Ankle replacement: current practice of foot & ankle surgeons in the United kingdom

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.

Survival and risk assessment in revision arthroplasty of the ankle

Aims

Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined.

Methods

This single-centre retrospective cohort study included 116 patients (117 ankles) who underwent revision TAA for failed primary TAA between July 2000 and March 2010. Survival analysis and risk factor assessment were performed, and clinical performance and patient satisfaction were evaluated preoperatively and at last follow-up.

Results

The mean duration from initial revision TAA to last follow-up was 15.0 years (SD 3.0; 11.2 to 20.5). The cumulative survival rates of the revised ankles were 81% (95% confidence interval (CI) 74% to 88%), 74% (65% to 82%), and 70% (61% to 79%) at five, ten, and 15 years, respectively. Comorbidities prior to primary TAA, aseptic loosening, instability, or grafting of cysts were found to be the most common risk factors for secondary revision. The median value for preoperative pain, as assessed using the visual analogue scale, declined from 6 (interquartile range (IQR) 5 to 8) to 2 (IQR 0 to 5) (p < 0.001) and the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 43 (SD 17) preoperatively to 70 (SD 20) (p < 0.001) at last follow-up.

Conclusion

Revision TAA offers acceptable survival rates after 15 years; it therefore offers a valuable option for treatment of implant failure in carefully selected cases. Although patient-reported outcomes improve substantially, the degree of improvement reported following primary TAA is not achieved.

The Rise of Total Ankle Arthroplasty Use: A Database Analysis Describing Case Volumes and Incidence Trends in the United States Between 2009 and 2019

BACKGROUND

Ankle arthrodesis has been the mainstay treatment for end-stage ankle arthritis. The popularity of total ankle arthroplasty (TAA) has been on the rise due to improved implant design and postoperative outcomes. The purpose of this study was to describe the basic epidemiology and trends of annual procedure volumes and incidence in the general American population as well as in different population subgroups from 2009 to 2019. We hypothesize that the incidence of TAA has significantly risen while the median length of hospital stay has decreased nationwide.

METHODS

The IBM MarketScan database was queried for patients who underwent TAA from January 2009 to December 2019 based on Current Procedural Terminology coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of TAA. Procedural volume and incidence were calculated for annual sums, gender, age subgroups, inpatient and outpatient TAA, as well as in four statistical geographic regions in the United States. Median length of hospital stay was calculated and trended annually for inpatient TAA.

RESULTS

A total of 41,060 primary TAAs were identified in the database from 2009 to 2019, in which 52.5% were performed in males. Annual volumes increased by 136.1%, from 2180 to 5147 procedures nationwide. Incidence reported per 100 000 population increased by 120.8%. Both inpatient and outpatient procedures have increased, by 242.5% and 86.6%, respectively. Median length of hospital stay decreased from 3 days in 2009 to 1 day in 2019 and did not differ between genders. Growth in incidence was demonstrated in males and females above the age of 54 years with the largest growth in annual incidence found between 65 and 74 years. Incidence rose in the South and West of the United States by 111.8% and 136.5%, respectively.

CONCLUSION

We found that annual volumes and incidence rates of primary TAA has increased between 2009 and 2019. Although both inpatient and outpatient surgery have become more frequent, inpatient volumes and incidence have increased almost 3 times more than those of outpatient surgery. Length of hospital stay decreased over the study years. When adjusted for the same study period, the cumulative annual growth rates of TAA were found to be 2 times greater than total knee arthroplasty and 3.6 times greater than total hip arthroplasty.

LEVEL OF EVIDENCE

Level III, retrospective database review.

Failure rates and patient-reported outcomes of revision of total ankle arthroplasty

INTRODUCTION

Despite the increasing number of revision total ankle arthroplasty (TAA), the literature on indications, surgical options, and outcomes is limited. This study reports on failure rates and patient-reported outcomes (PROM) for a cohort of 122 patients who underwent revision of TAA.

MATERIALS AND METHODS

A retrospective review of revision TAA between 2006 and 2020 was performed at one institution. Patient's demographics and different surgical procedures were analyzed with particular attention to comparing polyethylene exchange with revision of both metallic components and to additional interventions for axis correction. Failure rates and the European Foot and Ankle Society (EFAS) score were collected. The average follow-up period was 70.37 ± 46.76 months.

