Association of Smokeless Tobacco and Complications Following Ankle and Hindfoot Arthrodesis

BACKGROUND

The purpose of this study was to (1) evaluate the rates of postoperative complications following ankle or hindfoot arthrodesis among current smokeless tobacco users and people who smoke compared to matched controls, and (2) compare rates of postoperative complications in current smokeless tobacco users vs people who smoke tobacco cigarettes.

METHODS

A retrospective cohort study was conducted using a large national database. For patients who underwent ankle or hindfoot arthrodesis, smokeless tobacco users (n = 131) and people who smoke (n = 1948) were matched 1:4 with controls, and smokeless tobacco users (n = 131) were matched 1:4 with people who smoke tobacco cigarettes (n = 524). Orthopaedic complications within 90 days, 1 year, and 2 years were compared using multivariable logistic regressions.

RESULTS

Within 90 days of ankle or hindfoot arthrodesis, smokeless tobacco users demonstrated significantly higher rates of hardware removal (odds ratio [OR] 5.01, 95% CI 1.65-15.20), wound disruption or dehiscence (OR 3.00, 95% CI 1.21-7.44), and pooled complications (16.0% vs 5.9%, OR 2.84, 95% CI 1.50-5.38) compared with tobacco-naïve controls. The rates of hardware removal, wound disruption and dehiscence, and pooled complications remained significant in the smokeless tobacco cohort at 1 and 2 years. At 2 years following ankle or hindfoot arthrodesis, smokeless tobacco users additionally demonstrated significantly higher rates of infection (OR 6.08, 95% CI 1.15-32.05) and nonunion (OR 2.35, 95% CI 1.31-4.20) compared with tobacco-naïve controls. Within 90 days of ankle or hindfoot arthrodesis, smokeless tobacco users demonstrated significantly lower rates of malunion or nonunion than patients who smoke tobacco cigarettes (OR 0.34, 95% CI 0.12-0.97), whereas all other complications were not significantly different.

CONCLUSION

Smokeless tobacco use is associated with higher rates of complications following ankle or hindfoot arthrodesis compared with tobacco-naïve controls, and physicians should screen for smokeless tobacco use specifically and encourage cessation before operating electively.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Chronic Steroid Use Does Not Increase the Risk of Superficial Surgical Site Infection or Wound Dehiscence Following Total Ankle Arthroplasty

Introduction Total ankle arthroplasty (TAA) is an effective treatment for end-stage ankle arthritis. Recent surgical and technological advances have led to a significant increase in the surgical volume of TAA. While a majority of ankle arthritis is post-traumatic in nature, other causes include autoimmune or inflammatory conditions. Medical management of these conditions frequently requires chronic corticosteroid administration, which is a well-established risk factor for complications following surgery. The purpose of this study was to investigate the association between chronic preoperative steroid use and postoperative complications following TAA. Methods The American College of Surgeons National Surgical Quality Improvement (NSQIP) database was analyzed to identify all patients who underwent TAA between 2015 and 2020. Patient characteristics including demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. The data was analyzed using bivariate and multivariate logistic regression to identify all postoperative complications associated with chronic preoperative steroid use. Results A total of 1,606 patients were included in this study: 1,533 (95.5%) were included in the non-steroid cohort, and 73 (4.5%) were included in the chronic steroid cohort. Chronic steroid use was significantly associated with female sex (p < 0.001) and American Society of Anesthesiologists (ASA) ≥3 (p < 0.001). Chronic steroid use was not associated with superficial surgical site infection (SSI) (p = 0.634) or wound dehiscence (p = 0.999). The postoperative complication that was significantly associated with chronic steroid use was sepsis (p = 0.031). After adjusting for female sex and the ASA grade, chronic steroid use was found to be independently associated with sepsis (p = 0.013). Conclusion Preoperative chronic steroid use is not associated with superficial SSI or wound dehiscence within 30 days following TAA. As TAA becomes a more attractive alternative to ankle arthrodesis, a better understanding of preoperative risk factors can aid in widening indications and knowing what patients are at risk for complications.

Ankle arthrodesis and total ankle replacement in patients with congenital bleeding disorders suffering from severe ankle arthropathy

INTRODUCTION

In patients with congenital bleeding disorders suffering from severe ankle arthropathy, when conservative treatment and joint-preserving surgical techniques fail, there are two possible non-joint-preserving options: ankle arthrodesis (AA) and total ankle replacement (TAR).

AREAS COVERED

The scope and aim of this article was to analyze the current role of AA and TAR in patients with congenital bleeding disorders suffering from severe ankle arthropathy.

EXPERT OPINION

In patients with congenital bleeding disorders, both TAR and AA provide good results, mainly in terms of pain relief, although they are not exempt from complications (between 0% and 33% in TAR and between 5% and 23.5% in AA). The current controversy about which of the two surgical techniques, TAR or AA, gives better results, the current literature is not able to resolve it in patients with congenital bleeding disorders. While this question is being answered, my opinion regarding patients with congenital bleeding disorders is that the age of the patient must be taken into account. Given known prosthetic survival rates, the older the patient, the more we might be inclined to indicate TAR. Conversely, AA may be more appropriate for relatively young patients.

[Effectiveness comparison of supramalleolar osteotomy and ankle arthrodesis in treatment of inverted ankle osteoarthritis in Takakura 3A stage with talus tilt]

Objective

To compare the effectiveness of supramalleolar osteotomy (SMOT) and ankle arthrodesis (AA) in the treatment of inverted ankle osteoarthritis (OA) in Takakura 3A stage with talus tilt.

Methods

The clinical data of 41 patients with inverted ankle OA in Takakura 3A stage with talus tilt admitted between January 2016 to January 2020 and met the selection criteria were retrospectively analyzed, and they were divided into SMOT group (21 cases) and AA group (20 cases) according to the surgical method. There was no significant difference in baseline data such as gender, age, affected side, cause of injury, and preoperative talar tilt angle (TT), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS) score, short-form 36 health survey scale (SF-36) score, and sagittal range of motion (ROM) between the two groups ( P>0.05). The operation time, intraoperative blood loss, partial weight-bearing time, and complications were recorded in the two groups. AOFAS ankle-hindfoot score, VAS score, SF-36 score, and sagittal ROM were used to evaluate the effectiveness. Bone healing was observed and the time of bony healing was recorded. In the SMOT group, the tibial lateral surface angle (TLS), TT, and the tibial articular surface angle (TAS) were measured on ankle joint weight-bearing anteroposterior and lateral X-ray films and compared with those before operation. And Takakura staging assessment was also performed.

Results

The operation time and intraoperative blood loss in AA group were significantly less than those in SMOT group ( P<0.05). Patients in both groups were followed up 24-36 months, with an average of 28.9 months. Incision infection occurred in 2 patients in SMOT group and 1 patient in AA group, respectively, and no vascular or nerve injury occurred in both groups. The partial weight-bearing time of SMOT group was significantly less than that of AA group ( P<0.05), but there was no significant difference in bony healing time between the two groups ( P>0.05). At last follow-up, the difference of VAS score and SF-36 score before and after operation of AA group were less than those of SMOT group, and the difference of sagittal ROM before and after operation in SMOT group was less than that of AA group, with significant differences ( P<0.05). The difference of AOFAS ankle-hindfoot score before and after operation in AA group was slightly greater than that in SMOT group, but the difference was not significant ( P>0.05). The above scores in both groups significantly improved when compared with those before operation ( P<0.05). Sagittal ROM in AA group was significantly less than that before operation ( P<0.05), while there was no significant difference in SMOT group ( P>0.05). In the SMOT group, 17 patients (81.0%) showed improvement in imaging staging, 2 patients (9.5%) showed no improvement in staging, and 2 patients (9.5%) showed stage aggravation. TLS, TAS, and TT significantly improved when compared with those before operation ( P<0.05). At last follow-up, 2 patients in SMOT group received AA due to pain and stage aggravation, and 1 patient with bone nonunion underwent bone graft. Subtalar joint fusion was performed in 1 case of subtalar arthritis in AA group.

Conclusion

For inverted ankle OA in Takakura 3A stage with talus tilt, both SMOT and AA can significantly releave pain, improve foot function and quality of life, but AA has more definite effectiveness and better patient satisfaction.

