewed the medical records, plain radiographs, and gait MFM data of 54 ankles admitted to our hospital for the treatment of advanced ankle OA. Spatiotemporal gait parameters and three-dimensional motions of the hindfoot segment were analyzed according to sex, age, body mass index, Takakura classification, and the presence of subtalar compensation. Twenty ankles were categorized as compensated group, and 34 ankles as decompensated group.

RESULTS

No spatiotemporal gait parameters differed significantly according to the presence of subtalar compensation or ankle OA stage. Only normalized step width differed significantly (P = 0.028). Average hindfoot motion (decompensation vs. compensation) did not differ significantly between the sagittal and transverse planes. Graphing of the coronal movement of the hindfoot revealed collapsed curves in both groups that differed significantly. Compared with Takakura stages 3a, 3b, and 4, cases of more advanced stage 3b had a smaller sagittal range of motion than those of stage 3a (P = 0.028). Coronal movement of the hindfoot in cases of Takakura stage 3a/3b/4 showed a relatively flat pattern.

CONCLUSIONS

The spatiotemporal parameters were not affected by the hindfoot alignment resulting from subtalar compensation. The sagittal range of hindfoot motion decreased in patients with advanced ankle OA. Once disrupted, the coronal movement of the subtalar joint in ankle OA did not change regardless of ankle OA stage or hindfoot compensation state.

Total Ankle Arthroplasty in Young Patients

With continuing advancements in total ankle arthroplasty (TAA), it is quickly becoming the procedure of choice for older patients with end-stage ankle arthritis. Multiple studies have been conducted on younger patients who have undergone TAA with promising results, but is it the procedure of choice? Considerations of TAA versus ankle arthrodesis, TAA implant longevity, outcomes of revision TAA, and whether patients should be offered an arthrodesis with plans for conversion to arthroplasty may help elucidate whether pursuing ankle arthroplasty in a younger, more active population is the correct approach for surgeons.

Comparisons of ankle arthrodesis with different internal fixation methods in the treatment of post-traumatic osteoarthritis

BACKGROUND

The aim of this study was to explore the clinical efficacy of ankle arthrodesis with different internal fixation methods in the treatment of post-traumatic osteoarthritis.

METHODS

We collected 85 patients with post-traumatic osteoarthritis who underwent different ankle arthrodesis between December 2015 and December 2020. The operation performance, complication rate, hindfoot alignment, talus tilt angle, visual analogue scale (VAS), and American Orthopedic Foot and Ankle Society (AOFAS) score were preoperatively and postoperatively evaluated.

RESULTS

In an anterior approach, the locking plate-fixation exhibited a similarity in operation time, incision length, postoperative drainage, bone fusion, hindfoot alignment, and talus tilt angle with fibula support compression screw-fixation, but it was better in increasing postoperative AOFAS. The locking plate-fixation in the anterior approach had lower operation time, incision length, and postoperative drainage than that in the lateral approach. In addition, the lateral locking plate combined with posterolateral compression screw fixation (LLPPCSF) presented shorter bone fusion time, higher AOFAS score, and lower complication rate than either plate- or screw-fixation alone.

CONCLUSION

Lateral locking plate fixation was better than fibula support compression screw fixation in relieving postoperative pain. Anterior locking plate fixation was more time-saving and less invasiveness than lateral locking plate fixation, but its application was limited in low degree of ankle deformation. LLPPCSF was the most effective in improving bone fusion and postoperative pain, considering an optimal option for the treatment of post-traumatic osteoarthritis.

Bilateral Total Ankle Arthroplasty

Patients with bilateral ankle arthritis have higher rates of primary and secondary/inflammatory arthritis and a more debilitating condition than those with unilateral pathology. The limited bilateral total ankle arthroplasty (TAA) literature supports both 1-surgeon and 2-surgeon team bilateral TAAs as safe and effective with comparable improvements in patient-reported outcome measures (PROMs), complications, reoperations, and prosthesis survival as unilateral TAA and staged bilateral TAA. Additional benefits of bilateral arthroplasty supported in the hip and knee literature include cost reduction, noninferior and even superior perioperative complication profiles, improved PROM and satisfaction, shorter recovery time, early rehabilitation, and less time away from employment.

Outcomes of Total Ankle Arthroplasty After Periprosthetic Cyst Curettage and Bone Grafting

Total ankle arthroplasty (TAA) has become a popular management option for ankle arthritis. Periprosthetic osteolysis is one of the most common causes for reoperation in TAA. A CT scan should be done in all suspected osteolysis cases to confirm location, quantify size and aid in surgical planning. These patients are often asymptomatic with limited evidence regarding appropriate management. Smaller lesions should be monitored for progression in size. Periprosthetic cysts measuring 10-15mm in all three axes should be considered for debridment and curettage with autogenous bone grafting. The authors believe that bone grafting of large asymptomatic periprosthetic cysts could prevent implant failure.

Comparison of Loss of Bone Height Following Total Ankle Arthroplasty Versus Tibiotalocalcaneal Arthrodesis

Ankle arthrodesis and total ankle arthroplasty are both well-accepted surgical treatment options for end-stage ankle arthrosis. However, total ankle arthroplasty has gained popularity as the survivability of implants is improving. It is understood that there is loss of bone height following tibiotalocalcaneal arthrodesis, but to our knowledge, this has not been investigated in the setting of total ankle arthroplasty. A retrospective radiographic review was conducted over a 5-year period. We investigated all patients who underwent a tibiotalocalcaneal arthrodesis or total ankle arthroplasty for treatment of ankle arthritis by a single fellowship-trained orthopedic surgeon. The anterior and posterior height measurements were measured on preoperative and postoperative lateral radiographs. Differences between preoperative and postoperative heights were analyzed through a series of analyses of covariance. One hundred and thirty-three patients and 143 operative extremities were included: 71 operative extremities in the tibiotalocalcaneal arthrodesis group (mean age 55.5 ± 13.3 years, BMI 32.2 ± 7.9) and 72 in the total ankle arthroplasty group (mean age 65.4 ± 9.5 years, BMI 30.7 ± 6.4). Statistical analysis demonstrated a loss of height in the tibiotalocalcaneal arthrodesis group, and an increased anterior and posterior height in the total ankle arthroplasty group. However, when comparing the arthroplasty group and arthrodesis group only the anterior height measurement reached statistical significance when stratified by gender (p < .001). The potential change in height is an important factor to consider during surgical planning as a limb length discrepancy may result.