RESULTS

122 patients were treated with an exchange procedure. The surgery included 69 polyethylene exchanges, 12 revisions of one metallic component, and 41 revisions of both metallic components. The overall failure rate was 14.75%. The EFAS score, completed by 94 of the 122 patients, was used to evaluate clinical outcomes. Median EFAS score was 12.51 ± 5.53, and median EFAS sports score was 2.97 ± 3.04. Revision rates after polyethylene exchange were significantly higher than after exchanging both metallic components (p value = 0.03), while the EFAS score showed slightly better results in patients treated with polyethylene exchange. Adding procedures to induce axis correction led to significantly lower revision rates (p value = 0.03), and the EFAS score was also improved but without statistical significance.

CONCLUSIONS

The high failure rate of polyethylene exchange indicates that the intervention does not address the actual cause of failed TAA in many cases. Additional axis correction should be considered more frequently. If the underlying issues of prosthesis failure can be identified and sufficiently addressed, the results of revision surgery are likely to improve.

Early experience and patient-reported outcomes of 503 INFINITY total ankle arthroplasties

AIMS

This is a multicentre, non-inventor, prospective observational study of 503 INFINITY fixed bearing total ankle arthroplasties (TAAs). We report our early experience, complications, and radiological and functional outcomes.

METHODS

Patients were recruited from 11 specialist centres between June 2016 and November 2019. Demographic, radiological, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Questionnaire, and EuroQol five-dimension five-level score) were collected preoperatively, at six months, one year, and two years. The Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system was used to stratify deformity. Early and late complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts, and/or subsidence.

RESULTS

In all, 500 patients reached six-month follow-up, 420 reached one-year follow-up, and 188 reached two-year follow-up. The mean age was 67.8 years (23.9 to 88.5). A total of 38 patients (7.5%) presented with inflammatory arthritis. A total of 101 (20.0%) of implantations used patient-specific instrumentation; 167 patients (33.1%) underwent an additional procedure at the time of surgery. A total of seven patients died of unrelated causes, two withdrew, and one was lost to follow-up. The mean follow-up was 16.2 months (6 to 36). There was a significant improvement from baseline across all functional outcome scores at six months, one, and two years. There was no significant difference in outcomes with the use of patient-specific instrumentation, type of arthritis, or COFAS type. Five (1.0%) implants were revised. The overall complication rate was 8.8%. The non-revision reoperation rate was 1.4%. The 30-day readmission rate was 1.2% and the one-year mortality 0.74%.

CONCLUSION

The early experience and complications reported in this study support the current use of the INFINITY TAA as a safe and effective implant in the treatment of end-stage ankle arthritis. Cite this article: Bone Joint J 2021;103-B(7):1270-1276.

End-stage ankle osteoarthritis: arthroplasty offers better quality of life than arthrodesis with similar complication and re-operation rates-an updated meta-analysis of comparative studies

PURPOSE

Ankle arthrodesis (AA) has traditionally been the surgical standard for patients with an end-stage ankle osteoarthritis, with total ankle arthroplasty (TAA) recently becoming an alternative. The aim of this study was to update evidence in terms of functional outcomes, complications, and quality of life between AA and TAA by analyzing comparative studies.

METHODS

PubMed, MEDLINE, Scopus, and Cochrane Central databases were used to search keywords. A total of 21 studies entered our qualitative and quantitative analysis. Demographics, functional outcomes, and complications were extracted. Random and fixed-effect models were used for the meta-analysis of standardized mean differences (SMDs) and odds ratios (ORs).

RESULTS

A total of 18,448 patients were identified, with a mean age of 57.3 ± 11.3 years. TAA showed significantly greater post-operative range of motion (SMD - 0.883, 95% CI - 1.175 to - 0.590; I² < 0.001) and Ankle Osteoarthritis Scale scores (SMD - 1.648, 95% CI - 3.177 to - 0.118; I² = 97.67), but no differences in other patient-reported outcome scores were found. Patients undergoing TAA showed higher post-operative SF-36 (SMD - 0.960, 95% CI - 1.584 to - 0.336; I² = 68.77). The total complication rate was similar between the two procedures (OR 0.936, 95% CI 0.826 to 1.060; I² = 87.44), including the incidence of re-operations (OR 1.720, 95% CI 0.892 to 3.316; I² = 77.65).