Tibiotarsal Arthrodesis with Retrograde Intramedullary Nail and RIA Graft: A Salvage Technique

Ankle arthrodesis is a commonly used salvage procedure in the management of post-traumatic ankle fractures, which often result in severe disability and may require the amputation of the distal third of the leg. Successful ankle arthrodesis relies on a thorough assessment of local and systemic risk factors to ensure optimal results. Failure to accurately assess these factors may lead to unsatisfactory results. High-energy trauma causing bone defects and soft tissue necrosis often results in osteomyelitis, a condition that poses a significant threat to the success of the arthrodesis procedure. It is important to apply a standardised surgical protocol to minimise the possibility of superficial and deep infection and limit damage to the neighbouring soft tissues. Therefore, it is critical to undertake surgical lavage and debridement and administer systemic and local antibiotic therapy, along with the use of a spacer, to eradicate infection prior to performing arthrodesis. In this study, we present our experience in the recovery of limbs with post-traumatic complications via tibio-astragalic or tibio-calcaneal arthrodesis using a retrograde intramedullary nail technique. The approach involves a multi-step procedure using a previous antibiotic spacer implant and an autologous bone graft (RIA). This study spanned a period from January 2014 to December 2021 and included 35 patients (12 women and 23 men) with a mean age of 47.8 ± 20.08 years (range: 22-85 years). Among the patients, 18 had osteomyelitis following AO 43 C3 fractures, and 9 of them had previous exposure and bone loss at the time of injury. The remaining cases included 10 patients with AO 44 C fracture outcomes and 7 patients with AO 44 B fracture outcomes. Our results emphasise the importance of the meticulous management of local and systemic risk factors in ankle arthrodesis procedures. The successful eradication of infection and subsequent arthrodesis can be achieved via the implementation of surgical lavage, debridement, and systemic and local antibiotic therapy using spacers. This surgical protocol implemented by us has yielded excellent results, saving affected limbs from post-traumatic complications and avoiding the need for amputation. Our study contributes to the existing knowledge supporting the use of retrograde arthrodesis with intramedullary nails in severe cases where limb salvage is the primary goal. However, further research and long-term follow-up studies are needed to validate these results and evaluate the effectiveness of this technique in a larger patient population.

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.

Overview of Ankle Arthropathy in Hereditary Hemochromatosis

Hereditary hemochromatosis (HH) is an autosomal recessive bleeding disorder characterized by tissue overload of iron. Clinical systemic manifestations in HH include liver disease, cardiomyopathy, skin pigmentation, diabetes mellitus, erectile dysfunction, hypothyroidism, and arthropathy. Arthropathy with joint pain is frequently reported at diagnosis and mainly involves the metacarpophalangeal and ankle joints, and more rarely, the hip and knee. Symptoms in ankle joints are in most cases non-specific, and they can range from pain and swelling of the ankle to deformities and joint destruction. Furthermore, the main radiological signs do not differ from those of primary osteoarthritis (OA). Limited data are available in the literature regarding treatment; surgery seems to be the gold standard for ankle arthropathy in HH. Pharmacological treatments used to maintain iron homeostasis can also be undertaken to prevent the arthropathy, but conclusive data are not yet available. This review aimed to assess the ankle arthropathy in the context of HH, including all its aspects: epidemiology, physiopathology, clinical and imaging presentation, and all the treatments available to the current state of knowledge.

Radiographic Measurements of the Foot and Ankle After Ankle Arthrodesis

Background

Ankle arthrodesis is an established treatment for ankle arthritis. For patients with ankle arthritis, the position of the talus during ankle arthrodesis may affect the radiographic parameters of the foot. The purpose of this study is to assess the radiographic relationship between talar alignment and the longitudinal arch of the foot before and after ankle arthrodesis.

Methods

We retrospectively reviewed a single-surgeon series of 30 patients who had undergone ankle arthrodesis. Measured parameters included the lateral tibiotalar angle (LTTA), lateral talometatarsal angle (LTMA), lateral talocalcaneal angle (LTCA), cuneiform height (CH), and calcaneal pitch (CP). Additional data collected included demographics, fusion construct type, and visual analog scale (VAS) measurements.

Results

LTTA was increased from 68.2 ± 7.4 degrees preoperatively to 75.0 ± 6.4 degrees postoperatively (P = .001), LTMA increased from -2.0 ± 10.7 degrees to 4.0 ± 10.1 degrees (P < .001), CH increased from 20.1 ± 7.5 mm to 26.1 ± 8.4 mm (P < .001), LTCA and CP had no statistically significant change. VAS score decreased from 5.7 ± 2.7 to 1.3 ± 1.9 (P < .001).

Conclusion

Correcting the talar alignment in the sagittal plane during ankle arthrodesis improved the radiographic parameters of the foot, contributing to restoration of the longitudinal arch. The clinical significance of these findings is that in patients undergoing ankle arthrodesis, the surgeon should be aware that the alignment of the foot will be altered at the time of ankle arthrodesis and should be considered in preoperative planning. Further research is needed to determine the effect of ankle arthrodesis in patients determined to have pes planus preoperatively.

Level of Evidence

Level III, retrospective cohort study.

Comparison of Total Ankle Replacement and Ankle Arthrodesis for Ankle Arthropathy in Patients With Bleeding Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

There is limited literature comparing the publications on ankle arthrodesis (AA) and total ankle arthroplasty (TAA) in the setting of hemophilic arthropathy. Our objective is to systematically review the existing literature and to assess ankle arthroplasty as an alternative to ankle arthrodesis in this patient population.

METHODS

This systematic review was conducted and presented according to the PRISMA statement standards. A search was conducted on March 7-10, 2023, using MEDLINE (via PubMed), Embase, Scopus, ClinicalTrials.gov, CINAHL Plus with Full Text, and the Cochrane Central Register of Controlled Studies. This search was restricted to full-text human studies published in English, and articles were screened by 2 masked reviewers. Systematic reviews, case reports with less than 3 subjects, letters to the editor, and conference abstracts were excluded. Two independent reviewers rated study quality using the MINORS tool.

RESULTS

Twenty-one of 1226 studies were included in this review. Thirteen articles reviewed the outcomes associated with AA in hemophilic arthropathy whereas 10 reviewed the outcomes associated with TAA. Two of our studies were comparative and reviewed the outcomes of both AA and TAA. Additionally, 3 included studies were prospective. Studies showed that the degree of improvement in American Orthopaedic Foot & Ankle Society hindfoot-ankle score, visual analog scale pain scores, and the mental and physical component summary scores of the 36-Item Short Form Health Survey were similar for both surgeries. Complication rates were also similar between the 2 surgeries. Additionally, studies showed a significant improvement in ROM after TAA.

CONCLUSION

Although the level of evidence in this review varies and results should be interpreted with caution, the current literature suggests similar clinical outcomes and complication rates between TAA and AA in this patient population.

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

Background

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

Method

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

Results

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

Conclusions

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

Level of Evidence

Level III, therapeutic.

Septic History Limits the Outcome of Tibiotalocalcaneal Arthrodesis

Joint destruction necessitates tibiotalocalcaneal arthrodesis (TTCA) in cases of clinical deficits that cannot be controlled conservatively, possibly leading to sepsis. We aimed to compare the underlying etiology of posttraumatic joint destruction and the outcomes after TTCA in patients with a septic or aseptic history. Between 2010 and 2022, 216 patients with TTCA were retrospectively enrolled (septic TTCA (S-TTCA) = 129; aseptic TTCA (A-TTCA) = 87). Patient demographics, etiology, Olerud and Molander Ankle Scores (OMASs), Foot Function Index (FFI-D) scores, and Short Form-12 Questionnaire (SF-12) scores were recorded. The mean follow-up period was 6.5 years. Tibial plafond and ankle fractures were the most common causes of sepsis. The mean OMAS was 43.0; the mean FFI-D was 76.7; and the mean SF-12 physical component summary score was 35.5. All the scores differed significantly between the groups (p < 0.001). With an average of 11 operations until the arthrodesis was achieved, the S-TTCA patients underwent about three times as many operations as the A-TTCA patients (p < 0.001), and 41% of S-TTCA patients remained permanently unable to work (p < 0.001). The significantly worse results of S-TTCA compared to A-TTCA show the long and stressful ordeal that patients with a septic history suffer. Further attention must be paid to infection prophylaxis and, if necessary, early infection revision.

The Trans-Achilles Approach for Plate Supplementation of Ankle Arthrodesis With an Existing Hindfoot Fusion Nail: A Case Report

Tibiotalar arthrodesis revision surgeries are not uncommon. Several approaches have been described in the literature for ankle arthrodesis nonunions. In this article, we describe the posterior trans-Achilles approach, which ensures adequate surgical exposure while minimizing damage to the surrounding soft tissues. It provides a convenient method for utilizing bone grafts or substitutes and allows for the advantageous application of posterior plating. The possible complications of this approach are delayed wound healing, wound infection, injury to the sural nerve, and the potential need for a skin graft. Despite the advantages of this approach, infection, delayed union, and nonunion risks remain high in this patient population. Finally, the trans-Achilles approach is valid for complex ankle procedures, especially in revisions with compromised ankle soft tissue envelopes.

Preservation of the Subtalar Joint Determines Outcomes in a 10-Year Evaluation of Ankle Arthrodesis

Posttraumatic osteoarthritis may lead to surgical fusion of the ankle joint if non-surgical therapy fails. The indication for a fusion of the joint is based on the pain and disability of the patient, radiographic imaging, and surgeon experience, with no strict guidelines. We aimed to compare outcomes after tibiotalocalcaneal arthrodesis (TTCA) and tibiotalar arthrodesis (TTA) to highlight the functional importance of the subtalar joint. In total, 432 patients with ankle arthrodesis were retrospectively enrolled. Group A (n = 216) underwent TTCA; group B (n = 216) underwent TTA. Demographics, Olerud & Molander Ankle Score (OMAS), Foot Function Index (FFI-D), and Short Form-12 Questionnaire (SF-12) were recorded at a mean follow-up of 6.2 years. The mean OMAS was 50.7; the mean FFI-D was 68.9; the mean SF-12 physical component summary was 39.1. These scores differed significantly between the groups (p < 0.001). The overall revision rate was 18%, primarily for revision of non-union and infection (p < 0.001). Approximately 16% of group A and 26% of group B were able to return to previous work (p < 0.001). Based on significantly worse clinical scores of TTCA compared to TTA and the prolonged downtime and permanent incapacity, the indication for a generous subtalar joint arthrodesis with planned ankle arthrodesis should always be critically examined.