Second-Look Arthroscopy Shows Inferior Cartilage after Bone Marrow Stimulation Compared with Other Operative Techniques for Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare cartilage quality after different surgical interventions for osteochondral lesions of the talus (OLT), evaluated by second-look arthroscopy. Secondary aims were to report concomitant diagnoses, and to correlate cartilage quality with clinical and radiological outcomes. This review hypothesizes that the cartilage repair after bone marrow stimulation (BMS) is inferior to the other available treatment options.

METHODS

PROSPERO ID: CRD42022311489. Studies were retrieved through PubMed, EMBASE (Ovid), and Cochrane Library. Studies were included if they reported cartilage quality after second-look investigation after surgical treatment of OLT. The primary outcome measure was the cartilage quality success and failure rates (%) per surgical intervention group. Correlations between the cartilage quality and clinical or radiological outcomes were calculated.

RESULTS

Twenty-nine studies were included, comprising 586 ankles that had undergone second-look arthroscopy on average 16 months after initial surgery. The success rate for BMS was 57% (95% confidence interval [CI] = 48%-65%), for fixation (FIX) 86% (95% CI = 70%-94%), for osteo(chondral) transplantation (OCT) 91% (95% CI = 80%-96%), for cartilage implementation techniques (CITs) 80% (95% CI = 69%-88%), and for retrograde drilling 100% (95% CI = 66%-100%). The success rate of BMS was significantly lower than FIX, OCT, and CIT (P < 0.01). There were no significant differences between other treatment groups. A moderate positive significant correlation between the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and the International Cartilage Repair Society score (ICRS) was found (ρ = 0.51, P < 0.001).

CONCLUSIONS

Successful restoration of cartilage quality was found in the majority of surgically treated OLTs. However, BMS yields inferior cartilage quality compared with FIX, OCT, and CIT. Study Design. Systematic review and meta-analysis. Level of evidence. Level IV, systematic review and meta-analysis.

The effect of total ankle arthroplasty on mechanical energy exchange

Total ankle arthroplasty (TAA) is a common surgical solution for patients with debilitating arthritis of the ankle. Prior to surgery patients experience high levels of pain and fatigue and low mechanical energy recovery. It is not known if TAA restores healthy levels of mechanical energy recovery in this patient population. This study was designed to determine whether mechanical energy recovery was restored following TAA. Ground reaction forces during self-selected speed walking were collected from patients with symptomatic, unilateral ankle arthritis (N = 29) before and one and two years after primary, unilateral TAA. The exchange of potential (PE) and kinetic (KE) energy was examined, and direction of change (%congruity) and energy exchange (%recovery) between the two curves was calculated, with those subjects with low congruity experiencing high energy recovery. Linear regressions were used to examine the impact of walking speed, congruity, and amplitude of the center of mass (COM) displacement on %recovery, while ANOVA and ANCOVA models were used to compare energy recovery and congruity across the three time points. Gender, BMI, and age at surgery had no effect in this study. TAA improved walking speed (p = 0.001), increased energy recovery (p = 0.020), and decreased congruity (p = 0.002), and these levels were maintained over at least two years. Differences in congruity were independent of walking speed. In some patients, especially those who are severely debilitated by ankle arthritis, TAA is effective in restoring mechanical energy recovery to levels similar to an asymptomatic population of a similar age recorded by other studies.

Radiographic Evaluation of the Association between Foot Deformities and Ankle Medial Osteoarthritis

Background

Foot deformities can cause abnormal biomechanics of the ankle joint and the development of osteoarthritis. It was hypothesized that foot deformities would be related to medial ankle osteoarthritis, and this study investigated this relationship using radiographic measurements.

Methods

Seventy-six ankles of 76 patients (32 men and 44 women; mean age, 69.0 years) with medial ankle osteoarthritis were included. Eleven radiographic measurements evaluated ankle joint orientation (tibial plafond inclination [TPI], medial distal tibial angle [MDTA], and anterior distal tibial angle [ADTA]), ankle joint incongruency (tibiotalar tilt [TT]), foot deformities (lateral talo-first metatarsal angle [Lat talo-1MT], anteroposterior talo-first metatarsal angle [AP talo-1MT], and talonavicular coverage), talar body migration (medial talar center migration [MTCM] and anterior talar center migration [ATCM]), internal rotation (IR) of the talus, and mechanical tibiofemoral angle. All were statistically analyzed using Pearson's correlation coefficients and regression analyses.

Results

Ankle joint orientation to the ground (TPI, p = 0.002), increased foot arch (Lat talo-1MT, p < 0.001), and IR of the talus (p = 0.001) were significantly associated with ankle joint incongruency (TT) in linear regression analysis. Ankle joint incongruency (TT, p = 0.003), medial talar body migration (MTCM, p = 0.042), and increased foot arch (Lat talo-1MT, p = 0.022) were significantly associated with IR of the talus in the binary logistic regression analysis. MTCM was significantly correlated with TPI (r = 0.251, p = 0.029), TT (r = 0.269, p = 0.019), MDTA (r = 0.359, p = 0.001), ATCM (r = -0.522, p < 0.001), and AP talo-1MT (r = 0.296, p = 0.015). ATCM was significantly correlated with TPI (r = -0.253, p = 0.027), ADTA (r = 0.349, p = 0.002), and Lat talo-1MT (r = -0.344, p = 0.002).

