Effective Case Reports and Small Case Series

Once the mainstay of scientific journals, in the age of evidence-based medicine, case reports and small series are now considered to represent a lower hierarchy in the medical decision-making process. However, case reports and small series represent the culmination of the time-honored traditional medical education teaching method with the descriptive case presentation. Despite being infrequently cited as references, case reports and small series still offer important contributions to patient care. The authors present a review of the strengths and weaknesses of case reports and small series and discuss ways to incorporate this form of literature into structured medical education.

An Analysis of 50 Consecutive Total Ankle Replacements Undergoing Preoperative Computerized Tomography Scan-Based, Engineer-Provided Planning From a Single Noninventor, Nonconsultant Surgeon

Preoperative computerized tomography (CT) scan-based, engineer-provided alignment plans and patient-specific pinning blocks for total ankle replacement (TAR) are available for use in the United States. However, nonbiased studies that justify the additional expense associated with this technology through support of the marketed benefits of less procedural complexity, less intraoperative radiation and reduced surgical time, are lacking. Therefore, to verify the manufacturer's proposed benefits, we sought to investigate our experience with this preoperative CT scan-based, engineer-provided plan and patient-specific pinning blocks during primary TAR. In review of our 50 TAR patients, we found that "perfect" radiographic alignment was not consistently achieved and the accuracy of component prediction was modest. Furthermore, the preoperative plans and patient-specific pinning blocks did not simplify the complexity of our operations since the operative time, intraoperative image intensification time and radiation dose per case all exceeded published historical TAR controls. Interestingly, we identified a significant difference in placement accuracy between the arced and flat-top talar component types that were implanted with the arced being more frequently malaligned. We did not find associations between preoperative deformity severity and accuracy of postoperative alignment. These findings suggest that it is imperative to have surgeons continue to rely on their own surgical planning and experience to achieve optimum radiographic alignment rather than depending on engineer-based recommendations or "surface matched" pinning blocks. Ultimately, we were unable to support the purported benefits of this CT scan-based, engineer-provided alignment plan and patient-specific pinning blocks for this manufacturer's primary TAR systems.

Osteochondral Lesions of the Talar Dome

Osteochondral lesion of the talar dome (OCLT) can be a devastating injury that affects mobility. Etiology of these lesions is debated but trauma seems the most supported etiology. Diagnosis of lesions is based on imaging. Conservative management, including weight-bearing restrictions, physical therapy, and supportive measures, often is first-line treatment. Nonsurgical modalities have mixed results and surgical measures often are necessitated for symptom relief. Surgical treatments vary in invasiveness and often are dictated by OCLT size. Studies show patient satisfaction increases substantially after having these procedures performed after failing nonsurgical measures. Results are encouraging, although thorough work-up and discussion should be undertaken.

Closed Manipulation, Intraosseous Reduction, and Rigid Internal Fixation for Displaced Intra-Articular Calcaneal Fractures

Although open reduction and internal fixation for treating displaced intra-articular calcaneal fractures remain common, difficulty obtaining and maintaining both calcaneal morphology and subtalar articular surface reduction remain. In addition, open approaches induce a significant risk of wound-healing complications. For this reason, closed manipulation to restore calcaneal morphology, intra-osseous fracture reduction, and rigid locked nail fixation was developed and validated for clinical use. Conversion to an immediate primary or delayed reconstructive subtalar joint arthrodesis using the same instrumentation remains unique to this system. This article reviews the CALCANAIL surgical technique for performing operative fixation of displaced intra-articular calcaneal fractures.

Salvaging the Unsalvageable Severe Malunion Deformity After Displaced Intra-Articular Calcaneal Fractures: What Options Exist?

A subset of calcaneal fractures is so severe that it may warrant primary conservative treatment. Unfortunately, nonoperative management of these fractures can lead to the development of a calcaneal malunion and cause significant patient morbidity. Surgical management of these deformities often requires increasingly complex reconstructive procedures. The goals of surgery include re-establishing calcaneal height, restoring the talocalcaneal relationship, and creating a stable, plantigrade foot. This article highlights the available surgical treatment options (including calcanectomy, calcaneal allograft transplantation, vascularized autografts, and calcaneal prostheses) for the management of severe calcaneal malunion deformities.

Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures

Performing a thorough clinical evaluation following an acute displaced intra-articular calcaneal fracture is paramount for optimal surgical timing and long-term outcome. Initial survey must entail a comprehensive evaluation to rule out concurrent injuries. Focused lower extremity examination must involve a complete neurovascular and soft tissue evaluation to identify such conditions as compartment syndrome or compromised integument, which necessitate urgent intervention. Establishing baseline radiographs and advanced imaging is vital for surgical planning. Once deemed stable, protocol-driven treatment is best to ensure proper control of pain and edema and adequate management of economic and patient safety concerns.