CONCLUSION

While TAA and AA showed no differences in most post-operative functional outcomes, our review demonstrates that patients undergoing TAA show better health-related quality of life than AA. We found no evidence to suggest that TAA carries a higher risk of complications and re-operations compared to AA.

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.

A randomised, multi-centre trial of total ankle replacement versus ankle arthrodesis in the treatment of patients with end stage ankle osteoarthritis (TARVA): statistical analysis plan

BACKGROUND

The total ankle replacement versus ankle arthrodesis (TARVA) trial aims to determine which surgical procedure confers the greatest improvement in pain-free function for patients with end-stage ankle osteoarthritis. Both procedures are effective but there has not yet been a direct comparison to establish which is superior. This article describes the statistical analysis plan for this trial as an update to the published protocol. It is written prior to the end of patient follow-up, while the outcome of the trial is still unknown.

DESIGN AND METHODS

TARVA is a randomised, un-blinded, parallel group trial of total ankle replacement versus ankle arthrodesis. The primary outcome is the Manchester-Oxford Foot Questionnaire walking/standing domain score at 52 weeks post-surgery. Secondary outcomes include measures of pain, social interaction, physical function, quality of life, and range of motion. We describe in detail the statistical aspects of TARVA: the outcome measures, the sample size calculation, general analysis principles including treatment of missing data, the planned descriptive statistics and statistical models, and planned subgroup and sensitivity analyses.

DISCUSSION

The TARVA statistical analysis will provide comprehensive and precise information on the relative effectiveness of the two treatments. The plan will be implemented in January 2020 when follow-up for the trial is completed.

TRIAL REGISTRATION

ISRCTN registry number 60672307, ClinicalTrials.gov registration number NCT02128555. Registered 1 May 2014. Recruitment started in January 2015 and ended in January 2019.

Revision Surgery for Metal Component Failure in Total Ankle Arthroplasty

Background:

Metal component failure in total ankle arthroplasty (TAA) is difficult to treat. Traditionally, conversion to an arthrodesis has been advocated. Revision TAA surgery has become more common with availability of revision implants and refinement of bone-conserving primary implants. The goal of this study was to analyze the clinical results and patient-reported outcomes for patients undergoing revision total ankle arthroplasty.

Methods:

We retrospectively reviewed prospectively collected data on 52 patients with a mean age of 63.5 ± 9.6 years who had developed loosening or collapse of major metal components following primary TAA. These patients were compared to a case-matched control group of 52 primary TAAs performed at the host institution with a minimum of 2 years’ follow-up. Cases of isolated polyethylene exchange, infection, or extra-articular realignment procedures were excluded. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), and pain scores were prospectively collected. Clinical data was collected through review of the electronic medical record to identify reasons for clinical failure, where clinical failure was defined as second revision or conversion to arthrodesis or amputation.

Results:

The identified causes of failure of primary TAA were aseptic loosening of both components (42%), talar component subsidence/loosening (36%), coronal talar subluxation (12%), tibial loosening (8%), and talar malrotation (2%). Thirty-one patients (59.5%) underwent revision of all components, 20 (38.5%) just the talar and polyethylene components, and one (2%) the tibial and polyethylene components. The average time to revision was 5.5 years ± 5.4 with a follow-up of 3.1 years ± 1.5 after revision. Eleven (21.2%) revision arthroplasties required further surgery: 6 required conversion to arthrodesis and 5 required second revision TAA. Pain scores, SF-36 scores, SMFA scores, and AOFAS Hindfoot scores all improved after revision surgery but never reached the same degree of improvement seen after primary TAA.

Conclusions:

Clinical and patient-reported outcomes of revision ankle arthroplasty after metal component failure significantly improved after surgery, although the recovery time was longer. In this series, 21.2% of revision TAAs required a second revision TAA or arthrodesis surgery. Various prostheses performed similarly when used for revision surgery. Revision TAA can offer significant improvements postoperatively.

Level of Evidence:

Level III, therapeutic.

Patient-Reported Outcomes Before and After Primary and Revision Total Ankle Arthroplasty

BACKGROUND:

Studies examining the clinical outcomes of revision total ankle arthroplasty (TAA) are sparse. Revision TAA surgery has become more common with availability of revision implants and refinement of bone-conserving primary implants. In this study, patient-reported results and clinical outcomes were analyzed for a cohort of patients who underwent both primary and revision TAA at a single high-volume institution.