Conclusions

Ankle joint orientation, foot deformities, and talar rotation were associated with ankle joint incongruency in medial ankle osteoarthritis when evaluated radiographically. These findings need to be considered during surgical treatment for medial ankle osteoarthritis. However, the biomechanical significance of these radiographic measurements requires further investigation.

Low annual revision rate in ankle distraction for ankle osteoarthritis: A systematic review and meta-analysis

PURPOSE

Ankle osteoarthritis severely impacts patients' mental and physical quality of life. Besides total ankle replacement and ankle arthrodesis, ankle distraction has been shown to be a promising alternative. The primary aim of the present study was to determine the annual revision rates (ARRs) after ankle distraction. The secondary aim was to obtain an overview of patient-reported outcome measures and functional outcomes.

METHODS

A literature search until November 2023 was performed. Methodological quality was assessed using the methodological index for non-randomised studies criteria. Primary outcome was the ARR which was log-transformed and pooled using a random effects model. Secondary outcomes were pooled using a simplified pooling technique and included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS), range of motion (ROM) and post-operative complications.

RESULTS

The literature search resulted in 287 articles, of which 10 studies, comprising 602 patients, were included. The patients had a pooled mean age of 47 years (range of means: 40-68) and a mean follow-up of 35 months (range of means: 24-48). The overall methodological quality was moderate to fair. The pooled ARR after ankle distraction was 4% (95% confidence interval [CI], 3%-7%). Pooling of AOFAS showed mean 26-point improvement (from 54 to 80). Additionally, ROM dorsiflexion improved at 5°, and the plantarflexion remained at 31°. The overall complication rate was 41% (95% CI, 35%-48%), of which 77% (95% CI, 67%-85%) were pin-tract infections.

CONCLUSION

Ankle distraction results in an ARR of 4% (95% CI, 3%-7%) with clinically relevant improved AOFAS scores. The overall complication rate is 41% and is mainly attributable to treatable pin-tract infections (77% of recorded complications).

LEVEL OF EVIDENCE

Level IV, Systematic Review and Meta-Analysis.

Current Trends in Total Ankle Replacement

Ankle arthritis can result in significant pain and restriction in range of motion. Total ankle replacement (TAR) is a motion-preserving surgical option used as an alternative to total ankle arthrodesis to treat end-stage ankle arthritis. There are several generations of TAR techniques based on component design, implant material, and surgical technique. With more recent TAR implants, an attempt is made to minimize bone resection and mirror the native anatomy. There are more than 20 implant devices currently available. Implant survivorship varies among prosthesis types and generations, with improved outcomes reported with use of the more recent third- and fourth-generation ankle implants. Pre- and postoperative assessments of TAR are primarily performed by using weight-bearing radiography, with weight-bearing CT emerging as an additional imaging tool. Preoperative assessments include those of the tibiotalar angle, offset, and adjacent areas of arthritis requiring additional surgical procedures. US, nuclear medicine studies, and MRI can be used to troubleshoot complications. Effective radiologic assessment requires an understanding of the component design and corresponding normal perioperative imaging features of ankle implants, as well as recognition of common and device-specific complications. General complications seen at radiography include aseptic loosening, osteolysis, hardware subsidence, periprosthetic fracture, infection, gutter impingement, heterotopic ossification, and syndesmotic nonunion. The authors review several recent generations of TAR implants commonly used in the United States, normal pre- and postoperative imaging assessment, and imaging complications of TAR. Indications for advanced imaging of TAR are also reviewed. ©RSNA, 2023 Supplemental material is available for this article. Test Your Knowledge questions for this article are available through the Online Learning Center.

Outcomes of total ankle replacement - Current evidence

Total ankle replacement surgery is gaining popularity and is beginning to establish itself as a viable alternative to arthrodesis in the treatment of end-stage ankle arthritis. Only a few studies exist directly comparing these 2 techniques. Also lacking are the long-term outcome studies of ankle replacement surgery. A better understanding of clinical and patient-reported outcome measures after ankle fusion and replacement will enable the surgeon to better counsel the patient and help choose the right treatment. This article will summarise the reported clinical outcomes after total ankle replacements and survivorship analysis from the various national arthroplasty registers.

Salto Talaris Fixed-Bearing Total Ankle Arthroplasty: Long-Term Results at a Mean of 10.7 Years

Background

Total ankle arthroplasty (TAA) has become increasingly popular in the treatment for end-stage ankle arthritis in recent decades. However, there is limited evidence regarding the long-term clinical outcomes and complication rates of modern TAA implants.

Methods

This study presents a follow-up on a previous cohort involving 78 patients (81 ankles) who underwent Salto Talaris fixed-bearing TAA to treat end-stage arthritis, with a mean postoperative follow-up of 5.2 years. The aim of this follow-up study was to assess the radiographic (33 patients, 35 ankles) and clinical (48 patients, 50 ankles) results from the original cohort at a mean of 10.7 years (range, 7.8-14 years).

Results

At a mean of 10.7 years, the Kaplan-Meier estimated survivorship was 84.2% (95% CI, 71.9%-98.6%). For the patients reviewed, we did not find any change in patient-reported outcomes between an average 5- and 11-year follow-up. Measured total range of motion and plantarflexion did not change between 1 and 11 years, but dorsiflexion was measured as decreasing by an average of 4 degrees (P < .02).

Conclusion

In this longer-term follow-up of a limited cohort, we found that Salto Talaris fixed-bearing TAA demonstrated good long-term survival with relatively low rates of revision or other complications. Patient-reported outcome and range of motion measures revealed good stability.