Joint-Sparing Surgical Management of Sanders IV Displaced Intra-Articular Calcaneal Fractures

Displaced intra-articular calcaneal fractures represent life-altering injuries. Difficulty obtaining and maintaining calcaneal morphology and the significant risk of wound healing complications with an extensile lateral incision exist. Open reduction with internal fixation as a joint-sparing approach has been studied. Closed manipulation to restore calcaneal morphology, intra-osseous fracture reduction, and rigid locked CALCANAIL fracture nail fixation have recently been applied to Sanders IV fracture patterns. Spontaneous conversion to primary subtalar joint arthrodesis using the same instrumentation remains unique to this system. This article reviews open and percutaneous approaches for joint-sparing and primary arthrodesis procedures to treat Sanders IV fracture patterns.

Management of Calcaneal Fracture Malunion with Bone Block Distraction Arthrodesis: A Systematic Review and Meta-Analysis

One of the most severe complications in calcaneal fractures is a malunion. When a malunion occurs, subtalar bone block distraction arthrodesis provides restoration of calcaneal height, length, correction of varus deformity, and elimination of subtalar joint arthritis. A systematic review showed the union rate for all procedures was 95.78%. The overall complication rate was 38% for all procedures. This is the first study to categorically break down complications with statistical analysis. The data presented indicate the level of difficulty of the subtalar distraction bone block arthrodesis for calcaneal malunions and may even suggest the need for newer techniques.

Endoscopic Approach for the Excision of Giant Cell Tumor of Tendon Sheath Involving the Hindfoot: A Case Report

Giant cell tumor of tendon sheath (GCT-TS) is an often benign neoplasm that is relatively uncommon in the foot and ankle when compared to the upper extremities. Magnetic resonance imaging aids in characterizing the lesion, but diagnosis is confirmed with biopsy. Surgical excision is the preferred treatment. There is a lack of studies examining the long-term outcomes of endoscopic excision of GCT-TS, especially lesions found in the foot and ankle. The present study describes a case of a 42-year-old male with GCT-TS of the hindfoot treated with an endoscopic excision through a sinus tarsi approach. The patient was asymptomatic with no local signs of recurrence at the 67-month follow-up visit.

Sagittal Ankle and Midfoot Range of Motion Before and After Revision Total Ankle Replacement: A Retrospective Comparative Analysis

The most common reason for a revision total ankle replacement procedure is a painful, stiff ankle even after the initial surgery. Limited and conflicting data are available regarding the change in sagittal foot and ankle range of motion after revision total ankle replacement surgery. We sought to determine whether revision total ankle replacements would reduce compensatory midfoot range of motion. In determining this, a novel radiographic measurement system with stable osseous landmarks is used. A retrospective medical record review of patients who had undergone revision total ankle replacement from January 2009 to June 2016 was performed. Thirty-three patients (33 ankles) underwent revision total ankle replacement surgery and met the inclusion criteria with a mean follow-up period of 28.39 ± 14.68 (range 2 to 59) months. Investigation of preoperative and postoperative weightbearing lateral radiographic images was performed to determine the global foot and ankle, isolated ankle, and isolated midfoot sagittal ranges of motion. Statistical analysis revealed a significant increase in ankle range of motion (p = .046) and a significant decrease in midfoot range of motion (p < .001) from preoperatively to postoperatively. The change in global foot and ankle range of motion was not significant (p = .53). For this patient population, the increased ankle range of motion effectively resulted in less compensatory midfoot range of motion.

Living Cryopreserved Bone Allograft as an Adjunct for Hindfoot Arthrodesis

Hindfoot arthrodesis is a frequently performed procedure by foot and ankle surgeons. The relatively high nonunion rate associated with these procedures has led surgeons to use adjunctive bone graft to help augment osseous union. Cellular bone allografts are a specific type of graft that incorporates osteoconductive, osteoinductive, and osteogenic properties while also eliminating the common disadvantages of autografts and traditional allografts. This article discusses the role of cellular bone allografts in hindfoot arthrodesis procedures, a review of current literature, and a comparison of available products.

Mobility of the First Ray in Patients With or Without Hallux Valgus Deformity: Systematic Review and Meta-Analysis

The hypermobility theory of the first ray is the reason for the popularization of procedures such as the modified Lapidus procedure involving arthrodesis of the first tarsal-metatarsal joint for correction of hallux valgus deformity. Although many studies have involved motion of the first ray in hallux valgus patients, the presence and clinical significance of hypermobility in the first ray remains controversial. We performed a systematic review and meta-analysis to evaluate the difference in the first ray range of motion between patients with or without hallux valgus deformity. The databases used for the present review included Ovid EMBASE, Ovid MEDLINE, CINAHL, and the Cochrane Database. We searched for comparative studies that had evaluated the motion of the first ray in patients with or without hallux valgus. After screening for inclusion and exclusion criteria, we identified 3 studies that were relevant to our study question. All 3 studies showed more first ray motion in the hallux valgus group. Our quantitative synthesis showed a mean difference in the range of motion of the first ray of 3.62 mm (95% confidence interval 2.26 to 4.98) between those with and without hallux valgus deformity. Thus, we found statistically significantly increased first ray motion in patients with hallux valgus deformity compared with those without hallux valgus deformity. However, the clinical significance of this small amount of increased sagittal plane motion as a response to or a cause of hallux valgus remains unanswered.