Ankle Arthrodesis: Indications, Outcomes, and Patient Satisfaction

Background

Osteoarthritis of the ankle, which has a prevalence of 3.4% in the general population and affects 70% of candidates post-traumatically, is less common than hip or knee arthritis. Despite the recent progress in ankle arthroplasty surgery, ankle arthrodesis is still considered the gold-standard treatment for severe osteoarthritis of the ankle joint and can achieve impressive improvements in pain and function in the majority of patients. Our objective is to assess the clinical and functional outcomes of ankle arthrodesis, postoperative complications, and patient satisfaction.

Methodology

This was a descriptive cross-sectional study that took place at Future Hospital in Khartoum, Sudan, from July 2015 to July 2022. Our institute performed 102 ankle fusion surgeries; 14 patients were excluded from the study because they did not show up for their follow-up visit, meaning 88 candidates were included. Two cannulated screws (6.5 mm) were used for ankle fixation in all patients. The outcome was assessed two years after surgery. The American Orthopaedic Foot and Ankle Society (AOFAS) score was used to assess ankle function before surgery and two years after the procedure. Postoperative complications and patient satisfaction were reported. The primary researcher collected data through direct interviews.

Result

The mean age of the study participants was 52.2 years, with 36.4% being between 40 and 50 years of age. The study consisted of 43 women and 45 men. The male-to-female ratio was almost 1:1. In 56.8% of candidates, the right ankle was involved. The overall rate of complications was 11.4%. Concerning patient satisfaction, 75% of the patients were fully satisfied. Moreover, significant correlations were found between the mean postoperative AOFAS score and age group, diabetes mellitus, complications, and patient satisfaction.

Conclusion

Ankle arthrodesis was demonstrated to be an excellent surgical method for reducing pain and enhancing ankle joint function. The most frequent complications were delayed wound healing, infection, and non-union. The functional outcome and patient satisfaction of this procedure were statistically high; patients with a higher functional score had higher levels of satisfaction. In contrast, diabetic and elderly patients had higher rates of complications.

Sport and Exercise Activity After Isolated Ankle Arthrodesis for Advanced-Stage Ankle Osteoarthritis: A Single-Center Retrospective Analysis

Background

Ankle arthrodesis, a recognized operative treatment for advanced-stage ankle osteoarthritis (OA), is recommended when conservative treatment proves unsuccessful. This single-center retrospective analysis examined the change in functional outcomes and the type of sport/exercise activity performed by advanced-stage ankle OA patients after ankle arthrodesis treatment.

Methods

A total of 61 advanced-stage ankle OA patients (age, 63.1 ± 12.6 years) who had undergone ankle arthrodesis were included in this single-center retrospective study. The patients had functional outcomes evaluated via American Orthopaedic Foot & Ankle Society Score (AOFAS), Foot Function Index (FFI), Tegner Activity Level Scale (TAS), and High-Activity Arthroplasty Score (HAAS) questionnaires. Clinical status was compared across prearthritic, arthritic, and postarthrodesis periods, and satisfaction with return to sport/exercise activity was recorded.

Results

Patients' tarsal sagittal ROM (mean [95% CI]: 22.7 degrees [21.4-24.0]); time to union (15.7 weeks [11.8-19.6]); time to walk without gait aid (14.4 weeks [11.0-17.7]); time to return to work (17.9 weeks [15.1-20.8]); and time to exercise activity (20.6 weeks [17.9-23.4]) were recorded postarthrodesis. Hindfoot alignment angle toward a neutral position (difference: 11.4 degrees [9.2-13.6], P < .001) and functional outcomes (P < .001) significantly improved after arthrodesis surgery; however, only the TAS questionnaire indicated patients returned to their prearthritic activity level (P > .99). Patients generally reported "good" satisfaction with their recovery from ankle arthrodesis surgery, with 64% of patients returning to high-impact-type activity.

Conclusion

Advanced-stage ankle OA patients had improved functional outcomes at ~1 year postarthrodesis surgery, enabling the majority of patients to return to high-impact-type activity.

Level of Evidence

Level III, retrospective cohort study.

Mid-to long-term postoperative outcomes of ankle joint fusion in patients with haemophilia: A systematic review

INTRODUCTION AND AIM

The ankle joint is the most common site for haemophilic arthropathy. The aim of this study was to review the outcomes of ankle joint fusion in patients with haemophilia A or B. The primary outcome measures were union rates, time to union, perioperative blood loss/transfusion, postoperative complications and length of hospital stay (LOS). Secondary outcome measures were hind foot functional outcome scores and the visual analogue pain scale (VAS).

MATERIALS AND METHODS

A search of PubMed, Medline, Embase, Journals@Ovid and the Cochrane register was performed conforming to the PRISMA guidelines. Only human studies with a minimum follow-up of 1-year were included. The MINORS and ROBINS-1 tools were used for quality appraisal.

RESULTS

A total of 952 articles were identified and only 17 studies met the eligibility criteria after the screening. The mean age of the patients was 37.6 (SD 10.2). A total of 271 ankle fusions were performed with the open crossed-screw fixation being the most common technique. Union rates were 71.5%-100% at 2-6 months. The pooled postoperative complication and revision rates were 13.7% and 6.5%, respectively. The range of LOS was 1.8-10.6 days. The mean preoperative American orthopedic foot and ankle society (AOFAS) ankle-hindfoot score was 35 (SD 13.1) whereas the mean postoperative AOFAS score was 79.4 (SD 5.3). The mean preoperative VAS was 6.3 (SD 1.6) while the mean postoperative VAS score was .9 (SD .4) across 38 ankle fusions.

CONCLUSION

Ankle arthrodesis offers improved pain and function in haemophilic ankle arthropathy with lower revision and complication rates than that reported in the literature for total ankle replacement.

Anterior Ankle Incision Healing Complications With and Without Tourniquet Use: A Retrospective Comparative Cohort Study

Anterior ankle incisions and tourniquet use in foot and ankle surgery have both been associated with increased incidence of incisional healing complications. Although a tourniquet is commonly used for procedures such as total ankle replacement and ankle arthrodesis that utilize an anterior ankle incision, it is possible to avoid tourniquet use while preserving adequate visualization with atraumatic layered dissection and closure, appropriate use of electrocautery, and ligation of vessels as needed. The primary aim of this study is to report rates of anterior ankle incisional healing complications both with and without tourniquet use. A retrospective chart review was performed on consecutive patients undergoing total ankle replacement or ankle arthrodesis through a multi-provider foot and ankle surgery practice between 2013 and 2018. A total of 121 patients, 58 (47.9%) in the tourniquet group and 63 (52.1%) in the no-tourniquet group, were included in this study with a median follow-up period of 36 (range 2-96) months. There was a higher rate of incisional healing complications for the tourniquet group (5.2%) compared to the no-tourniquet group (3.2%), however this did not reach statistical significance (p = .670). There was no significant difference in operative time between the tourniquet and no-tourniquet group (p = .405). The overall incisional healing complication rate was 4.1%. Although avoiding tourniquet use alone does not appear to significantly reduce anterior ankle incisional healing complications, the described technique has yielded an overall lower rate of incisional complications compared to those commonly reported in the literature.

Tibiotalar and Tibiotalocalcaneal Arthrodesis with Paragon28 SilverbackTM Plating System in Patients with Severe Ankle and Hindfoot Deformity

BACKGROUND AND OBJECTIVES

The treatment of end-stage ankle osteoarthritis (OA) and associated hindfoot deformities remains a major challenge for orthopedic surgeons. Numerous techniques and surgical approaches have been proposed for tibiotalar (TT) and tibiotalocalcaneal (TTC) arthrodesis, from arthroscopic to open, as well as numerous devices proposed for internal fixation (retrograde intramedullary nails, cannulated screws, and plating systems). The aim of this study was to retrospectively analyze the results, with at least 18 months of follow-up, with Silverback^TM TT/TTC Plating System Paragon28 in a group of 20 patients with severe OA and hindfoot deformities (mainly secondary post-traumatic OA).

MATERIALS AND METHODS

The demographic characteristics and past medical history of the patients were collected and analyzed to identify the cause of the pathology. The degree of OA and deformity were quantified based on foot and ankle weight-bearing radiography and CT examination. Pre- and post-operative clinical and functional scores (ROM, VAS, AOFAS, FFI, and SF-36) and radiographic parameters (anterior distal tibial angle, tibiotalar angle, coronal tibiotalar angle, and hindfoot alignment angle) were evaluated.