Level of Evidence

Level III, therapeutic.

Ankle arthrodesis or total ankle arthroplasty surgery for end stage ankle arthritis, which is best? A review of the best available evidence

BACKGROUND

End Stage Ankle Arthritis (ESAA) causes pain and dysfunction. It is treated effectively with Total Ankle Arthroplasty (TAA) or Ankle Arthrodesis (AA). Currently there is no consensus on which surgical procedure is superior. This paper will provide a systematic review of all published high-quality studies directly comparing TAA and AA for the surgical treatment of ESAA to determine superiority.

METHODS

A comprehensive literature review of the highest quality studies published that directly compare clinical outcomes of TAA and AA for surgical treatment of ESAA was conducted. Each study was assigned a Level of Evidence (LOE) rating (I-III) and then summarized to assign a grade of recommendation (A-C, I). Superiority was determined for the clinical outcomes of pain, activity, Health Related Quality of Life (HRQL), readmission to hospital, revision surgery and general complications.

RESULTS

There is fair evidence (GOR B) that supports both TAA and AA for the surgical treatment of ESAA. However, TAA trended to be superior for pain relief (GOR B), activity (GOR B), health related quality of life (GOR B) and readmission rate (GOR B) while AA trended to be superior for revision rates (GOR B). Conflicting evidence was presented for general complications (GOR C) CONCLUSION: Due to the lack of level I papers and the findings from the papers reviewed not being consistent, no definitive conclusion on which procedure is better can be made. However, there is enough evidence to provide a basis for which procedure is more effective in each of the outcomes reviewed. This should be considered when deciding on which procedure is best suited for a patient on a case-by-case basis. To allow for a stronger recommendation, further studies-ideally, high-quality level I randomized control trials directly comparing Ankle Arthrodesis and Total Ankle Arthroplasty are needed.

LEVEL OF EVIDENCE

Level III, systematic review.

Navigating the Challenges of Total Ankle Replacement: Deformity Correction and Infection Considerations

In recent years, total ankle replacement (TAR) has gained widespread acceptance as a surgical treatment for end-stage ankle arthritis. This shift is due to notable improvements in implant design, surgical instrumentation, technique, and surgeon expertise, resulting in high levels of patient satisfaction comparable to ankle fusion. Additionally, indications for TAR have expanded to include advanced deformities that were previously considered unsuitable for the procedure, making ankle arthrodesis the only option. Despite these advancements, TAR still carries a higher complication rate compared to other ankle surgeries. The complex anatomy of the ankle, coupled with limited soft tissue, presents significant challenges in managing complications associated with TAR.

Total Ankle Replacement Infections: A Systematic Review of the Literature

Periprosthetic infection (PJI) after TAR is a serious complication, often requiring further surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. This systematic review aims to summarize the current evidence on the management of TAR PJI and provide a comprehensive overview of this topic, especially from an epidemiologic point of view. Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Seventy-one studies met the inclusion criteria, reporting on cases of TAR PJI. A total of 298 PJIs were retrieved. The mean incidence of PJI was 3.8% (range 0.2-26.1%). Furthermore, 53 (17.8%) were acute PJIs, whereas most of them (156, 52.3%) were late PJIs. Most of the studies were heterogeneous regarding the treatment protocols used, with a two-stage approach performed in most of the cases (107, 35.9%). While the prevalence of ankle PJI remains low, it is potentially one of the most devastating complications of TAR. This review highlights the lack of strong literature regarding TAR infections, thus highlighting a need for multicentric studies with homogeneous data regarding the treatment of ankle PJI to better understand outcomes.

Anatomical principles of ankle denervation - An update

BACKGROUND

Denervation is a surgical option in ankle arthrosis when conservative therapy has failed. Sectioning all joint branches is essential for its success. The locations of the articular branches of the saphenous (Sa), tibial (Ti), sural (Su), superficial (Ps) and deep peroneal (Pp) nerves are specified.

METHODS

In 16 cryopreserved specimens, the courses of the nerves were prepared. Their articular branches were identified, and their respective locations documented by using a new reference system.

RESULTS

The articular branches to the ankle ranged from 5 to 30 cm measured from the foot sole. The Sa should be transected at 22.5 cm, the Su at 20 cm, and the Pp at 15 cm. The Ti should be skeletonized up to 25 cm. Epifascial dissection of the Ps is to be performed below 15 cm.

CONCLUSION

The study specifies the joint branches of the ankle in an intraoperatively reproducible reference system and thus minimizes the required skin incisions.

Foot biomechanics in patients with advanced subtalar- and mid-tarsal joint osteoarthritis and poorly responding to conservative treatment

BACKGROUND

A comprehensive insight into the effects of subtalar- and mid-tarsal joint osteoarthritis on lower limb's biomechanical characteristics during walking is lacking. Our goal was to assess joint kinematics and kinetics and compensatory mechanisms in patients with subtalar and mid-tarsal joint osteoarthritis.

METHODS

Patients with symptomatic and radiographically confirmed osteoarthritis of the subtalar and mid-tarsal (n = 10) and an asymptomatic control group (n = 10) were compared. Foot joint kinematics and kinetics during the stance phase of walking were quantified using a four-segment foot model.

RESULTS

During pre-swing phase, the tibio-talar range of motion in the sagittal plane of the patient group decreased significantly (P = 0.001), whereas the tarso-metatarsal joint range of motion in the sagittal plane was greater in the pre-swing phase (P = 0.003). The mid-tarsal joint showed lower transverse plane range of motion in the patient group during the loading response and pre-swing phase (P < 0.001 resp. P = 0.002). The patient group showed a lower Tibio-talar joint peak plantarflexion moment (P = 0.004), peak plantarflexion velocity (P < 0.001) and peak power generation in the sagittal plane (P < 0.001), and a lower mid-tarsal joint peak adduction and abduction velocity (P < 0.001 resp. P < 0.001) and peak power absorption (P < 0.001).