Anterior Incision Offloading for Primary and Revision Total Ankle Replacement: A Comparative Analysis of Two Techniques

Background:

There exists a high risk of post-operative complications with primary and revision total ankle replacement surgery. Delayed wound healing of the anterior incision is common. The reason for this is multi-factorial and, to date, most of the research has focused on predisposing factors involving the patients themselves. Only recently have researchers begun to look at the post-operative dressing as a possible consideration when trying to prevent incision wound healing complications. Currently, no standard post-operative dressing for primary or revision total ankle replacement exists. However, the principles of post-operative edema reduction to improve healing, as advocated by Sir Robert Jones and demonstrated in his compressive dressing, have been known for decades. We have been using a modified Sir Robert Jones compressive dressing for both primary and revision total ankle replacements. Recently, we have added an aperture pad made of cotton cast padding over the anterior incision in order to protect the area from pressure necrosis.

Methods:

This is a comparison study of the post-operative wound complications involving 35 patients that received the original dressing and 33 patients that received the addition of the aperture pad.

Results:

With no significant difference in the patient populations, the results demonstrate a 3-fold decrease in the number of anterior incision wound healing complications with the use of the aperture pad.

Conclusion:

This dressing represents a simple, reproducible, easy to apply and inexpensive way to prevent post-operative edema and anterior incision wound healing complications.

First Metatarsal-Phalangeal Joint Arthrodesis: Primary, Revision, and Salvage of Complications

Arthrodesis of the first metatarsal-phalangeal joint has been proposed for treatment of severe hallux valgus, end-stage hallux rigidus, rheumatoid arthritis, and revision of failed surgery due to the perceived safety and efficacy. This article discusses the principles of first metatarsal-phalangeal joint arthrodesis in primary and revision situations, joint preparation, configurations of osteosynthesis, and common complications, including salvage of nonunion and revision of malunion with realignment osteotomy.

Intraoperative Radiation Exposure During Revision Total Ankle Replacement

Intraoperative C-arm image intensification is required for primary total ankle replacement implantation. Significant radiation exposure has been linked to these procedures; however, the radiation exposure during revision total ankle replacement remains unknown. Therefore, we sought to evaluate the radiation exposure encountered during revision total ankle replacement. The data from 41 patients were retrospectively analyzed from a prospective database: 19 Agility(™) to Agility(™); 4 Agility(™) to Custom Agility(™); 9 Agility(™) to INBONE(®) II; 5 Agility(™) to Salto Talaris(®) XT; 2 Scandinavian Total Ankle Replacement Prosthesis to Salto Talaris(®) XT; and 2 INBONE(®) I to INBONE(®) II revision total ankle replacements were performed. Two broad categories were identified: partial revision (Agility(™) to Agility(™), Agility(™) to Custom Agility(™), INBONE(®) I to INBONE(®) II) and complete conversion (Agility(™) to INBONE(®) II, Agility(™) to Salto Talaris(®) XT, Scandinavian Total Ankle Replacement Prosthesis to Salto Talaris(®) XT). The mean radiation exposure per case was significant at 3.49 ± 2.21 mGy. Complete conversions, specifically Agility(™) to INBONE(®) II, exhibited the greatest radiation exposure and C-arm time. Revision implant selection and revision type (complete or partial) directly contributed to radiation exposure. Accordingly, revision systems requiring less radiation exposure are preferable. Surgeons should strive to minimize intraoperative complications and limit additional procedures to those necessary, because both lead to additional radiation exposure.

A Prospective Comparison of Clinical, Radiographic, and Intraoperative Features of Hallux Rigidus: Long-Term Follow-Up and Analysis

Forty-seven patients (50 feet) underwent surgical intervention for symptomatic hallux rigidus from February 1998 to April 1999. Thirty-eight patients (41 feet) returned at 1 year for a follow-up evaluation. Of these 38 patients, 20 (21 feet) returned for the 15-year follow-up evaluation. Subjective evaluations were performed using the modified American Orthopaedic Foot and Ankle Surgery hallux metatarsophalangeal-interphalangeal 100-point scale. Long-term postoperative objective physical examination and radiographic analysis were performed. These data were compared with the preoperative and short-term follow-up data. The subjective evaluation showed a statistically significant differing over the long term, with a mean increase of 27.6 points. The results of the physical examination and radiographic measurements were mixed. The long-term dorsal range of motion was not significant across surgery type. Radiographically, the procedure types resulted in similar changes, suggesting that neither joint preservation nor joint destructive procedures were more stable over time. Plantar transposition of the capital fragment, offsetting the longitudinal shortening of the first metatarsal, was not significant, confirming the short-term findings. For this patient population, the long-term results of surgical intervention for hallux rigidus, regardless of procedure type, provided subjective patient improvement but no statistically significant increase in first metatarsophalangeal joint function or dorsal range of motion.