METHODS:

We retrospectively reviewed prospectively collected data on 29 patients with failed primary total ankle arthroplasty. Cases of isolated polyethylene exchange, infection, or extra-articular realignment procedures were excluded. Patient-reported outcome (PRO) measures and clinical results were reviewed in this longitudinal study.

RESULTS:

Fifteen patients (51.7%) underwent revision of just the talar and polyethylene components while 13 patients (44.8%) underwent revision of all components. The most common cause was talar subsidence (51.7%). The average time to revision was 3.9 years with a follow-up of 3.2 years after revision, and 3 (10.3%) revision arthroplasties required further surgery; 2 required conversion to arthrodesis and 1 required second revision TAA. Improvements in PROs were better after primary than revision TAA.

CONCLUSIONS:

Clinical and patient-reported results of revision ankle arthroplasty after metal component failure improved significantly but never reached the improvements seen after primary ankle arthroplasty. In our series, 10.3% of revision TAAs required a second revision TAA or arthrodesis surgery.

LEVELS OF EVIDENCE:

Therapeutic Level III, comparative series.

[Endoprosthesis failure in the ankle joint : Histopathological diagnostics and classification]

INTRODUCTION

Endoprostheses of the ankle joint show higher revision rates of 3.29 revisions per 100 component years. The aims of this study were the application and modification of the consensus classification of the synovia-like interface membrane (SLIM) for periprosthetic failure of the ankle joint, the etiological clarification of periprosthetic pseudocysts and a detailed measurement of proliferative activity (Ki67) in the region of osteolysis.

MATERIAL AND METHOD

Tissue samples from 159 patients were examined according to the criteria of the standardized consensus classification. Of these, 117 cases were derived from periprosthetic membranes of the ankle. The control group included 42 tissue specimens from the hip and knee joints. Particle identification and characterization were carried out using the particle algorithm. An immunohistochemical examination with Ki67 proliferation was performed in all cases of ankle pseudocysts and 19 control cases.

RESULTS

The consensus classification of SLIM is transferrable to endoprosthetic failure of the ankle joint. Periprosthetic pseudocysts with the histopathological characteristics of the appropriate SLIM subtype were detectable in 39 cases of ankle joint endoprostheses (33.3%). The mean value of the Ki67 index was 14% and showed an increased proliferation rate in periprosthetic pseudocysts of the ankle (p-value 0.02037).

CONCLUSION

In periprosthetic pseudocysts an above average higher detection rate of type 1 SLIM induced by abrasion (51.3%) with an increased Ki67 proliferation fraction (p-value 0.02037) was found, which can be interpreted as local destructive intraosseus synovialitis. This can be the reason for formation of pseudocystic osteolysis caused by high mechanical stress in ankle endoprostheses. A simplified diagnostic classification scoring system of dysfunctional endoprostheses of the ankle is proposed for collation of periprosthetic pseudocysts, ossifications and the Ki67 proliferation fraction.

Ankle Arthrodesis Versus Total Ankle Arthroplasty

Reoperation rates are higher in total ankle arthroplasties (TAAs) compared with ankle arthrodesis. Infection rates for primary TAAs are 1.4% to 2.4%. The survival rate of TAA is approximately 75% to 90% at 10 years. Arc of motion is maintained with TAAs compared with ankle arthrodesis. Ankle arthrodesis increases arc of motion through the talonavicular joint. Several factors are strong reasons to favor ankle fusion rather than TAA. TAA and ankle arthrodesis are effective treatments of end-stage ankle arthritis but the choice must be tailored to individual patients.

Identifying the learning curve for total ankle replacement using a mobile bearing prosthesis

BACKGROUND

Total ankle arthroplasty remains a technically demanding surgery highly influenced by the operator experience. However, no consensus exists regarding the ideal number of cases that need to be performed before a surgeon is considered proficient. The aim of this study was to identify the learning curve of a specific replacement system with regards to intraoperative and postoperative outcomes.

METHODS

The first 31 patients undergoing total ankle arthroplasty were examined. No additional procedures were performed at the time of the TAA. Intraoperative characteristics, postoperative complications, as well as clinical and radiologic outcomes were assessed with 24-month follow-up. Learning curves, examining the relationship between surgeon experience and patient outcomes, were determined using the Moving Average Method.