CONCLUSIONS

These findings suggest that patients with subtalar and mid-tarsal joint osteoarthritis adopt a cautious walking strategy potentially dictated by pain, muscle weakness, kinesiophobia and stiffness. Since this poorly responding population faces surgical intervention on the short term, we recommend careful follow-up after fusion surgery since biomechanical outcome measures associated to this post-surgical stage is lacking.

Changes in Relative Work of the Lower Extremity and Distal Foot Joints After Total Ankle Replacement: An Exploratory Study

Ankle osteoarthritis does not only led to lower ankle power generation, but also results in compensatory gait mechanics at the hip and Chopart joints. Much of previous work explored the relative work distribution after total ankle replacement (TAR) either across the lower extremity joints where the foot was modelled as a single rigid unit or across the intrinsic foot joints without considering the more proximal lower limb joints. Therefore, this study aims, for the first time, to combine 3D kinetic lower limb and foot models together to assess changes in the relative joint work distribution across the foot and lower limb joints during level walking before and after patients undergo TAR. We included both patients and healthy control subjects. All patients underwent a three-dimensional gait analysis before and after surgery. Kinetic lower limb and multi-segment foot models were used to quantify all inter-segmental joint works and their relative contributions to the total lower limb work. Patients demonstrated a significant increase in the relative ankle positive joint work contribution and a significant decrease in the relative Chopart positive joint work contribution after TAR. Furthermore, there exists a large effect toward decreases in the relative contribution of the hip negative joint work after TAR. In conclusion, this study seems to corroborate the theoretical rationale that TAR reduces the compensatory strategy in the Chopart and hip joints in patients suffering from end-stage ankle osteoarthritis.

Bilateral lower extremity gait and function after unilateral total ankle arthroplasty: a case report

BACKGROUND

End-stage ankle osteoarthritis is one of the leading causes of chronic disability in North America. The main purpose of this case report was to describe the functional recovery of a person following total ankle arthroplasty (TAA) surgery using the INFINITY™ system for end stage osteoarthritis of the left ankle.

CASE DESCRIPTION

We report a case of a 55-year-old male who had attempted conservative management for end stage ankle osteoarthritis in his left ankle but ultimately elected to undergo TAA using The INFINITY™ Total Ankle System. He not only had significant left ankle pain limiting his daily function, but also had developed severe right knee pain. We performed gait analysis both before and 6 months after his TAA surgery to examine the sagittal and frontal-plane motions of bilateral ankle, knee, and hip joints during gait.

OUTCOMES

At 6 months post-surgery, the patient demonstrated a 44-point improvement in his Foot and Ankle Outcome questionnaire scores as well as an increase in both left knee and left ankle motion in the sagittal and frontal planes. Kinematic deviations in the left ankle, hip, and knee joints during gait also reduced post-surgery. Despite improvement in his left ankle and overall function, the participant's right knee pain and altered kinematics of the right limb during gait worsened after surgery.

DISCUSSION

Interventions, either before or after ankle surgery, should consider bilateral lower extremities simultaneously in order to optimize patient care and minimize future secondary complications for individuals with unilateral ankle osteoarthritis.

Accuracy of a Patient-Specific Total Ankle Arthroplasty Instrumentation

BACKGROUND

Total ankle arthroplasty (TAA) is a preferred surgical option for end-stage ankle osteoarthritis; however, it is a demanding procedure with a higher historical rate of revision compared with ankle fusion. Patient-specific instrumentation (PSI) has been introduced to optimize prosthesis alignment and theoretically overall improve TAA outcomes. The goal of this study is to report on the experience and surgical outcomes of one implant with specific evaluation of the accuracy and reproducibility of the system with respect to prosthesis alignment and prediction of implant size.

METHODS

A retrospective, multicentered study involving 4 foot and ankle fellowship-trained orthopaedic surgeon's patients undergoing TAA between January 1, 2015, and December 31, 2018, using the PROPHECY PSI system.

RESULTS

80 TAA procedures were performed. On average the postoperative tibial component alignment was 89.9 (range, 86.1-96.5) degrees in the coronal plane, with a mean sagittal alignment of 88.1 (range, 81.3-96.7) degrees. The mean deviation from neutral sagittal alignment improved from 4.9 ± 3.9 degrees preoperatively to 2.7 ± 1.7 degrees postoperatively, whereas the mean coronal alignment improved from 3.3 ± 2.5 degrees to 1.3 ± 1.1 degrees. The PSI software correctly determined the tibial implant size in 70 patients (89%). Prediction of talar implant sizing was less accurate than the tibial component, with 56 patients (71%) using the predicted sized implant. The overall implant survival at a mean follow-up of 45 months (range, 27-76) was 97.5%.

CONCLUSION

We found that this PSI system accurately and reliably assisted in implant total ankle prosthesis positioning within a clinically acceptable margin and without significant outliers. Prediction of implant size was not as accurate as component orientation.

LEVEL OF EVIDENCE

Level III, retrospective study.

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.

Protocol for a randomised feasibility trial comparing a combined program of education and exercise versus general advice for ankle osteoarthritis

BACKGROUND

Ankle osteoarthritis (OA) is a serious problem with high associated pain and disability. While education and exercise are recommended for the initial management of OA, this has not been investigated in ankle OA. The primary aim of this study is to establish the feasibility of running a full-scale randomised controlled trial (RCT) investigating a combined education and exercise program compared to a general advice program for people with ankle OA. The secondary aims are to collect preliminary data which will inform sample size calculations, and understand the perspectives of people with ankle OA on their participation in the trial.