Vascularized Pedicled Fibula Onlay Bone Graft Augmentation for Complicated Tibiotalocalcaneal Arthrodesis With Retrograde Intramedullary Nail Fixation: A Case Series

Tibiotalocalcaneal arthrodesis stabilized with retrograde intramedullary nail fixation is associated with a high incidence of complications. This is especially true when performed with a bulk structural allograft and poor soft tissue quality. In select high-risk limb salvage cases, we have augmented tibiotalocalcaneal arthrodesis procedures stabilized using retrograde intramedullary nail fixation with a vascularized pedicled fibular onlay bone graft. We present the data from 10 such procedures with a mean follow-up period of 10.9 ± 5.4 (range 6 to 20) months involving 10 patients (9 males and 1 female). The etiology was avascular osteonecrosis of the talus and/or distal tibia and a resultant large volume cavitary bone defect (8 ankles), severe equinocavovarus contracture (1 ankle), and failed total ankle replacement (1 ankle). A frozen femoral head bulk allograft was used twice, a whole frozen talus allograft once, and a freeze-dried calcaneal allograft once. The fibula was mobilized with intact musculoperiosteal perforating branches of the peroneal artery as a vascularized pedicle onlay bone graft fixated with a screw and washer construct. The mean fibular graft length was 10.2 ± 2.3 cm. The mean interval to radiographic fusion was 2.6 ± 0.6 months and to weightbearing was 3.1 ± 1.4 months. Two stable bulk allograft-host bone and fibular graft-host bone nonunions occurred after intramedullary nail hardware failure. Tibiotalocalcaneal arthrodesis augmented by vascularized pedicled fibular graft stabilized with retrograde compression intramedullary nail fixation offers a reliable option for complex salvage situations when few other options exist.

Catastrophic Failure of an Infected Achilles Tendon Rupture Repair Managed with Combined Flexor Hallucis Longus and Peroneus Brevis Tendon Transfer

Deep infection is one of the most devastating complications following repair of an Achilles tendon rupture. Treatment requires not only culture-driven antibiotic therapy, but more importantly, appropriate débridement of some or even all of the Achilles tendon. This may necessitate delayed reconstruction of the Achilles tendon. The authors present a successful case of reconstruction of a chronically infected Achilles tendon in an otherwise healthy 43-year-old man via a multistaged approach using the flexor hallucis longus and peroneus brevis tendons. We also provide a brief review of the literature regarding local tendon transfer used in the reconstruction of Achilles tendon rupture.

Use of Soft-Tissue Procedures for Managing Varus and Valgus Malalignment with Total Ankle Replacement

Achieving frontal plane alignment of the ankle joint during total ankle replacement is essential for long-term success. Tendon and ligament lengthening, ligament reinforcement, tendon transfer, nonanatomic tendon transfer ligament reconstruction, and periarticular osteotomies are safe, straightforward, minimally invasive, and reproducible procedures to correct varus and valgus deformities associated with end-stage degenerative joint disease. Using reproducible topographic anatomic landmarks is essential to these techniques properly and limit complications. The approach to frontal plane deformities is stepwise, with liberal use of tendon and ligament lengthening and reconstruction, a low threshold for nonanatomic tendon transfer ligament reconstructions, and tendon transfers and/or periarticular osteotomies.

Incidence of Complications During Initial Experience with Revision of the Agility and Agility LP Total Ankle Replacement Systems: A Single Surgeon's Learning Curve Experience

As the frequency in which foot and ankle surgeons are performing primary total ankle replacement (TAR) continues to build, revision TAR will likely become more commonplace, creating a need for an established benchmark by which to evaluate the safety of revision TAR as determined by the incidence of complications. Currently, no published data exist on the incidence of intraoperative and early postoperative complications during revision of the Agility or Agility LP Total Ankle Replacement Systems during the surgeon learning curve period; therefore, the authors sought to determine this incidence during the senior author's learning curve period.

Total Ankle Replacement Survival Rates Based on Kaplan-Meier Survival Analysis of National Joint Registry Data

National joint registry data provides unique information about primary total ankle replacement (TAR) survival. We sought to recreate survival curves among published national joint registry data sets using the Kaplan-Meier estimator. Overall, 5152 primary and 591 TAR revisions were included over a 2- to 13-year period with prosthesis survival for all national joint registries of 0.94 at 2-years, 0.87 at 5-years and 0.81 at 10-years. National joint registry datasets should strive for completion of data presentation including revision definitions, modes and time of failure, and patients lost to follow-up or death for complete accuracy of the Kaplan-Meier estimator.

Management of Osseous and Soft-Tissue Ankle Equinus During Total Ankle Replacement

Obtaining functional alignment of a total ankle replacement, including physiologic sagittal plane range of motion, is paramount for a successful outcome. This article reviews the literature on techniques available for correction of osseous and soft-tissue equinus at the time of index total ankle replacement. These techniques include anterior tibiotalar joint cheilectomy, posterior superficial muscle compartment lengthening, posterior ankle capsule release, and release of the posterior portions of the medial and lateral collateral ligament complexes. The rationale for these procedures and the operative sequence of events for these procedures are presented.

Incidence of Complications During the Surgeon Learning Curve Period for Primary Total Ankle Replacement: A Systematic Review

Surgeons performing primary total ankle replacement have achieved outcomes comparable to ankle arthrodesis. However, while many reports exist suggesting the presence of a surgeon learning curve period during initial performance of primary total ankle replacement, no published analysis of the actual incidence of complications encountered during this period exists. Therefore, we sought to provide such an analysis through systematic review. A total of 2453 primary total ankle replacements with 1085 complications (44.2%) were identified. Our results revealed conflicting data whether an acceptably low incidence of high-grade complications leading to total ankle replacement failure exists during the surgeon learning curve period.