RESULTS

All of the patients showed clinical and radiographic fusion at an average of 14 weeks (range 12-48), with improvement in pain and functional scores, without major surgical complications and/or infections.

CONCLUSIONS

Despite the limitations of our study, the results with this new plating system showed good results in terms of bone consolidation, post-operative complications, and improvement of pain and quality of life in patients with severe OA and deformities of the ankle and hindfoot.

Complications Following Total Ankle Arthroplasty Versus Ankle Arthrodesis for Primary Ankle Osteoarthritis

INTRODUCTION

There are minimal data comparing complications between ankle arthrodesis (AA) versus total ankle arthroplasty (TAR) for operative management of primary osteoarthritis (OA). This study aimed to compare outcomes following AA versus TAR for primary ankle OA using a large patient database.

METHODS

Patients who received AA or TAR for primary ankle OA from 2010 to 2019 were queried from PearlDiver. Rates of common joint complications were compared at 90 days, 1 year, and 2 years postoperatively using multivariable logistic regression.

RESULTS

A total of 1136 (67%) patients received AA and 584 (33%) patients underwent TAR. Patients that received AA exhibited significantly higher rates of at least one common joint complication at 90 days (19.3% vs 12.6%; odds ratio [OR] 1.69), 1 year (25.6% vs 15.0%; OR 2.00), and 2 years (26.9% vs 16.2%; OR 1.91) postoperatively. This included higher rates of adjacent fusion or osteotomy procedures, periprosthetic fractures, and hardware removal at each postoperative follow-up (all P < .05). Rates of prosthetic joint infection were comparable at 2 years postoperatively (4.3% vs 4.2%; OR 0.91).

CONCLUSION

The AA cohort exhibited higher rates of postoperative joint complications in the short and medium-term, namely, subsequent fusions or osteotomies, periprosthetic fractures, and hardware removal.

LEVELS OF EVIDENCE

Level III.

Reoperation Rates Following Total Ankle Arthroplasty Versus Ankle Arthrodesis for Posttraumatic Indications

AIMS

This studied aimed to compare rates of reoperation for patients who received primary ankle arthrodesis (AA) versus total ankle replacement (TAR) for posttraumatic indications between 2010 and 2016 Q2 using a nationwide claims database.

METHODS

A retrospective cohort study analyzing patients who received primary AA or TAR for posttraumatic indications was performed using PearlDiver. Reoperations assessed included prosthetic joint infection (PJI), hardware removal, adjacent joint fusion, and local open reduction internal fixation (ORIF). Multivariable logistic regression was used to compare rates of reoperations at 1 and 2 years postdischarge.

RESULTS

A total of 862 (74%) patients received AA and 318 (26%) patients underwent TAR for a posttraumatic indication. At 1 year, 305 (35.4%) AA patients had at least 1 reoperation compared with 55 (17.3%) TAR patients (OR 2.32; 95% CI, 1.68-3.26). At 2 years, 364 (42.2%) AA patients and 66 (20.8%) TAR patients had at least 1 reoperation (OR 2.51; 95% CI, 1.84-3.45). ORIF, hardware removal, and adjacent joint fusions were more likely for AA patients at both time intervals (all Ps < .05).

CONCLUSION

Patients who received primary AA for posttraumatic indications exhibited higher rates of major reoperations in the short to medium term compared with patients who underwent TAR.

LEVELS OF EVIDENCE

Level III: Retrospective cohort study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVELS OF EVIDENCE

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

Total ankle arthroplasty with the use of Zimmer prosthesis and a review of the results of previous research conducted in this field

The aim of this article is to describe surgical technique and early results of Total Ankle Replacement (TAR) from lateral approach using Zimmer TM prosthesis. The study uses theoretical knowledge which is the result of research conducted by other authors, and practical knowledge due to the fact that our center performs that type of operation. Arthrodesis as the current standard in the treatment of advanced degenerative ankle disease, apart from its advantages, also has many disadvantages. The relative durability and reduction of the patients' pain have been achieved at the expense of the adjacent joints. Their accelerated arthrosis is the result of compensatory loads as a consequence of change in foot biomechanics. That determined implementation of solutions that will guarantee elimination of pain in the ankle joint, preserve its motor function and improve gait, while having no negative impact on the mobility of adjacent joints.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Lower Limb Salvage Using Patent-Specific 3D-Printed Titanium Cage Following Severe Left Ankle Traumatic Partial Amputation: A Pediatric Case Report

BACKGROUND

Patients with large bony defects of the ankle who wish to avoid amputation have limited surgical intervention options for limb salvage. Each of these interventions are technically complex and present significant risk for complications. The use of a patient-specific 3D-printed titanium cage in conjunction with a tibiotalocalcaneal (TTC) arthrodesis using a retrograde nail is another management option. This case adds to the scarce published literature on this technique.

CASE PRESENTATION

This report presents the case of a 16-year-old female who suffered a traumatic partial amputation of her left distal lower extremity following an all-terrain-vehicle accident that resulted in a 10.0 × 10.0 cm skin laceration and a 5-cm subsegmental bony loss of the distal tibia. She was successfully treated using a patient-specific 3D-printed titanium truss cage in conjunction with a TTC arthrodesis using a retrograde nail.

CONCLUSIONS

The decision to amputate or attempt limb salvage in a severely injured lower limb is still a topic of active debate. However, literature has shown that patients who undergo limb salvage surgery have better psychological health outcomes and equivalent functional outcomes as patients who have undergone amputation. Therefore, research on techniques that optimize and advance limb salvage surgery is needed. As the numerous potential benefits and limitations of patient-specific 3D-printed implants are assessed throughout the field of orthopedics, further research and cost-analysis will be required. Cases such as the one presented add to the limited existing literature of patient-specific 3D-printed implant for treatment of large distal lower extremity bony defects.

LEVELS OF EVIDENCE

Level V (Case Report).

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

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

Utilization Trends of Total Ankle Arthroplasty and Ankle Fusion for Tibiotalar Osteoarthritis: A Nationwide Analysis of the United States Population

Introduction: Studies evaluating utilization and trends of total ankle arthroplasty (TAA) and ankle fusion (AF) are sparse. The purpose of this study was to use a nationwide administrative claims database to compare baseline demographics between TAA and ankle arthrodesis and to determine whether patients who had a TAA have increased rates of: (1) utilization, (2) in-hospital length of stay (LOS), and (3) costs of care. Methods: PearlDiver, a nationwide claims database was queried from 2005 to December 2013 for all patients who underwent primary TAA or AF for the treatment of osteoarthritis of the ankle and foot. Baseline demographics of age, sex, geographic distribution, and the prevalence of comorbidities comprising the Elixhauser comorbidity index (ECI) were compared between patients who had TAA and AF. Linear regression was used to compare differences in utilization and in-hospital LOS between the 2 cohorts during the study interval. Annual charges and reimbursement rates for TAA were assessed during the study period. A P value less than .05 was considered to be statistically significant. Results: A total of 21 433 patients undergoing primary TAA (n = 7126) and AF (n = 14 307) were included. Patients undergoing TAA had significantly greater ECI driven by arrythmias, congestive heart failure, diabetes mellitus, electrolyte/fluid disorders, iron deficiency anemia than patients undergoing AF (P < .001). From 2005 to 2013, TAA utilization increased from 21.5% to 49.4% of procedures (P < .0001). There was reduced in-hospital LOS over the time interval for patients with TAA compared with AF (2.15 days vs. 3.11 days, P < .0001). Total ankle arthroplasty reimbursements remained stable while charges per patient increased significantly from $40 203.48 in 2005 to doubling by the end of 2013 to $86 208.59 (P < .0001). Conclusion: This study demonstrated increased use of TAA compared to AF showing decreased in-hospital LOS and increased cost of care with stagnant reimbursement rates.Level of Evidence: Level III.

Periprosthetic ankle infection: eradication rate, complications, and limb salvage. A systematic review

BACKGROUND

This systematic review investigated the outcomes of revision surgery after periprosthetic ankle infection (PAI).

METHODS

According to the PRISMA statement, 9 studies with 131 PAIs surgically treated and analyzed were included. Demographics and surgical techniques with eradication rates and complications were reported.

RESULTS

Methicillin-sensitive Staphylococcus aureus (MSSA) (30.4%) and coagulase-negative Staphylococcus (CNS) (26.5%) were the most common microorganisms. The eradication rate was 91.7% with permanent antibiotic spacers (SPC), 84.4% with 2-stage, 79.4% with arthrodesis (AA), and 58.8% with debridement and implant retention (DAIR). DAIR showed a significantly lower eradication rate than 2-stage (p = 0.016) and SPC (p = 0.043). Amputations occurred in 25% of patients after SPC, 8.8% after AA and 3.9% after DAIR. SPC showed a significantly higher amputation rate than DAIR and 2-stage (p = 0.044, and p = 0.017, respectively).

CONCLUSIONS

SPC and 2-stage revision show the highest eradication rates, but 2-stage has a lower risk of amputation.

Does Concurrent Distal Tibiofibular Joint Arthrodesis Affect the Nonunion and Complication Rates of Tibiotalar Arthrodesis?