RESULTS

The operatory time, and the risk of intraoperative fractures decreased with increasing surgeon experience with the learning curve stabilizing after the 14th and 24th patient, respectively. Furthermore, there appeared to be a learning curve associated with most of the important clinical and radiological outcomes. The number of patients required to stabilize the learning curve for the VAS, ROM, and AOFAS was 11, 14 and 28, respectively. Radiographically, there appeared to be a learning curve of 22 patients required to stabilize the tibio-talar ratio. There was no learning curve associated with the SF-12 PCS and MCS as well as the α-, β-, and γ-angle.

CONCLUSION

This study demonstrates that a surgical learning curve does indeed exist when performing TAA. Most of the operative variables as well as clinical and radiological outcomes stabilize after a surgeon has performed 28 cases.

Epidemiology of Total Ankle Arthroplasty: Trends in New York State

The rate of total ankle arthroplasty (TAA) is increasing in the United States as its popularity and indications expand. There currently is no national joint registry available to monitor outcomes, and few studies have addressed the challenges faced with TAA. The purpose of this study was to evaluate the incidence, complications, and survival rates associated with TAA using a large statewide administrative discharge database. Individuals who underwent primary TAA from 1997 to 2010 were identified in the Statewide Planning and Research Cooperative System database from the New York State Department of Health. The age, sex, comorbidities, state of residence, primary diagnosis, and readmissions within 90 days were analyzed for patients with an ICD-9-CM procedure code of 81.56 (TAA). Failure of a TAA implant was defined as revision, tibiotalar arthrodesis, amputation, or implant removal. During the 14-year period, 420 patients underwent 444 TAAs (mean patient age of 61 years, 59% women, mean Charlson-Deyo comorbidity score of 0.45, and 86% New York State residents). The primary diagnosis was 37.4% osteoarthritis, 34.3% traumatic arthritis, and 15.5% rheumatoid arthritis. Surgery for failure was associated only with a younger age (56.5 vs 62 years, P=.005). The rate of subsequent failure procedures following TAAs performed in New York State was 13.8%. The incidence of TAAs is steadily increasing. The overall survival rate in New York State is better than rates reported in other national registries, but it is not yet comparable to those of hip and knee replacements. [Orthopedics. 2016; 39(3):170-176.].

Total ankle joint replacement

Ankle arthritis results in a stiff and painful ankle and can be a major cause of disability. For people with end-stage ankle arthritis, arthrodesis (ankle fusion) is effective at reducing pain in the shorter term, but results in a fixed joint, and over time the loss of mobility places stress on other joints in the foot that may lead to arthritis, pain and dysfunction. Another option is to perform a total ankle joint replacement, with the aim of giving the patient a mobile and pain-free ankle. In this article we review the efficacy of this procedure, including how it compares to ankle arthrodesis, and consider the indications and complications.

What are the patterns of prophylactic postoperative oral antibiotic use after foot and ankle surgery?

BACKGROUND

The CDC estimates 23% of healthcare-associated infections to be surgical site infections, with alarming prevalence of antibiotic-resistant organisms. While there is consensus regarding preoperative prophylaxis, orthopaedic surgeons' use of prophylactic postoperative oral antibiotics is less defined.

QUESTIONS/PURPOSES

We investigated surgeons' use of prophylactic postoperative oral antibiotics after elective outpatient foot or ankle procedures, identifying (1) frequency of use, (2) regimen preferences, (3) personal indications, and (4) associated experience and demographics.

METHODS

Using a cross-sectional survey design, a questionnaire was emailed to all active and candidate members of the American Orthopaedic Foot and Ankle Society. Supplementary questions captured demographic information. We invited 1136 members to participate; 22 addresses produced delivery failure messages, leaving 1114 members as potential participants. After nonresponses and exclusions, 312 (28%) responses were analyzed. Statistical analysis used Pearson's chi-square test, Fisher's exact test, and multivariate regression.