The Salto Talaris XT Revision Ankle Prosthesis

The Salto Talaris XT Revision Ankle Prosthesis is an anatomically designed fixed-bearing prosthesis available in the United States based on the design of previous Salto systems. The Salto Talaris XT Revision Ankle Prosthesis design optimizes surface area, cortical contact, and ultrahigh-molecular-weight polyethylene conformity. Two tibial component designs, both with the same base plate dimensions, are available, the standard conical fixation plug affixed to a short keel and a long-stemmed version. The author presents an overview of the Salto Talaris XT Revision Ankle Prosthesis surgical technique and pearls for successful application.

Management of Massive Hindfoot Osteolysis Secondary to Failed INBONE I Total Ankle Replacement

This article presents a procedure whereby a failed INBONE I saddle talar component and polyethylene insert associated with massive cystic changes within the talus and calcaneus secondary to aseptic osteolysis was treated with impaction cancellous allograft bone graft impregnated with autogenous proximal tibia bone marrow aspirate and conversion to an INBONE II sulcus talar component and polyethylene insert. Concomitantly, a percutaneous tendo-Achilles lengthening and posterior capsule release was performed to enhance ankle dorsiflexion. The rationale for these procedures, the operative sequence of events, and recovery course are presented in detail. Causes for concern regarding subsequent revision, should this be required, are raised.

Peroneal Tendon Reconstruction and Coverage for Treatment of Septic Peroneal Tenosynovitis: A Devastating Complication of Lateral Ankle Ligament Reconstruction With a Tendon Allograft

Septic peroneal tenosynovitis is a rare and significant challenge. A search of peer-reviewed published studies revealed only 5 case reports to guide treatment, none of which resulted in significant loss of both peroneal tendons necessitating reconstruction. No clear guidance is available regarding how to provide reliable reconstruction of both peroneal tendons after a significant loss secondary to septic tenosynovitis. In the present report, we describe the case of a young, active-duty soldier who underwent lateral ankle ligament reconstruction with a tendon allograft whose postoperative course was complicated by septic peroneal tenosynovitis resulting in significant loss of both peroneal tendons. Reconstruction was achieved in a staged fashion with the use of silicone rods and external fixation to maintain physiologic tension and preserve peroneal tendon function, followed by reconstruction of both peroneal tendons and the superior peroneal retinaculum with a tensor fascia lata autograft. Soft tissue coverage was obtained with an anterolateral thigh free tissue transfer and a split-thickness skin graft. The patient returned to full activity as an active-duty soldier with minimal pain and no instability of the right lower extremity. The muscle strength of both peroneal tendons remained at 5 of 5, and no objective findings of ankle instability were seen at 3.5 years postoperatively.

Incidence of revision after primary implantation of the Salto ® mobile version and Salto Talaris ™ total ankle prostheses: a systematic review

The incidence of revision of total ankle replacement prostheses remains unclear. We undertook a systematic review to identify the material relating to the incidence of revision after implantation of the Salto(®) mobile version and Salto Talaris™ total ankle prostheses. Studies were eligible for inclusion only if they had involved primary total ankle replacement with these prostheses and had included the incidence of revision. Eight studies involving 1,209 Salto(®) mobile version prostheses, with a weighted mean follow-up period of 55.2 months, and 5 studies involving 212 Salto Talaris™ total ankle prostheses, with a weighted mean follow-up period of 34.9 months, were included. Forty-eight patients with Salto(®) mobile version prostheses (4%) underwent revision, of whom 24 (70.5%) underwent ankle arthrodesis, 9 (26.5%) metallic component replacement, and 1 (3%) below-the-knee amputation. Five (2.4%) Salto Talaris™ total ankle prostheses underwent revision (3 metallic component replacement and 2 ankle arthrodeses). Restricting the data to the inventor, design team, or disclosed consultants, the incidence of revision was 5.2% for the Salto(®) mobile version and 2.6% for the Salto Talaris™ total ankle prostheses. In contrast, data that excluded these individuals had an incidence of revision of 2.8% for the Salto(®) mobile version and 2.0% for the Salto Talaris™ total ankle prostheses. We could not identify any obvious difference in the etiology responsible for the incidence of revision between these mobile- and fixed-bearing prostheses. The incidence of revision for the Salto(®) mobile version and Salto Talaris™ total ankle prostheses was lower than those reported through systematic review for the Agility™ and Scandinavian Total Ankle Replacement™ systems without obvious selection (inventor) or publication (conflict of interest) bias.

Is the internet a reliable source of information for patients seeking total ankle replacement?