Tibiotalar arthrodesis successfully treats ankle arthritis but carries risk of nonunion. It is unclear whether concurrent distal tibiofibular arthrodesis affects tibiotalar nonunion rate. The purpose of this study is to compare tibiotalar nonunion and complication rates in patients with versus without a distal tibiofibular arthrodesis. This is a retrospective review of 516 consecutive ankle arthrodesis performed between March 2002 and May 2016. A total of 319 ankles (312 patients) underwent primary, open tibiotalar arthrodesis (227 with distal tibiofibular arthrodesis, 92 without). Primary outcome measure was nonunion rate. Secondary outcome measures were time to tibiotalar union, rate of development of post-operative deep vein thrombosis (DVT)/pulmonary embolism (PE), rate of deep wound complications, and rate of return to operating room (OR). No differences in nonunion rates were observed in both cohorts of patients with versus without distal tibiofibular arthrodesis: 17/227 (7.5%) versus 11/92 (12%) (p = 0.2), respectively, odds ratio was 0.74, 95% CI: 0.29~2.08 (p = 0.55). There was no difference in deep wound complications (5.3% versus 10.9%, p = 0.42), time to union (3.7 months versus 4.1 months, p = 0.72), or rate of development of DVT/PE (5.2% versus 2.2%, p = 0.18) between patients with and without distal tibiofibular arthrodesis, respectively. This is the first study directly comparing nonunion and complication rates in primary, open ankle arthrodesis with and without distal tibiofibular arthrodesis. Inclusion of the distal fibular joint with the tibiotalar fusion was not associated with a change in tibiotalar nonunion rate, time to union, wound complications, or postoperative DVT/PE.

Vitamin D Deficiency and Outcomes After Ankle Fusion: A Short Report

BACKGROUND

Vitamin D deficiency has been postulated as a cause for impaired bone healing and remodeling. The purpose of this study was to assess the potential association between low vitamin D levels and reoperation for nonunion following ankle fusion surgery.

METHODS

All adult patients (aged ≥18 years) who underwent ankle fusion procedures at a tertiary referral center from January 2010 to January 2019 with available vitamin D levels within 12 months preoperatively were retrospectively reviewed (n = 47). Patients were categorized as vitamin D deficient (<30 ng/mL) vs normal (31-80 ng/mL). The primary outcome was the incidence of reoperation secondary to nonunion. Secondary outcomes included incidence of reoperation not related to nonunion and the need for repeat reoperation.

RESULTS

The average level in the vitamin D-deficient group (n = 17; 36.2%) was 16.9 vs 46.4 ng/mL in the normal group (n = 30; 63.8%). All recorded reoperations for nonunion occurred exclusively in the vitamin D-deficient cohort (4/17 [23.5%]; P = .013). There were similar reoperation rates for causes other than nonunion (2/17 [11.8%] vs 4/30 [13.3%]; P > .99) and repeat reoperation rates (3/17 [17.6%] vs 1/30 [3.3%]; P = .128) among vitamin D-deficient vs normal patients.

CONCLUSION

Vitamin D deficiency may be associated with an increased risk of reoperation for nonunion after ankle fusion.

Technique Tip: Correcting Malalignment of the Talus Using a Pin-Based Distracter During Arthroscopic Ankle Arthrodesis

It is technical demanding work to perform arthroscopic ankle arthrodesis to treat end-stage ankle osteoarthritis with excessive talar tilt. This article aimed to provide an effective technique tip for the treatment of Takakura stage 3b ankle osteoarthritis with a talar tilt angle more than 15 degrees under arthroscopy. A conventional anterior arthroscopic approach is used. After arthroscopic examination and debridement, one pin which is parallel to the distal tibial surface is inserted into the tibial side of the ankle, the other pin which is parallel to the talar dome surface is inserted into the talar side of the ankle, both at the coronal plane. Then a distracter is used in the medial side to open the interspace of the tibiotalar joint and correct the talar tilt through the 2 pins, under which circumstance the tibiotalar joint surface can be well prepared. Next an anti-distracter is used in the lateral side to close the tibiotalar interspace and correct the talar tilt through the 2 pins, in which condition 3 fully threaded cannulated lag screws can be inserted through guide pins in a cross pattern to fix the ankle joint. We used the pin-based distracter to open and close tibiotalar interspace, correct the talar tilt and maintain a good mechanical axis for fusion, and the outcomes were good.

Postoperative Complications Following Ankle Arthrodesis in Patients With Hepatitis C: Matched Propensity Score Analysis

BACKGROUND

Hepatitis C is associated with increased adverse events following surgery. The goals of this study were therefore to evaluate postoperative outcomes in patients with hepatitis C following ankle arthrodesis.

MATERIALS AND METHODS

A review of Medicare patients was performed to identify patients who underwent ankle arthrodesis. Patients were then divided into those with a preoperative history of hepatitis C and those who did not and were matched using propensity scores. Outcomes of interest were analyzed using multivariate logistic regression.

RESULTS

A diagnosis of hepatitis C was associated with a significantly increased risk of myocardial infarction, emergency department visits, and readmission within 90 days following surgery. In addition, hepatitis C is associated with an increased length of stay, cost of hospitalization, and total hospital charge.

CONCLUSIONS

A diagnosis of hepatitis C was associated with a significant increase in hospital resource utilization during the initial inpatient stay and the immediate post-discharge period.Level of Evidence: III.

The Impact of Coronal Plane Deformity on Ankle Arthrodesis and Arthroplasty

BACKGROUND

Ankle coronal plane deformity represents a complex 3-dimensional problem, and comparative data are lacking to guide treatment recommendations for optimal treatment of end-stage ankle arthritis with concomitant coronal plane deformity.

METHODS

In total, 224 patients treated for end-stage ankle arthritis were enrolled in an observational trial. Of 112 patients followed more than 2 years, 48 patients (19 arthrodesis, 29 arthroplasty) had coronal plane deformity and were compared to 64 patients without coronal plane deformity (18 arthrodesis, 46 arthroplasty) defined as greater than 10 degrees of varus or valgus. The arthroplasty implants used had different internal constraints to intracomponent coronal plane tilting. Patients completed Musculoskeletal Functional Assessment (MFA) and SF-36 preoperatively and at 3, 6, 12, 24, and 36 months postoperatively. Measures included change in SF-36 and MFA, as well as compared reoperation rates and pain scales.

RESULTS

For the groups with coronal plane ankle deformity, the median for the arthrodesis group was 19.0 degrees and the median for the arthroplasty group was 16.9 degrees. In the deformity cohort during the follow-up period, we had 7 major reoperations: 2 in the arthrodesis group and 5 in the arthroplasty group, all with the less constrained implant design. MFA, vitality, and social function of the SF-36 improved for all groups. Patients without preoperative deformities had greater improvement with fusion or replacement at both 2 and 3 years. There was no difference in improvement between those patients with coronal deformity who received arthroplasty vs arthrodesis.

CONCLUSION

Patients with and without coronal plane deformity may benefit from ankle arthroplasty and arthrodesis, although greater improvements may be expected in those without preoperative deformity. In this study, at final follow-up of 3 years, overall we found no meaningful difference in patient-reported outcomes between the patients with preoperative coronal plane deformities whether they had a fusion or a replacement as treatment for end-stage ankle arthritis.

LEVEL OF EVIDENCE

Level II, comparative study.

The Potential of Bone Debris as a Bioactive Composite for Bone Grafting in Arthroscopic Ankle Arthrodesis

Arthroscopic ankle arthrodesis (AAA) has advantages of being less invasive and achieving a high bone union rate. However, there are still some nonunion or delayed union cases, especially those of high-grade deformity. During AAA, curettage of the subchondral bone using an abrader burr provides bone debris, and there is the possibility of bone debris being used as autograft to improve bone union. The purpose of this study is to analyze bone debris histologically, and the effect of its implantation on bone union of AAA. Bone debris from 6 patients was collected during AAA. Bone debris/atelocollagen composite was made and cultured for 4 weeks. Histological analyses were performed before and after culture. Twenty-six patients with AAA were divided into 2 groups with or without bone debris implantation, and the time to union after surgery was evaluated. In histological analysis of bone debris/atelocollagen composite, bone debris contained bone, cartilage and synovium fragment at time 0. After 4 weeks of culture, osteocalcin positive cells migrated and proliferated in the gel. Ki67 positive cells significantly increased after culture. In clinical cases, time to union was significantly shorter in the bone debris group (9.3 ± 1.3 weeks) than that in the control (12.4 ± 3.1 weeks). This study showed that bone debris contained the osteochonductive and osteoinductive properties, and there is the potential for its implantation into the ankle joint to improve bone union in ankle arthrodesis.