METHODS

Thirty individuals aged 35 years or older with symptomatic radiographic ankle OA will be recruited from the community and randomised to receive either a combined education and exercise program or a general advice program, both of which will be delivered by a physiotherapist in a group setting. Primary outcomes of feasibility include responses to study advertisements, number of eligible participants, recruitment rate, adherence with the intervention, fidelity of the intervention, adverse events, drop-out rate, and credibility and expectancy of the intervention. Secondary participant-reported outcomes will include global rating of change, patient acceptable symptom state, severity of ankle pain and stiffness, self-reported function, quality of life, satisfaction with treatment, and use of co-interventions. Follow up will be at 8 weeks and 3 months. Physical measures of 40 m walking speed, timed stairs descent, heel raise endurance and ankle dorsiflexion range of motion will be collected at baseline and 8 weeks. Primary feasibility outcomes will be reported descriptively, and estimates of the variability of secondary participant-reported and physical outcomes will be calculated. Semi-structured interviews will be conducted with participants to understand perspectives about the intervention and participation in the trial, with data analyzed thematically.

DISCUSSION

Study findings will establish the feasibility of running a full-scale RCT to investigate a combined education and exercise program compared to a general advice program for people with ankle OA. This study is a necessary first step to advance the international research agenda of evaluating the efficacy of exercise in the management of ankle OA.

TRIAL REGISTRATION

ACTRN12623000017628. Registered 10 January 2023, https://www.anzctr.org.au/ACTRN12623000017628.aspx .

What Is the Efficacy of Intra-articular Injections in the Treatment of Ankle Osteoarthritis? A Systematic Review

BACKGROUND

Ankle osteoarthritis (OA) is painful and can impact a patient's physical and mental quality of life. Although intra-articular injections are commonly used to alleviate symptoms, there is conflicting evidence concerning their efficacy. Therefore, an updated systematic review would be informative.

QUESTION/PURPOSE

In this systematic review, we asked: Are there clinically important benefits or harms associated with the use of intra-articular injections in the treatment of ankle OA?

METHODS

We used PubMed, Embase, and the Cochrane Library to search for randomized controlled trials on intra-articular injections for the treatment of ankle OA in June 2021, and updated the search in January 2022; eligible dates were from the date of inception of each database through January 2022. Reference lists of eligible studies and previous reviews were manually screened. Two reviewers independently assessed studies for eligibility. We included seven studies. Three compared hyaluronic acid (HA) with saline, one compared HA with exercise, one compared four different regimens of HA [ 34 ], one compared platelet-rich plasma (PRP) with saline, and one compared botulinum toxin Type A (BoNT-A) with HA. A total of 340 patients were included: 141 in the HA arms, 48 in the PRP arm, 38 in the BoNT-A arm, and 113 in the saline arms. Across all studies, the mean age was 52 ± 21 years, and 35% were women (119 of 340 patients). Methodologic quality was assessed using the Cochrane Risk of Bias 2.0 tool. Of the included studies, the risk of bias was low in two studies, presented some concerns in one study, and was high in four studies. According to the Grading of Recommendations Assessment, Development, and Evaluation methodology, the level of evidence was very low for HA, moderate for PRP, and very low for BoNT-A. The level of heterogeneity was high, and we opted to perform a systematic review rather than a meta-analysis. A clinically relevant difference was based on whether the between-group difference surpassed the cutoff point determined as the minimum clinically important difference.

RESULTS

No clinically relevant differences were found among HA, PRP, and BoNT-A and their control groups at 3, 6, or 12 months. No studies reported any serious adverse events in any treatment group.

CONCLUSION

Given the lack of observed efficacy in this systematic review, these treatments should not be used in practice until or unless future high-quality studies find evidence of efficacy.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Evaluating and Comparing the Correlation and Performance of PROMIS and FAAM ADL in a Foot and Ankle Patient Population

BACKGROUND

There is a paucity of literature assessing 2 of the commonly used static Patient-Reported Outcomes Measurement Information System (PROMIS) forms (PROMIS Global-10 and PROMIS Physical Function Short Form 10a [PF SF 10a]) and the Foot and Ankle Ability Measure Activities of Daily Living (FAAM ADL).

METHODS

The PROMIS Global-10, PROMIS PF SF 10a, and FAAM ADL were compared among new foot and ankle patients. Spearman rho (ρ) correlations were calculated, and ceiling and floor effects were determined.

RESULTS

The FAAM ADL demonstrated strong correlations with PROMIS PF SF 10a, P = .88, 95% confidence interval (CI): 0.86-0.90, P < .001, and PROMIS Global-10 Physical Health (P = .75, 95% CI: 0.71-0.78, p < .001). The FAAM ADL and PROMIS Global-10 Mental Health demonstrated a moderate correlation (P = .41, 95% CI: 0.34-0.47, P < .001). No PROM demonstrated an appreciable floor effect. The PROMIS Global-10 Physical Health demonstrated the lowest ceiling effect (n=11 [1.6%]).

CONCLUSION

Because the PROMIS Global-10 captures physical health adequately, provides mental health insight, and performs as well (if not better), we recommend the PROMIS Global-10 among the PROMs studied.Level of Evidence: Level III.

Changes in the subtalar joint alignment after supramalleolar osteotomy for varus ankle arthritis

BACKGROUND

The subtalar joint may compensate for tibio-talar deformity, but what would happen to the joint after the deformity was corrected is not well known. Supramalleolar osteotomy (SMOT) is an effective procedure for the treatment of varus deformity of ankle arthritis. The objective of this study was to investigate the subtalar joint alignment pre and postoperatively following SMOT, and the factors which influenced the alignment of the subtalar joint.

METHODS

Thirty-one patients with varus ankle arthritis (Takakura stage 2, 3a and 3b) who were treated using SMOT were retrospectively reviewed. The subtalar and ankle joint alignment was measured on weightbearing radiograph and weightbearing computerized tomography (WBCT).