The modern patient population relies on the Internet to provide knowledge about medical procedures. However, a gap between established medical guidelines and the information provided on the Internet exists. Because of the general poor quality of the medical information available on the Internet and the increasing popularity of total ankle replacement (TAR) with its known potential serious complications, we undertook the present study to evaluate the information on TAR available to the general public through the Internet and to determine the quality of information according to authorship type and site certification status. Three common search engines were used to identify a total of 105 websites. The TAR information quality was rated as "excellent," "high," "moderate," "low," or "unacceptable." The sites were evaluated for authorship or sponsorship, content, and other criteria. The data were analyzed as a complete set, as a comparison among authorship types (academic, private, industry, or other), and by certification status. Websites with scores of excellent or high were 35% of the sites reviewed, and 48% were ranked as poor or unacceptable. Of the authorship types, the highest quality authorship was for the industry and other sites, which rated high or excellent 46% of the time. Eight percent of the sites evaluated were certified; however, certification status was not associated with improved information quality. Our study has demonstrated a low quality of TAR information available across all website types, regardless of authorship type. We suggest a partnership between professional organizations and physicians to ensure that provider websites reflect the current indications and contraindications of TAR to enhance patient education.

All-inside, anatomical lateral ankle stabilization for revision and complex primary lateral ankle stabilization: a technique guide

Lateral ankle instability is a common mechanical problem that often requires surgical management when conservative efforts fail. Historically, myriad open surgical approaches have been proposed. Recently, consideration for arthroscopic management of lateral ankle instability has become popular, with promising results. Unfortunately, recurrent inversion ankle injury following lateral ankle stabilization can occur and require revision surgery. To date, arthroscopic management for revision lateral ankle stabilization has not been described. We present a novel arthroscopic technique combining an arthroscopic lateral ankle stabilization kit with a suture anchor ligament augmentation system for revision as well as complex primary lateral ankle stabilization.

Strategies for Revision Total Ankle Replacement

As the frequency of primary total ankle replacement (TAR) continues to build, revision will become more commonplace. At present there are no “standard principles” associated with revision TAR. What is clear is that the current approaches are technically complex, fraught with complications and no one approach represents the only answer. Exchange of TAR metallic components to the same system standard or dedicated revision components are viable options with limited occurrence of complications. Explantation and conversion to custom-design long stemmed components has limited availability. Explantation and conversion to another TAR system is high-risk and has strong potential for complications. The use of metal reinforced polymethylmethacrylate cement augmentation of failed TAR systems and tibio-talo-calcaneal arthrodesis should be reserved for very select situations where other options are not possible. There is a real need for long-term survivorship following revision TAR and future efforts ought to be directed in this area.

Incidence of complications after Achillon® mini-open suture system for repair of acute midsubstance achilles tendon ruptures: a systematic review

The most appropriate operative treatment of acute midsubstance Achilles tendon ruptures is controversial. One approach uses a mini-open, device-assisted suture system (Achillon(®) System(™), Integra LifeSciences Corp, Plainsboro, NJ) that has been generally available since 2002. To date, the incidence of complications with this system has not yet been evaluated. Therefore, we conducted a systematic review of electronic databases and relevant peer-reviewed sources as outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the preparation of systematic reviews. Studies that reported acute (injury to surgery interval ≤ 10 days) midsubstance Achilles tendon ruptures repaired with the Achillon(®) mini-open suture system, provided a detailed description of all complications encountered, and a mean follow-up period of 12 months or more and 15 repairs or more were included. A total of 33 studies were identified, of which 8 (24%) met our inclusion criteria involving 253 repairs. Four studies were prospective and involved 169 repairs. The weighted mean age for the entire cohort was 39.5 (range 22 to 82) years, and the weighted mean follow-up period was 19.2 (range 5 to 44) months. The incidence of complications was 8.3% (21 of 253) and included 8 (3.2%) repeat ruptures, 5 (2%) incision problems, 3 (1.2%) sural nerve injuries, 3 (1.2%) suture reactions or irritations, and 2 (0.8%) infections. Our systematic review revealed that this mini-open, device-assisted suture system provides a safe and reproducible technique to repair acute midsubstance Achilles tendon ruptures with an acceptable incidence of complications.

Reverse Evans peroneus brevis medial ankle stabilization for balancing valgus ankle contracture during total ankle replacement

Medial ankle instability secondary to deltoid ligament insufficiency is frequently encountered when performing total ankle replacement and remains a challenge. In the present techniques report, we describe a "reverse" Evans peroneus brevis tendon nonanatomic deltoid ligament reconstruction for medial ankle stabilization harvested through limited incisions using simple topographic anatomic landmarks. The harvested peroneus brevis tendon is brought through a drill hole in the talus from laterally to medially, aiming for the junction of the talar neck and body plantar to the midline. The tendon is the brought superiorly and obliquely to the anterior medial aspect of the distal tibia where it is secured under a plate and screw construct. This modified Evans peroneus brevis tendon nonanatomic deltoid ligament reconstruction is useful in providing medial ankle stability during or after primary and revision total ankle replacement.

Safety of ankle arthroscopy for the treatment of anterolateral soft-tissue impingement

PURPOSE

To quantify the overall incidence of complications related to arthroscopic treatment of anterolateral soft-tissue ankle impingement.