Clinical Outcomes of Total Ankle Arthroplasty Versus Ankle Arthrodesis for the Treatment of End-Stage Ankle Arthritis in the Last Decade: a Systematic Review and Meta-analysis

Ankle arthrodesis (AA) and total ankle arthroplasty (TAA) are the 2 primary surgical treatments for patients with end-stage ankle arthritis. The comparative outcomes between AA and TAA using modern techniques remain unclear. A systematic search to identify all relevant articles comparing AA with TAA was conducted through 3 online databases. The clinical outcomes were extracted for meta-analysis, including AOFAS (American Orthopaedic Foot & Ankle Society) score, VAS (visual analog scale), AOS (Ankle Osteoarthritis Scale), gait analysis, ROM (range of motion), satisfaction, complication, and reoperation. Our meta-analysis shows no heterogeneity in any subgroup analyses. There were no significant differences in AOFAS total, pain, and alignment scores between the AA and TAA groups. The TAA group had significant improvement in AOFAS function score compared with the AA group. There was no significant difference in VAS and AOS total scores between the 2 groups. No significant differences in gait analysis were observed between the 2 groups. The TAA group had significant improvement in both ROM and change in ROM compared with the AA group. There was no significant difference in satisfaction rate between the 2 groups. The TAA group had significantly higher complication and reoperation rates compared with the AA group. Our meta-analysis provides updated evidence on clinical outcomes comparing AA with TAA using third-generation implants. The TAA group had better improvement in AOFAS function and ROM than the AA group. No significant differences in pain relief, gait analysis, or patient satisfaction were observed between the 2 groups.

Ankle hemophilic arthropathy: literature review

Hemophilia is a bleeding disorder characterized by the deficiency of a coagulation factors. The hemarthrosis is the most common and earliest manifestation. Repeated hemarthrosis over time causes the development of hemophilic arthropathy. Among most involved joints, the ankle is the one where much uncertainty remains about the best course of action in managing the various degrees of hemophilia manifestations. These manifestations range from simple acute swelling and pain to devastating deformity. The purpose of our review is to draw a comprehensive picture of ankle hemophilic arthropathy epidemiology, pathophysiology, clinical symptoms and signs, radiological features and all the treatments available at present days. This review confirms that the first line of treatment considered should be the replacement therapy of the coagulation deficient factors that, preventing hemarthrosis, stops the development and progression of ankle's joint damage. The treatments proposed in literature for advanced stage of arthropathy are many and vary according to the severity of the case. They range from conservative ones such as physiotherapy, orthosis, intra-articular injections, laser therapy, external beam radiation therapy, radio-synovectomy and oral drug to invasive surgical treatment such as ankle arthrodesis and total ankle replacement. Whatever is the chosen treatment, according to the arthropathy severity we believe that it must be carried out in reference centers for foot and ankle surgery assisted by expert hematologists.

Effect of Patient Demographics on Minimally Important Difference of Ankle Osteoarthritis Scale Among End-Stage Ankle Arthritis Patients

BACKGROUND

Ankle replacement and ankle arthrodesis are standard treatments for treating end-stage ankle arthritis when conservative treatment fails. Comparing patient-reported outcome scores to the instrument's minimal important difference (MID) helps physicians and researchers infer whether a meaningful change in health from the patient's perspective has occurred following treatment. The objective of this study was to estimate the MID of the Ankle Osteoarthritis Scale among a cohort of operatively treated end-stage ankle arthritis patients undergoing ankle replacement or arthrodesis.

METHODS

A survey package including the Ankle Osteoarthritis Scale was completed by participants preoperatively and 2 years postoperatively. Distribution and anchor-based approaches to calculating the MID were used to estimate the MID of the Ankle Osteoarthritis Scale and its 2 domains. The distribution-based approaches used were the small and medium effect size methods, while the mean absolute change method and linear regression method were the anchor-based approaches. Bootstrap sampling was used to obtain the variance of MID estimates. The MID was estimated for sex, age, operative, and baseline health subgroups. The cohort comprised 283 participants, totaling 298 ankles.

RESULTS

The MID did not vary with sex or operative procedure. Age-based differences in MID values may exist for the Ankle Osteoarthritis Scale total score, and MID values were generally smallest among the oldest patients. Patients with the best and worst ankle-related health preoperatively had higher MID values than patients reporting mid-range Ankle Osteoarthritis Scale values preoperatively.

CONCLUSION

The best estimate of the MID of the Ankle Osteoarthritis Scale total score is 5.81. Our findings indicate that the MID of the Ankle Osteoarthritis Scale may not vary by sex or operative subgroups but likely varies by age and preoperative Ankle Osteoarthritis Scale score.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Differences in Gait and Stair Ascent After Total Ankle Arthroplasty and Ankle Arthrodesis

BACKGROUND

Ankle arthrodesis has historically been the standard of care for end-stage ankle arthritis; however, total ankle arthroplasty (TAA) is considered a reliable alternative. Our objective was to compare 3-dimensional foot and ankle kinetics and kinematics and determine the ankle power that is generated during level walking and stair ascent between TAA and ankle arthrodesis patients.

METHODS

Ten patients who underwent TAA with a modern fixed-bearing ankle prosthesis and 10 patients who previously underwent ankle arthrodesis were recruited. Patients were matched for age, sex, body mass index, time from surgery, and preoperative diagnosis. A minimum of 2-year follow-up was required. Patients completed instrumented 3D motion analysis while walking over level ground and during stair ascent. Between-group differences were assessed with a 2-tailed Mann-Whitney exact test for 2 independent samples.

RESULTS

Sagittal ankle range of motion (ROM) was significantly higher in the TAA group (21.1 vs 14.7 degrees, P = .003) during level walking. In addition, forefoot-tibia motion (25.3±5.9 degrees vs 18.6±5.1 degrees, P = .015) and hindfoot-tibia motion (15.4±3.2 degrees vs 12.2±2.5 degrees, P = .022) were significantly greater in the TAA group. During stair ascent, sagittal ankle ROM (25 vs 17.1 degrees, P = .026), forefoot-tibia motion (27.6 vs 19.6 degrees, P = .017), and hindfoot-tibia motion (16.8 vs 12 degrees, P = .012) was greater.

CONCLUSION

There were significant differences during level walking and stair ascent between patients with TAA and ankle arthrodesis. TAA patients generated greater peak plantarflexion power and sagittal motion within the foot and ankle compared to patients with an ankle arthrodesis. Further investigation should continue to assess biomechanical differences in the foot and ankle during additional activities of daily living.

LEVEL OF EVIDENCE

Level III, comparative study.

Screw Internal Fixation and Ilizarov External Fixation: A Comparison of Outcomes in Ankle Arthrodesis

The purpose of this study was to compare the mid-term clinical outcomes between screw internal fixation and Ilizarov external fixation in patients who underwent ankle arthrodesis and to elucidate the differences between the 2 fixation methods. This study investigated 43 ankles in 41 patients who underwent ankle arthrodesis at 1 of the 2 study institutions. There were 15 men and 26 women, and their mean age was 66.2 (range 49 to 87) years. The primary disease included osteoarthritis (OA) (79%), rheumatoid arthritis (RA) (16.3%), and Charcot joint (4.7%). Patients were divided into 2 groups depending on the surgical approach: the screw group (S) and the Ilizarov group (I). The following items were evaluated and compared between the 2 groups: patient characteristics, Tanaka-Takakura classification based on preoperative plain X-ray images, duration of surgery, blood loss, surgical complications, time to start weightbearing, and the Japanese Society of Surgery of the Foot (JSSF) standard rating system for the ankle-hindfoot. Duration of surgery was significantly shorter in the S group (162.3 versus 194.9 min), and the amount of blood loss was also significantly lower in the S group (29.2 versus 97.5 ml). Preoperative JSSF scale was significantly lower in the I group (44.8 versus 33), but postoperative JSSF scale was not significantly different between the 2 groups (82.1 versus 77.9). The S group had satisfactory clinical outcomes with a shorter duration of surgery and smaller amount of blood loss than the I group. However, severe patients in the I group achieved similar treatment outcomes.

Excision Arthroplasty With Interpositional Achilles Tendon Autograft: A Novel Approach to Talonavicular Joint Osteoarthritis Associated With Ankle Arthrodesis

Talonavicular joint arthritis is a great concern after ankle fusion. Although arthrodesis is the gold standard treatment for this complication, it could initiate a vicious cycle of further adjacent joint arthritis. An alternative that may delay or eliminate the need for arthrodesis is excision arthroplasty; however, there are only a few reports on its application on a talonavicular joint. We report 3 cases of excision arthroplasty with interpositional Achilles tendon autograft for the treatment of end-stage talonavicular osteoarthritis in low-demand elderly patients. In 1 patient, excision arthroplasty was performed after tibiotalocalcaneal arthrodesis, and in 2 patients, it was performed after tibiotalar arthrodesis, in which the subtalar joints were also damaged and fused simultaneously on performance of the interpositional arthroplasty of the talonavicular joint. In all cases, pain relief and functional activities of daily living improvement were achieved with this procedure. At a minimum follow-up of 1 year, no patient reported adjacent joint symptoms or flatfoot progression. These cases show that interpositional arthroplasty with Achilles tendon autograft is an effective treatment for end-stage talonavicular arthritis in patients with fused ankle and subtalar joints. This procedure was helpful in relieving pain and improving activities of daily living function in low-demand elderly patients with the preservation of movement of the talonavicular joint. Autograft was considered to be superior to other grafts with respect to availability, graft rejection, or allergy development. Fused subtalar joint resolved the concerning issues, such as flatfoot progression and muscular weakness of ankle plantar flexion, associated with this procedure.