RESULTS

The foot and ankle offset (FAO), tibial articular surface angle (TAS), tibio-talar surface angle (TTS), and subtalar vertical angle (SVA) were significantly corrected (P＜0.05). The subtalar inclination angle (SIA) decreased in 19 patients and increased in the other 12 cases after the SMOT (P＜0.001). The shift of subtalar joint (ΔSIA) showed an inverse correlation with the preoperative FAO (P＜0.001, r = -0.621).

CONCLUSIONS

The shift of subtalar joint after SMOT could maintain the neutral position of the hindfoot and showed a negative correlation with the preoperative FAO. The ΔSIA was greater in the severer preoperative hindfoot deformity.

LEVEL OF EVIDENCE

Level IV, case series.

Outcomes in Ankle Replacement Study (OARS)

Aims

The aim of this study was to capture 12-month outcomes from a representative multicentre cohort of patients undergoing total ankle arthroplasty (TAA), describe the pattern of patient-reported outcome measures (PROMs) at 12 months, and identify predictors of these outcome measures.

Methods

Patients listed for a primary TAA at 19 NHS hospitals between February 2016 and October 2017 were eligible. PROMs data were collected preoperatively and at six and 12 months including: Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ (foot and ankle)) and the EuroQol five-dimension five-level questionnaire (EQ-5D-5L). Radiological pre- and postoperative data included Kellgren-Lawrence score and implant position measurement. This was supplemented by data from the National Joint Registry through record linkage to determine: American Society of Anesthesiologists (ASA) grade at index procedure; indication for surgery, index ankle previous fracture; tibial hind foot alignment; additional surgery at the time of TAA; and implant type. Multivariate regression models assessed outcomes, and the relationship between MOXFQ and EQ-5D-5L outcomes, with patient characteristics.

Results

Data from 238 patients were analyzed. There were significant improvements in MOXFQ and EQ-5D-5L among people who underwent TAA at six- and 12-month assessments compared with preoperative scores (p < 0.001). Most improvement occurred between preoperative and six months, with little further improvement at 12 months. A greater improvement in MOXFQ outcome postoperatively was associated with older age and more advanced radiological signs of ankle osteoarthritis at baseline.

Conclusion

TAA significantly benefits patients with end-stage ankle disease. The lack of substantial further overall change between six and 12 months suggests that capturing PROMs at six months is sufficient to assess the success of the procedure. Older patients and those with advanced radiological disease had the greater gains. These outcome predictors can be used to counsel younger patients and those with earlier ankle disease on the expectations of TAA.

"It's like a nail being driven in the ankle": A qualitative study of individuals' lived experiences to inform a core domain set for ankle osteoarthritis

OBJECTIVES

Explore individuals' lived experience with ankle osteoarthritis and to identify health-related domains for ankle osteoarthritis based on the perspectives of people living with the condition, as an initial step to address the International Foot and Ankle Osteoarthritis Consortium's recommendation to develop a core domain set for ankle osteoarthritis.

METHODS

A qualitative study using semi-structured interviews was conducted. Interviews were undertaken with individuals with symptomatic ankle osteoarthritis who were aged ≥35 years. Interviews were recorded, transcribed verbatim and thematically analysed.

RESULTS

Twenty-three individuals (16 females; mean (range) age 62 (42-80) years) were interviewed. Five themes were identified: pain, often severe, is a central feature of living with ankle osteoarthritis; stiffness and swelling are key symptoms; ankle osteoarthritis induced mobility impairments compromise enjoyment in life; ankle osteoarthritis instability and balance impairments lead to concerns about falling; there are financial implications of living with ankle osteoarthritis. We propose 17 domains based on individuals' experiences.

CONCLUSION

Study findings indicate that individuals with ankle osteoarthritis live with chronic ankle pain, stiffness and swelling which affect their ability to participate in physical, and social activities, maintain an active lifestyle, and work in physical occupations. From the data, we propose 17 domains that are important to people with ankle osteoarthritis. These domains require further evaluation to ascertain their inclusion in a core domain set for ankle osteoarthritis.

Platelet-Rich Plasma Injections for the Treatment of Ankle Osteoarthritis

BACKGROUND

Ankle osteoarthritis is debilitating and usually affects relatively young people, often as a result of previous ankle traumas, frequently occurring in sports. Platelet-rich plasma (PRP) injections for ankle osteoarthritis have shown no evidence of benefit over the course of 26 weeks. Previous studies on PRP for knee osteoarthritis showed that clinically significant improvements with PRP occurred between 6 to 12 months in the absence of initial benefit. No studies have evaluated the effect of PRP from 6 to 12 months in ankle osteoarthritis.

PURPOSE

To assess the efficacy of PRP injections in ankle osteoarthritis over the course of 52 weeks.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In this 52-week follow-up trial, 100 patients with ankle osteoarthritis were randomized to a PRP group or placebo (saline) group. Patients received 2 intra-articular talocrural injections: at inclusion and after 6 weeks. Patient-reported outcome measures were used to assess pain, function, quality of life, and indirect costs over 52 weeks.

RESULTS

Two patients (2%) were lost to follow-up. The adjusted between-group difference for the patient-reported American Orthopaedic Foot & Ankle Society score over 52 weeks was -2 points (95% CI, -5 to 2; P = .31) in favor of the placebo group. No significant between-group differences were observed for any of the secondary outcome measures.

CONCLUSION

For patients with ankle osteoarthritis, PRP injections did not improve ankle symptoms and function over 52 weeks compared with placebo injections.

REGISTRATION

NTR7261 (Netherlands Trial Register).