METHODS

Electronic databases and relevant peer-reviewed sources, including OvidSP/Medline (http://ovidsp.tx.ovid.com) and Google Scholar, were systematically searched for the terms "anterolateral" AND "ankle" AND "impingement" OR "soft-tissue impingement" AND "arthroscopy." In addition, we manually searched common American and European (including British) orthopaedic and podiatric scientific literature for relevant articles. Studies were eligible for inclusion only if they included the following: a standard 2-portal anterior arthroscopic approach, a minimum mean follow-up of 12 months, and detailed descriptions of all complications encountered.

RESULTS

After we considered all the potentially eligible articles, 15 (28.8%) met our inclusion criteria for the study. There were a total of 396 patients (397 ankles), with 16 total complications (4%), 3 (0.8%) of which were major. The weighted mean patient age was 31.2 years, and the weighted mean follow-up was 33.7 months.

CONCLUSIONS

The results of this systematic review showed an overall incidence of complications of 4%. The complications were categorically divided into major and minor complications, with a very low incidence of major complications (0.8%) and an acceptably low incidence of minor complications (3.3%). On the basis of these findings, arthroscopic treatment of anterolateral ankle soft-tissue impingement is a very safe procedure when indicated.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Outcomes and safety of endoscopic tarsal tunnel decompression: a systematic review

Open surgical decompression of the tarsal tunnel is the standard surgical approach for compression of the tibial nerve within the tarsal tunnel. Complications associated with this approach can be significant and periods of non-weight bearing are required. An alternative approach allowing for minimal soft tissue trauma and reduced time to ambulation is therefore desirable. Endoscopic tarsal tunnel decompression may provide such an alternative. The authors performed a systematic review of electronic databases and other relevant sources to identify material regarding the safety of endoscopic tarsal tunnel decompression. Only articles that included clear information concerning the safety of endoscopic tarsal tunnel decompression with a follow-up of at least 12 months were included. Three studies were identified involving 37 feet, with a weighted mean follow-up of 27 months. There were no permanent complications relating to iatrogenic nerve injury, deep infection, or prolonged wound healing problems documented despite initiating ambulation within one week of surgery. Two patients (5.6%) developed recurrence more than 2 years postoperative and one (2.7%) showed no improvement. Endoscopic tarsal tunnel decompression is a safe procedure with a low rate of recurrence or failure and allows for near-immediate ambulation. However, additional prospective investigations comparing open and endoscopic approaches to tarsal tunnel decompression are warranted.

Management of extensive tibial osteolysis with the Agility™ total ankle replacement systems using geometric metal-reinforced polymethylmethacrylate cement augmentation

Although total ankle replacement has endured improvement in implant design since its conception, failure requiring revision remains a known endpoint. We describe a technique for management of extensive tibial osteolysis for failed Agility™ total ankle replacement systems using geometric metal-reinforced polymethylmethacrylate cement augmentation. This technique provides immediate component stability and is a cost-effective alternate to impaction bone grafting. With this technique, the complications we have experienced have been limited to minor delayed incisional healing, and all patients have resumed meaningful weightbearing activities with stable integration of the tibial component.

Arthroscopic synovectomy, irrigation, and debridement for treatment of septic ankle arthrosis: a systematic review and case series

Septic arthrosis of the ankle is a rare, often devastating, infection, with a high potential for morbidity and mortality. Delay in treatment can lead to cartilage erosion, painful synovitis, and osteomyelitis. Septic ankle arthrosis deserves prompt recognition and intervention. However, quality, sound, protocol-directed arthroscopic treatment of septic ankle arthrosis of the ankle has not yet been reported. We performed a systematic review of the electronic databases and other relevant peer-reviewed sources to determine the outcomes and treatment protocols associated with septic ankle arthrosis treated with arthroscopic synovectomy, irrigation, and debridement. Nine studies, involving a total of 15 ankles, met our inclusion criteria. In addition, we present the short-term outcomes of a protocol-driven arthroscopic synovial biopsy, deep culture procurement, synovectomy, irrigation, and debridement approach for 8 ankles (8 patients). To our knowledge, this would be the largest individual case series specific to arthroscopic treatment of septic ankle arthrosis. The most common infectious organism reported in the systematic review and in our case series was methicillin-sensitive Staphylococcus aureus. Arthroscopic synovectomy, irrigation, and debridement represents an acceptable treatment method for septic ankle arthrosis and demonstrated outcomes similar to the more traditional open approach, with fewer complications. Additional, appropriately weighted, randomized controlled studies with long-term follow-up are warranted.

Registry data trends of total ankle replacement use

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

Management of extensive talar osteolysis with Agility™ total ankle replacement systems using geometric metal-reinforced polymethylmethacrylate cement augmentation

The Agility™ Total Ankle Replacement System, almost exclusively without polymethylmethacrylate cement fixation, was the most commonly used implant in the United States from 1998 to 2007. Much attention has been given to the intraoperative complications and incision healing-related problems. However, it is the intermediate- and long-term complications, specifically, aseptic osteolysis, talar component loosening, subsidence, and progressive malalignment, that require careful consideration, because the revision options are limited. We describe a technique for management of extensive talar aseptic osteolysis for revision of Agility™ total ankle replacement systems with use of geometric metal-reinforced polymethylmethacrylate cement augmentation. This technique preserves the subtalar joint, provides immediate component stability and restoration of component alignment and height, and is a cost-effective alternative to other available options and still allows for additional revision should late failure occur.