Results and Outcomes of Combined Cross Screw and Ilizarov External Fixator Frame in Ankle Fusion

Ankle fusion is a treatment option for end-stage ankle arthritis. Fusion site stability and optimal foot positioning are crucial parameters. We present the results of our double fixation technique, combining both cross-screw fixation and Ilizarov external fixator frame via transmalleolar approach. We reviewed the files from 52 patients operated for ankle fusion in our center. In our technique, we use a transmalleolar approach, initial stabilization with 2 cannulated, half-threaded cross screws, and final stabilization with an Ilizarov external fixator frame. Fusion stability, weightbearing time, complication rates, and final functional scores were recorded and evaluated. Mean frame removal time was 11.2 ± 2.1 weeks, and 71.6% of patients were fully weightbearing at that time. Absolute fusion stability was reported in 88.46% of patients at that time, while no pseudarthrosis was noted in final follow-up at 12 months. According to the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot-ankle score evaluation at 12 months, 90.4% of patients reported excellent and 9.6% good results. None of the patients was referred for symptomatic forefoot arthritis, and there were no cases of deep infection or deep vein thrombosis. Material-related complications were reported in 1 patient who was treated with implant removal after 1 year. Ankle fusion is a salvage procedure that offers optimal results in end-stage ankle arthritis. Our technique offers absolute fusion site stability with excellent functional results, minor complications, and the advantages of early protected weightbearing. Careful patient selection in addition to fine foot positioning should be regarded as crucial for the final outcome.

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

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

Long-term Autograft Harvest Site Pain After Ankle and Hindfoot Arthrodesis

BACKGROUND

Pain following autograft harvest has been studied; however, published literature has typically focused on the iliac crest with follow-up limited to only a few years. It remains unknown if pain continues or improves over time. The purpose of this study was to evaluate long-term pain associated with autograft harvest to supplement hindfoot or ankle arthrodesis.

METHODS

Subjects in the control arm of a previously conducted trial comparing autograft with a synthetic bone graft for hindfoot or ankle arthrodesis were invited back for a single visit at a minimum of 5 years following their initial surgery. Harvest site, fusion site, and weight-bearing pain were evaluated using a 100-point visual analog scale (VAS). Of the 130 invited subjects, 60 (46.1%) returned for assessment, 58 of whom completed pain assessments.

RESULTS

At a mean follow-up of 9.0 years (range, 7.8-10.5), more than a third (36.6%) of subjects had some level of harvest site pain. Using VAS greater than 20 mm as a threshold of clinical significance, pain remained clinically significant in 5.2% of subjects. There was a significant correlation between harvest site pain and both weight-bearing and fusion site pain. There was not a significant correlation between harvest site pain and volume of graft harvested.

CONCLUSION

Autograft harvest can result in chronic, clinically significant pain that can last up to 10 years. In the era of shared decision making, this information will help surgeons and patients quantify the risks of chronic pain after arthrodesis procedures that include a secondary operative incision for graft harvest.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Return to Sports and Activity After Total Ankle Arthroplasty and Arthrodesis: A Systematic Review

BACKGROUND

There is no consensus regarding participation in sports and recreational activities following total ankle replacement (TAR) and ankle arthrodesis (AA). This systematic review summarizes the evidence on return to sports and activity after operative management with either TAR or AA for ankle osteoarthritis (OA).

METHODS

A literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed. Risk of bias of included studies was assessed using Methodological Index for Non-Randomized Studies (MINORS) criteria. Included studies reported sport and activity outcomes in patients undergoing TAR and AA, with primary outcomes being the percentage of sports participation and level of sports participation.

RESULTS

Twelve studies met inclusion criteria for analysis. There were 1270 ankle procedures, of which 923 TAR and 347 AA were performed. The mean reported patient age was 59.2 years and the mean BMI was 28 kg/m². The mean follow-up was 43 months. Fifty-four percent of patients were active in sports preoperatively compared with 63.7% postoperatively. The mean preoperative activity participation rate was 41% in the TAR cohort, but it improved to 59% after TAR, whereas the preoperative activity participation rate of 73% was similar to the postoperative rate of 70% in the AA cohort. The most common sports in the TAR and AA groups were swimming, hiking, cycling, and skiing.

CONCLUSION

Participation in sports activity was nearly 10% improved after operative management of ankle OA with TAR and remains high after AA. The existing literature demonstrated a large improvement in pre- to postoperative activity levels after TAR, with minimal change in activity after AA; however, AA patients were more active at baseline. The most frequent postoperative sports activities after operative management of ankle OA were swimming, hiking, cycling, and skiing. Participation in high-impact sports such as tennis, soccer, and running was consistently limited after surgery. This review of the literature will allow patients and foot and ankle surgeons to set evidence-based goals and establish realistic expectations for postoperative physical activity after TAR and AA.

LEVEL OF EVIDENCE

Level III, systematic review.

Comparison of Total Ankle Arthroplasty and Ankle Arthrodesis in End-Stage Hemophilic Arthropathy

BACKGROUND

Total ankle arthroplasty (TAA) can result in excellent outcomes in patients with end-stage arthritis, but most patients with end-stage hemophilic ankle arthropathy (ESHAA) still undergo ankle arthrodesis (AA). The purpose of this study was to analyze clinical and radiological results of TAA and AA for ESHAA.

METHODS

A total of 29 cases (16 TAAs and 13 AAs) of painful ESHAA were included. For clinical outcome evaluation, visual analog scale (VAS) for pain, Foot Function Index (FFI), and range of motion (ROM) were analyzed. Postoperative clinical and radiological complications were also analyzed. The mean duration of follow-up was 6.8 ± 3.0 years. The mean age was 44.1 ± 9.9 years.

RESULTS

The VAS for pain was significantly improved from 5.5 ± 2.3 to 0.9 ± 1.2 (P < .001). The FFI scale was significantly improved from 61.6% ± 15.5% to 16.6% ± 15.4% (P < .001). In FFI disability and activity subscales, the TAA group exhibited meaningful outcomes relative to those of the AA group (P = .012 and .036, respectively). The total ROM in the TAA group changed from 30.8 ± 12.6 degrees to 37.3 ± 12.8 degrees at final follow-up (P = .090). Three cases of osteolysis and 1 case of heterotopic ossification were noted in the TAA group. No cases of nonunion were noted in the AA group. Progressive arthrosis of adjacent joints after AA was observed in 1 case.

CONCLUSION

Both TAA and AA in ESHAA exhibited significant improvement in pain based on VAS and FFI scales. Compared to AA, TAA resulted in superior outcomes in FFI disability and activity subscales, suggesting that TAA may be considered as a surgical option alongside AA for ESHAA.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Complications of En Bloc Osteochondral Talar Allografts and Treatment of Failures: Literature Review and Case Report

Reoperation rates and complication rates can be high for patients receiving an osteochondral talar allograft transplant. Complications can include graft failure, delamination of the graft, arthrofibrosis, advancing osteoarthritis, nonunion of malleolar osteotomies, and partial or complete osteonecrosis of the talus. Graft failure refers to failure of graft incorporation with subsequent necrosis and subsidence. Treatment options for talar graft failure are limited, and outcomes for these treatments have rarely been reported. We present a review of the published data on the complications and treatments for failed talar allograft transplantation. A case report is presented on a young woman who experienced graft failure and osteonecrosis of her talar allograft transplant. Because of the size of the present osteonecrosis, an ankle arthrodesis was performed as the initial revision procedure. Talar necrosis was removed and revascularized from the ankle fusion with solid fusion was confirmed with computed tomography. Symptomatic adjacent joint pain quickly developed in the hindfoot after the ankle fusion, and 12 months later an ankle fusion conversion to total ankle arthroplasty was performed. The patient has returned to normal activity with significant reduction in pain at most recent follow-up visit. This patient was followed for 7 years from initial osteochondral talar allograft transplantation and for 2 years from conversion of ankle fusion to total ankle arthroplasty. It is important to understand the techniques, indications, and outcomes for the various revision options for talar allograft failure. This case report illustrates how multiple revision options can be used to provide the best outcome for the patient.

End-stage Ankle Arthritis Treated by Ankle Arthrodesis with Screw Fixation Through the Transfibular Approach: A Retrospective Analysis

OBJECTIVE

To evaluate the clinical outcome of ankle arthrodesis with screw fixation through the transfibular approach for end-stage ankle arthritis.

METHODS

Data of 22 patients (28 ankles) with end-stage ankle arthritis admitted to the Department of Orthopedics and Surgery of the First Hospital of Jilin University from May 2015 to December 2018 were analyzed retrospectively. The study included 9 men and 13 women, with a mean age of 56.86 ± 11.27 years (range, 37-75 years). The mean duration of the disease was 11.36 ± 12.80 years (range, 3 months-50 years). A total of 16 patients had posttraumatic arthritis, 5 patients had osteoarthritis, and 1 patient had rheumatoid arthritis. There were 12 cases of the left ankle and 16 cases of the right ankle; 16 cases were unilateral and 6 were bilateral. The same surgical procedure was applied to all patients. Collected data included the operation time, intraoperative and postoperative blood loss, hospitalization time, bone union rate, time to bone union, and complications. The American Orthopedic Foot and Ankle Society (AOFAS) ankle hindfoot score and the visual analogue scale (VAS) were used to evaluate the preoperative status and the postoperative outcome at the last follow up.