RESULTS

The majority (75%) of respondents reported use of prophylactic postoperative oral antibiotics. Most users (69%) prescribed to fewer than 25% of patients, although 16% prescribed for all elective cases. The most frequent regimen was cephalexin 500 mg four times a day (63%) and the most common duration was 5 to 7 days (50%). Surgeons' most common indications were previous infection (71%), medical comorbidities (65%), and previous wound-healing difficulties (56%). Those who do and do not prescribe prophylactic postoperative oral antibiotics showed no difference in surgical site infection rate or any demographic category.

CONCLUSIONS

Surgeons' reported use of prophylactic postoperative oral antibiotics after elective foot or ankle surgery was common, without demographic association. Commonalities were identified in antibiotic regimen and personal indications for this practice. Comparative clinical studies are warranted to elucidate the efficacy of prophylactic postoperative oral antibiotics and establish evidence-based guidelines for their use.

The Orthopaedic Foot and Ankle Outcomes Research (OFAR) network: feasibility of a multicenter network for patient outcomes assessment in foot and ankle

INTRODUCTION

There is an increasing need for orthopaedic practitioners to measure and collect patient-reported outcomes data. In an effort to better understand outcomes from operative treatment, the American Orthopaedic Foot & Ankle Society (AOFAS) established the Orthopaedic Foot and Ankle Outcomes Research (OFAR) Network, a national consortium of foot and ankle orthopaedic surgeons. We hypothesized that the OFAR Network could successfully collect, aggregate, and report patient-reported outcome (PRO) data using the National Institutes of Health (NIH) Patient Reported Outcomes Measurement Information System (PROMIS).

METHODS

Ten sites enrolled consecutive patients undergoing elective surgery for 1 of 6 foot/ankle disorders. Outcome instruments were collected preoperatively and at 6 months postoperatively using the PROMIS online system: Foot and Ankle Ability Measure (FAAM), Foot Function Index (FFI), and PROMIS physical function (PF) and pain computerized adaptive tests (CAT). During the 3-month period, 328 patients were enrolled; 249 (76%) had completed preoperative patient-reported outcomes data and procedure-specific data. Of these, 140 (56%) also completed 6-month postoperative patient- reported outcomes data.

RESULTS

Ankle arthritis and flatfoot demonstrated consistently worse preoperative scores. Five of 6 disorders showed significant improvement at 6 months on PF CAT and FAAM, 4 of 6 showed improvement on pain interference CAT, and no disorders showed improvement on FFI. Ankle arthritis and flatfoot demonstrated the greatest magnitude of change on most patient-reported outcomes scales.

CONCLUSION

We were able to enroll large numbers of patients in a short enrollment period for this preliminary study. Data were easily aggregated and analyzed. Substantial loss of follow-up data indicates a critical area requiring further effort. The AOFAS OFAR Network is undergoing expansion with goals to ultimately facilitate large, prospective multicenter studies and optimize the quality and interpretation of available outcome instruments for the foot and ankle population.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Assessment of a three-grade classification of complications in total ankle replacement

BACKGROUND

Prompted by the success of hip and knee arthroplasty, total ankle replacement (TAR) has become increasingly popular as a treatment for end stage arthritis of the ankle. A 3-grade classification of complications to assist in prediction of early implant failure has been proposed. We have compared the experience of a tertiary referral center in the United Kingdom to the proposed system.

METHODS

A retrospective review of the Sheffield Foot and Ankle Unit TAR database was performed from 1995 to 2010. All complications were recorded and categorized using Glazebrook et al's proposed system of increasing severity. Low-grade complications including postoperative bone fracture, intraoperative bone fracture, and wound healing problems rarely lead to revision. Medium-grade complications, technical error and subsidence, lead to failure <50% of the time. High-grade complications--deep infection, aseptic loosening, and implant failure--lead to revision >50% of the time. In our center, 217 TAR were implanted in 198 patients with a minimum follow-up of 30 months.

RESULTS

The complication rate was 23%, with a revision rate of 17%. All complications recorded in our study except intraoperative bone fracture and wound healing had a failure rate of at least 50%.

CONCLUSION

Unfortunately most complications associated with TAR have a significant impact on the life span of a TAR. Glazebrook et al's proposed 3-tier system did not reliably reflect our experience. Hence, we would categorize complications as either high or low risk for early failure of TAR.

LEVEL OF EVIDENCE

Level IV, case series.