Republication of "Keeping It in the Fairway: Golf Handicap Following Total Ankle Arthroplasty"

Background

Total ankle arthroplasty (TAA) provides a surgical alternative to tibiotalar arthrodesis when treating end-stage ankle arthritis. TAA preserves range of motion at the tibiotalar joint leading to improved postoperative function. Many patients who undergo TAA wish to maintain a high level of activity, including participation in low-impact sports such as golf. There are several studies in the total hip and total knee arthroplasty literature that have looked at the effect of total joint arthroplasty on golf handicap. We hypothesized that similar to hip and knee arthroplasty research, TAA is likely to result in a postoperative increase in golf handicap.

Methods

After obtaining institutional review board approval, we retrospectively identified 60 patients (from 140 consecutive TAAs performed between August 2016 and February 2017) who had undergone TAA, played golf pre- and postoperatively, and had at least 1 year of postoperative follow-up. The average postoperative follow-up for the cohort was 28.1 months. Variables including preoperative and postoperative golf handicaps, swing laterality, age, gender, surgical laterality, implant used, and operating surgeon were recorded.

Results

The average preoperative and postoperative handicaps were 19.7 and 17.9, respectively, which did not represent a statistically significant difference (P = .07). Patients who played 3 or more rounds per week had better preoperative and postoperative handicaps compared to patients who played 2 rounds or less; however, the change in their handicap following TAA and the number of rounds played per week was not affected. There was no association between the change in handicap and the follow-up period, handedness of golf shot, surgical laterality, implant used, or the operating surgeon.

Conclusion

Our findings showed that golf handicap was not negatively affected following TAA in this series.

Level of Evidence

Level IV, case series.

Evaluation of clinico-radiological outcome of fibular valgization osteotomy with supra-malleolar osteotomy in patients with ankle osteoarthritis

PURPOSE

There are controversies about combining distal tibia medial opening-wedge osteotomy (DTMO) with fibular valgization osteotomy (FVO) when performing supramalleolar osteotomy (SMO) for medial ankle osteoarthritis. This study aimed to assess the effect of FVO on the coronal translation of the mechanical axis by comparing the improvement of radiological indices after DTMO with and without FVO.

METHODS

Forty-three ankles (mean follow-up: 42.0 months) were reviewed after SMO. Among them, 35/43 (81.4%) underwent DTMO with FVO, while 8/43 (18.6%) underwent DTMO only. To evaluate the effect of FVO radiologically, the medial gutter space (MGS) and talus centre migration (TCM) were measured.

RESULTS

Post-operatively, MGS and TCM were not significantly different after DTMO only and DTMO with FVO. However, the improvement of MGS was significantly higher in the combined FVO group (0.8 mm (standard deviation [SD] 0.8 mm) vs. 1.5 mm (SD 0.8 mm); p = 0.015). More lateral translation of the talus was achieved in the FVO group (5.1 mm (SD 2.3 mm) vs. 7.5 mm (SD 3.0 mm); p = 0.033). However, the changes in the MGS and TCM were not significantly correlated with the clinical outcomes (p > 0.05).

CONCLUSION

Our radiological evaluation confirmed a significant medial gutter space widening and lateral talar translation after the addition of FVO. The SMO with fibular osteotomy allows greater shifting of the talus and, therefore, the weight-bearing axis.

Preoperative incongruent subtalar joint predicts less favorable clinical outcome in total ankle arthroplasty

BACKGROUND

This study aimed to determine the clinical effect of incongruent subtalar joint space on total ankle arthroplasty (TAA).

METHODS

Thirty-four consecutive patients who underwent TAA were grouped according to the status of subtalar joint incongruency. A comparison of clinical and radiographic parameters between groups as well as multiple regression analysis was performed to identify contributing factors to the final functional outcome.

RESULTS

The final American Orthopaedic Foot and Ankle Society (AOFAS) score was significantly higher in the congruent group compared to that of the incongruent group (p = 0.007). There were no significant differences between the two groups in measured radiographic angles. In multiple regression analysis, the female sex (p = 0.006) and incongruency of the subtalar joint (p = 0.013) were found to be significant contributing factors to the final AOFAS score.

CONCLUSIONS

A thorough preoperative investigation should be taken into the state of the subtalar joint for TAA.

Arthroscopic vs. Open-Ankle Arthrodesis on Fusion Rate in Ankle Osteoarthritis Patients: A Systematic Review and Meta-Analysis

Although open surgery is the conventional option for ankle arthritis, there are some reports in the literature regarding the use of the arthroscopy procedure with outstanding results. The primary purpose of this systematic review and meta-analysis was to analyze the effect of the surgery technique (open-ankle arthrodesis vs. arthroscopy) in patients with ankle osteoarthritis. Three electronic databases (PubMed, Web of Science, and Scopus) were searched until 10 April 2023. The Cochrane Collaboration's risk-of-bias tool was used to assess the risk of bias and grading of the recommendations assessment, development, and evaluation system for each outcome. The between-study variance was estimated using a random-effects model. A total of 13 studies (including n = 994 participants) met the inclusion criteria. The meta-analysis results revealed a nom-significant (p = 0.072) odds ratio (OR) of 0.54 (0.28-1.07) for the fusion rate. Regarding operation time, a non-significant difference (p = 0.573) among both surgical techniques was found (mean differences (MD) = 3.40 min [-11.08 to 17.88]). However, hospital length stay and overall complications revealed significant differences (MD = 2.29 days [0.63 to 3.95], p = 0.017 and OR = 0.47 [0.26 to 0.83], p = 0.016), respectively. Our findings showed a non-statistically significant fusion rate. On the other hand, operation time was similar among both surgical techniques, without significant differences. Nevertheless, lower hospital stay was found in patients that were operated on with arthroscopy. Finally, for the outcome of overall complications, the ankle arthroscopy technique was a protective factor in comparison with open surgery.