RESULTS

The mean follow-up period was 26.14 ± 10.99 months. The mean operation time was 101.82 ± 33.33 min. The mean blood loss was 116.78 ± 68.86 mL during the procedure and 111.07 ± 52.18 mL after the procedure. The mean hospitalization time was 14.22 ± 5.42 days. Bone union of the ankle joint was achieved in all patients. The mean time to bone union was 14.83 ± 2.14 weeks. There was significant difference in the operation time between the patients undergoing unilateral and bilateral ankle arthrodesis. The AOFAS ankle hindfoot score increased from the preoperative value of 43.46 ± 4.39 points to 80.39 ± 5.37 points at the last follow up. During the same interval, the VAS score improved from 6.14 ± 0.80 points to 1.64 ± 0.73 points. The AOFAS ankle hindfoot score of patients who underwent unilateral ankle arthrodesis improved from the preoperative 43.19 ± 3.95 points to 81.75 ± 5.23 points at the last follow up, and the VAS score improved from 6.19 ± 0.83 points to 1.69 ± 0.70 points. The AOFAS ankle hindfoot score of patients undergoing bilateral ankle arthrodesis improved from the preoperative value of 43.83 ± 5.08 points to 78.67 ± 5.05 points at the last follow up, while the VAS score improved from 6.08 ± 0.82 points to 1.58 ± 0.79 points. There was significant difference in the maximum walking distance and walking on any surface between the patients undergoing unilateral and bilateral ankle arthrodesis. One patient developed superficial peroneal nerve palsy, which resolved within 1 year after the operation. In another patient, healing of the incision skin was delayed. During the follow-up period, none of the patients developed an infection of the incision or local skin necrosis; screw loosening, withdrawal, or breakage did not occur in any patient.

CONCLUSION

The ankle arthrodesis with screw fixation through the transfibular approach provides satisfactory clinical outcomes for end-stage ankle arthritis.

Tibial Stress Fracture Following Ankle Arthrodesis

BACKGROUND

End-stage ankle arthritis is frequently treated with either tibiotalar or tibiotalocalcaneal (TTC) arthrodesis, but the inherent loss of accommodative motion increases mechanical load across the distal tibia. Rarely, patients can go on to develop a stress fracture of the distal tibia without any antecedent traumatic event. The purpose of this study was to determine the incidence of tibial stress fracture after ankle arthrodesis, highlight any related risk factors, and identify the effectiveness of treatment strategies and their healing potential.

METHODS

A retrospective chart review was performed at 2 large academic medical centers to identify patients who had undergone ankle arthrodesis and subsequently developed a stress fracture of the tibia. Any patient with a tibial stress fracture before ankle arthrodesis, or with a nontibial stress fracture, was excluded from the study.

RESULTS

A total of 15 out of 1046 ankle fusion patients (1.4%) developed a tibial stress fracture at a mean time of 42 ± 82 months (range, 3-300 months) following the index procedure. The index procedure for these 15 patients who went on to subsequently develop stress fractures included isolated ankle arthrodesis (n = 8), ankle arthrodesis after successful subtalar fusion (n = 2), primary TTC arthrodesis (n = 2), and ankle arthrodesis subsequent to successful subtalar fusion with resultant ankle nonunion requiring revision TTC nailing (n = 3). Four patients had undergone fibular osteotomy with subsequent onlay strut fusion, and 5 had undergone complete resection of the lateral malleolus. Stress fracture location was found to be at the level of the fibular osteotomy in 2 patients and at the proximal end of an existing or removed implant in 9. Fourteen of the 15 patients had a nondisplaced stress fracture and were initially treated with immobilization and activity modification. Of these, 3 failed to improve with nonoperative treatment and subsequently underwent operative fixation (intramedullary nail in 2; plate fixation in 1). Only 1 of the 15 patients presented with a displaced fracture and underwent immediate plate fixation. All patients reported pain improvement and were ultimately healed at final follow-up.

CONCLUSION

In this case series review, we found a 1.4% incidence of tibial stress fracture after ankle arthrodesis, and both hardware transition points and a fibular resection or osteotomy appear to be risk factors. Operative intervention was required in approximately 25% of this population, but the majority of tibial stress fractures following ankle fusion were successfully treated nonoperatively, and ultimately all healed.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Intramedullary nail versus external fixator for ankle arthrodesis in Charcot neuroarthropathy: A meta-analysis of comparative studies

PURPOSE

Ankle Charcot neuroarthropathy presents a great challenge for treatment. While conservative treatments yield poor results, arthrodesis is considered the treatment of choice for unstable Charcot ankles. There are two methods used for ankle fusion: retrograde intramedullary nail (IMN) and external fixator (EF). Literature reports inconclusive results on which method is better for arthrodesis.

METHODS

The aim of this meta-analysis is to look for significant difference between the two techniques in terms of fusion rate and complications. Four comparative studies including 117 patients (117 interventions) were located and analyzed.

RESULTS

IMN was found to yield double fusion rate than EF ( p = 0.2) with 5 weeks less time to heal ( p = 0.4). While no significance was noted for revision surgery and amputation rates, EF yielded higher rates of hardware infection ( p = 0.01) and wound infection ( p = 0.01). The IMN method seems to offer quicker and better fusion rate when compared to EF with significantly lower postoperative infection rates.

CONCLUSION

In the clinical context of high-risk patients such as the diabetic population, IMN technique could be a better option in the case of ulcer-free ankles/feet or in the presence of medial/lateral ulcers. In case of presence of plantar ulcers, EF might be a better choice to avoid the plantar approach for nail insertion. Future research with bigger sample sized and randomized studies are warranted for validation.

Primary Arthrodesis for Diabetic Ankle Fractures

Background

Treatment of ankle fractures in patients with diabetes is associated with increased complication rates. Ankle arthrodesis is considered a salvage procedure after failed ankle fracture fixation, yet primary ankle arthrodesis has been proposed as a treatment option for patients with significant diabetes-related complications. To date, the characteristics of patients who undergo primary ankle arthrodesis and the associated outcomes have not been described.

Methods

A retrospective review was performed of 13 patients with diabetes who underwent primary arthrodesis for traumatic ankle fracture. Patient demographics were characterized in addition to their diabetes complications, Adelaide Fracture in the Diabetic Ankle (AFDA) score, and fracture type. Outcomes assessed included reoperation rates, infection rates, wound complications, nonunion/malunion, amputation, and development of Charcot arthropathy postoperatively.

Results

Patients who underwent primary arthrodesis had high rates of diabetes complications, average AFDA scores of 6.4, and high rates of severe injuries, including 38.5% open fractures and 69.2% fracture dislocations. The overall complication rate for primary arthrodesis of ankle fractures in diabetes patients was more than 75% in this cohort. Complications included a 38.5% reoperation rate, 38.5% infection rate, 53.8% wound complication rate, and 23.1% amputation rate. Despite a high nonunion rate at the attempted fusion sites, 89.9% of fractures healed and patients had a stable extremity.

Conclusion

This review is the first to characterize the epidemiology and complications of diabetes patients undergoing primary ankle arthrodesis for ankle fractures. In this cohort, patients with multiple diabetic complications and severe injuries underwent primary arthrodesis, which led to an overall high complication rate. Further research is needed to determine the appropriate treatment option for these high-risk patients, and tibiotalocalcaneal stabilization without arthrodesis may be beneficial.

Level of Evidence

Level IV, retrospective case series.

Radiographic Sagittal Tibio-Talar Offset in Ankle Arthrodesis-Accuracy and Reliability of Measurements

Radiographic outcome assessment of ankle arthrodesis (AA) requires accurate measurement techniques. This study aimed to identify the most reliable methods for sagittal tibio-talar alignment measurements with regard to the tibio-talar offset after AA. Lateral weight-bearing radiographs of 38 fused ankles were selected for retrospective review. The sagittal tibio-talar angle (STTA), the modified tibio-talar ratio (mT-T ratio) and the sagittal tibio-talar offset (tibCOR, procLAT) were measured by three independent observers. Intra- and interobserver correlation coefficients (ICC) and mean measurement differences were calculated to assess measurement reliability and accuracy. By defining the talar longitudinal axis as a line from the inferior aspect of the posterior tubercle of the talus to the most inferior aspect of the talar neck, STTA showed excellent (ICC 0.924; CI 95% 0.862–0.959) and mTT-ratio provided high (ICC 0.836; CI 95% 0.721–0.909) interobserver reliability, respectively. For tibio-talar offset measurement the tibCOR method showed superior reliability and better interobserver agreement compared to the procLAT technique. The STTA and a modified T-T ratio are recommended for future scientific radiographic measurements in AA.