Trends in treatment of advanced ankle arthropathy by total ankle replacement or ankle fusion

BACKGROUND

Total ankle replacement (TAR) and ankle fusion (AF) are the 2 major operative options for treatment of advanced ankle arthropathy; there is, however, no large epidemiologic study comparing nationwide trends of these 2 procedures. The current study used a nationwide database to compare epidemiologic profiles of TAR and AF.

METHODS

Data collected for the Nationwide Inpatient Sample (NIS) from 2000 to 2010 were reviewed. Procedures were identified by searching for ICD-9-CM codes 81.11 (AF) and 81.56 (TAR). Patients' demographics and comorbidities, geographic distribution, and cost of procedures were compared.

RESULTS

The NIS analysis identified 2666 TAR and 16 419 AF cases which was extrapolated to 13 145 TAR and 80 426 AF nationwide. Spearman's ρ showed an increase in the number of AF per year while the number of TAR cases remained relatively flat per year until 2006, after which there was a steady increase in the number of TAR performed. Patients receiving a TAR tended to be older, female, and white. Patients who underwent AF were more likely to be obese or diabetic than TAR patients. Both TAR and AF were performed more frequently in private urban hospitals through 2007. However, in 2010, the number of TAR procedures was greater in academic centers compared to private urban hospitals.

CONCLUSIONS

Despite recent increases in the number of TAR implanted, AF was still performed more than 6 times more frequently for advanced ankle arthropathy. A trend was demonstrated toward an increasing number of TAR being implanted in academic centers, and in patients with more underlying comorbidities than was previously seen.

LEVEL OF EVIDENCE

Level II, prognostic study.

Registry data trends of total ankle replacement use

Joint arthroplasty registry data are meaningful when evaluating the outcomes of total joint replacement, because they provide unbiased objective information regarding survivorship and incidence of use. Critical evaluation of the registry data information will benefit the surgeon, patient, and industry. However, the implementation and acceptance of registry data for total ankle replacement has lagged behind that of hip and knee implant arthroplasty. Currently, several countries have national joint arthroplasty registries, with only some procuring information for total ankle replacement. We performed an electronic search to identify publications and worldwide registry databanks with pertinent information specific to total ankle replacement to determine the type of prostheses used and usage trends over time. We identified worldwide registry data from 33 countries, with details pertinent to total ankle replacement identified in only 6 countries. The obtained information was arbitrarily stratified into 3 distinct periods: 2000 to 2006, 2007 to 2010, and 2011. Within these study periods, the data from 13 total ankle replacement systems involving 3,980 ankles were identified. The vast majority (97%) of the reported ankle replacements were 3-component, mobile-bearing, uncemented prostheses. Three usage trends were identified: initial robust embracement followed by abrupt disuse, minimal use, and initial embracement followed by sustained growth in implantation. Before the widespread acceptance of new total ankle replacements, the United States should scrutinize and learn from the international registry data and develop its own national joint registry that would include total ankle replacement. Caution against the adoption of newly released prostheses, especially those without readily available revision components, is recommended.

Thrombembolic complications after total ankle replacement

The literature addressing functional outcome and survivorship of prosthesis components is constantly growing. However, the data on thromboprophylaxis and thrombembolic complications in patients who underwent TAR are scarce. A total of 31 studies were included in the systemic literature review. The incidence of thrombembolic complications varied between 0.0 % and 9.8 %. Most commonly, low molecular weight heparin was used as thromboprophylaxis for 6 weeks postoperatively. The incidence of thrombembolic complications was comparable with that of symptomatic deep vein thrombosis in patients with total knee or hip replacement.

How do patients with end-stage ankle arthritis decide between two surgical treatments? A qualitative study

OBJECTIVE

To examine how patients decide between ankle fusion and ankle replacement in end-stage ankle arthritis.

DESIGN

Purposive patient selection, semistructured interviews, thematic analysis.

SETTING

Royal National Orthopaedic Hospital, Stanmore, UK.

PARTICIPANTS

14 patients diagnosed with end-stage ankle osteoarthritis.

RESULTS

We interviewed 6 men and 8 women with a mean age of 58 years (range 41-83). All had opted for surgery after failure of at least 6 months of conservative management, sequentially trading-off daily activities to limit the evolving pain. To decide between two offered treatments of ankle fusion and total ankle replacement (TAR), three major sources informed the patients' decision-making process: their surgeon, peers and the internet. The treating surgeon was viewed as the most reliable and influential source of information. Information gleaned from other patients was also important, but with questionable reliability, as was information from the internet, both of which invariably required validation by the surgeon and in some cases the general practitioner.