Modified Evans peroneus brevis lateral ankle stabilization for balancing varus ankle contracture during total ankle replacement

Lateral ankle instability is frequently encountered when performing total ankle replacement and remains a challenge. In the present techniques report, I have described a modification of the Evans peroneus brevis tendon lateral ankle stabilization harvested through limited incisions using simple topographic anatomic landmarks. The harvested peroneus brevis is then transferred either to the anterior distal tibia concomitantly with total ankle replacement or through the tibia when performed after total ankle replacement and secured with plate and screw fixation. This modified Evans peroneus brevis tendon is useful in providing lateral ankle stability during or after primary and revision total ankle replacement.

Incidence of nonunion after isolated arthroscopic ankle arthrodesis

PURPOSE

To determine the incidence of nonunion after isolated arthroscopic ankle arthrodesis.

METHODS

Electronic databases and relevant peer-reviewed sources, including OvidSP/Medline (http://ovidsp.tx.ovid.com) and Google, were systematically searched for the terms "arthroscopic ankle arthrodesis" AND "nonunion". Additionally, we manually searched common American, British, and European orthopaedic and podiatric scientific literature for relevant articles. Studies were eligible for inclusion only if they included the following: isolated ankle arthrodesis, greater than 20 ankles, minimum mean follow-up of 12-months, a 2-portal anterior arthroscopic approach, fixation with 2 or 3 large-diameter cannulated cancellous screws, and the nonunion rate with no restriction on cause.

RESULTS

After considering all the potentially eligible articles, 7 (25.9%) met the inclusion criteria. A total of 244 patients (244 ankles)-148 (60.7%) male and 96 (39.3%) female patients, with a weighted mean age of 49.2 years-were included. For those studies that specified the exact follow-up, the weighted mean was 24.1 months. A total of 21 nonunions (8.6%) were reported, with 14 (66.7%) being symptomatic and requiring further intervention.

CONCLUSIONS

The results of this systematic review reveal an acceptable incidence of nonunion of 8.6%. However it is important to recognize that of these nonunions, 66.7% were symptomatic. This supports the belief that regardless of approach, nonunion of an ankle arthrodesis is problematic. In light of this finding, additional prospective studies are warranted to compare directly the incidence of nonunion between open, minimum incision, and arthroscopic approaches with a variety of fixation constructs.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

Tibialis posterior recession for balancing varus ankle contracture during total ankle replacement

Correction of soft tissue varus contracture with total ankle replacement is a challenge. In the present techniques report, I describe tibialis posterior recession using topographic anatomic landmarks that can be useful in correcting soft tissue contracture of the tibialis posterior musculotendinous unit associated with longstanding varus contractures during primary and revision total ankle replacement.

Incidence of revision after primary implantation of the Scandinavian Total Ankle Replacement system: a systematic review

Total ankle replacement was initially popularized in the 1970s as an alternative to ankle arthrodesis for advanced ankle arthritis; however, failures were catastrophic. Current implants show promise, focusing on normal joint anatomy and function with greatly improved materials and more precise surgical technique. Nevertheless, even with advancements in technology and implant engineering, implant failure remains a problem. Debate has existed and published reports vary greatly concerning the incidence of failure and revision of the Scandinavian Total Ankle Replacement system. Thus, a systematic review was performed revealing a 10.7% revision rate at weighted mean follow-up of 64 months.

Incidence of repeat amputation after partial first ray amputation associated with diabetes mellitus and peripheral neuropathy: an 11-year review

The reliability and durability of partial first ray amputation in patients with diabetes and peripheral neuropathy has recently been questioned. In an effort to determine the repeat amputation rate after a partial first ray amputation associated with diabetes mellitus and peripheral neuropathy at our institution, we performed an 11-year retrospective review. A total of 59 patients (40 males and 19 females), with a mean age of 63 (range 39 to 97) years, were included. The mean follow-up was 33.8 (range 1 to 123) months, with initial incision healing occurring in all 59 patients. Despite the initial healing, 69% developed a mean of 3.1 subsequent foot ulcerations at a mean of 10.5 months, 36% required ancillary surgical procedures, and more than 90% of patients were prescribed multiple courses of antibiotics at a mean of 26.6 clinic visits during the follow-up period. A total of 25 patients (42.4%) underwent more proximal repeat amputation at a mean of 25 (range 1 to 97) months after the initial partial first ray amputation. The results of our retrospective review revealed that nearly 1 of every 2 patients with diabetes and peripheral neuropathy who undergo a partial first ray amputation will progress to a more proximal repeat amputation, despite initial healing. These data question the reliability and durability of this level of amputation as a primary procedure in this patient population. A more proximal level amputation, such as a balanced transmetatarsal, might provide a better functional and reliable residual weightbearing foot and should be considered at the initial presentation. This is especially true given that nearly one half of the patients died during the follow-up period. However, this remains a matter for conjecture because of the limited data available; therefore, additional prospective investigations are warranted.