CONCLUSIONS

Patients seek knowledge from a wealth of sources including the internet, web forums and other patients. While they leverage each of these sources to guide decision-making, the most important and influential factor in governing how patients decide on any particular surgical intervention is their surgeon. A high quality doctor-patient relationship, coupled with clear, balanced and complete information is essential to enable shared decision-making to become a standard model of care.

Mobile- and fixed-bearing total ankle prostheses: is there really a difference?

Approximately 1% of the world's adult population is affected by ankle osteoarthritis (OA). Therapeutic options include conservative and surgical measures. Because of substantial progress in total ankle replacement, ankle fusion is no longer the "gold standard" therapy for end-stage ankle OA. Various ankle prostheses have been designed and are currently available. This article reviews the in vitro studies addressing the biomechanics and kinematics of the replaced ankle. Furthermore, a systematic literature review was conducted to assess possible differences in clinical outcomes, including prosthesis survivorship and postoperative range of motion between mobile- and fixed-bearing total ankle prostheses.

Total ankle replacement using HINTEGRA, an unconstrained, three-component system: surgical technique and pitfalls

Total ankle replacement (TAR) has become a valuable treatment option in patients with end-stage ankle osteoarthritis. One popular 3-component system, the HINTEGRA TAR, is an unconstrained system that provides inversion-eversion stability. More natural biomechanics of the replaced ankle may be expected when anatomic considerations drive prosthesis design. The HINTEGRA prosthesis includes 2 anatomically contoured metal components and a polyethylene insert, providing axial rotation and physiologic flexion-extension mobility. This article describes the HINTEGRA TAR design and surgical technique. Use of the prosthesis for complex hindfoot reconstruction in patients with an osteoarthritic, varus, or valgus ankle deformity is described.

Management of specific complications related to total ankle arthroplasty

Total ankle arthroplasty (TAA) has evolved over time and modern 3-component implants offer good and reliable clinical results. Despite recent improvements, TAA is still associated with a relatively high incidence of complications. Surgeon experience seems to play the most important role. This review highlights the most common intraoperative and postoperative complications, such as malleolar fracture, impingement, cyst formation, malalignment, and loosening, and offers a differentiated concept for their management.

Total ankle replacements: an overview

One of the most widely debated topics amongst foot and ankle surgeons is the treatment of end stage arthritis. With the advent of the newer generation of total ankle replacement (TAR), a viable option over an arthrodesis is now available for patients with end-stage ankle arthritis. When compared with an ankle arthroplasty, recent reports suggest the ankle arthrodesis has poor long-term outcomes (20 years+) and can experience short- and long-term complications. Proper training, strict patient selection, and proper implant contribute to a successful outcome. As advances continue to be made in both implant design and surgical technique, the benefits of a TAR appears to provide the foot and ankle surgeon a good alternative for the appropriate patient.

Lower extremity implant registries: has the time come in the United States?

Because of the current health care environment, involved parties are requesting the assessment of patient safety and efficacy following a lower extremity operation. Many foreign countries have registries to assess postoperative patient safety. A similar system does not exist in the United States. The purpose of this study was to create a registry to assess the safety and efficacy of lower extremity implants and procedures. The EVEREST Lower Extremity Registry is an Internet-based database designed to collect clinical outcomes and survivorship data of total ankle implants, hardware implants, and soft-tissue procedures. All data are collected remotely on a secure Web site. Data are collected at defined intervals according to implant or procedure. The investigators consent patients preoperatively using a central Institutional Review Board and are encouraged to enroll consecutive patients. Routine patient reports allow sites constant feedback regarding their patients versus the entire registry population. Patient engagement begins with providing a personalized implant card and is followed with the appropriate scheduling prompts based on interval due dates. Currently, there are 15 sites contributing data to the registry. There are 47, 79, and 27 patients enrolled in the total ankle, ankle hardware, and soft-tissue registries, respectively. Longest term follow-up collected is 12 months. Early outcomes suggest that many surgeons are willing to assimilate a registry system into their practice. This registry supports the critical need for data collection in lower extremity medicine.