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

BACKGROUND: Enhanced recovery after surgery programs, also called fast-track protocols, were developed and successfully applied in the last decade for hip and knee reconstruction. Specific fast-track protocols have not yet been applied to ankle prostheses. The aim of the study was to develop and validate an enhanced recovery protocol for total ankle replacement (TAR) evaluating the clinical and radiographic results. We hypothesize that on the basis of well-defined pre- and postoperative characteristics, the current knowledge on ankle replacement, and referring to hip and knee reconstruction, it is possible to identify a "patient type" to be safely eligible to a Fast-Track Protocol with at least comparable results and without increasing the complications risk. METHODS: We identified 8 predictive variables that might affect the outcome of TAR. Those variables were the body mass index, the state of anxiety or depression, the functional preoperative status, ankle equinus, the coronal malalignment, the surgical time, the surgical accessory procedures, and the bone quality. These characteristics were evaluated for each patient with almost validated outcome tools attributing a specific score. Based on the score obtained, the patients were divided into 2 groups: the Standard Protocol group (Control Group) and the Fast-Track Protocol group (Study Group). The main difference between treatment of the 2 groups relates to the use of postoperative plaster casts: in the Fast-Track group the cast was removed the first day after surgery and walking was allowed in sports shoes assisted with crutches, whereas in the Standard Protocol group, the cast was removed after 3 weeks. Clinical and radiographic evaluation was performed for all patients preoperatively and postoperatively every 6 months. RESULTS: A total of 163 patients received a score between 1 and 5 and were included in the control group (Standard Protocol); 47 patients received a score of 0 and were allocated to the study group (Fast-Track Protocol). Clinically, except for the preoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score, no statistically significant differences were recorded in the multiple comparisons between the 2 groups. No significant differences were found regarding complications. CONCLUSION: In selected patients, it is possible to apply an enhanced recovery protocol of rehabilitation, focused on immediate weightbearing and mobilization without any plaster or boot. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Learning curve assessment for total ankle replacement using the transfibular approach.

BACKGROUND: Total ankle arthroplasty is an increasingly effective option for the treatment of end-stage arthritis. One recent innovation utilizes a transfibular, lateral approach. Like any new system, there is likely a learning curve associated with its use. We analyzed a series of patients who received a total ankle arthroplasty via a transfibular approach to state if it is possible to identify and to evaluate effects of a learning curve in the use of this novel total ankle replacement system. METHODS: 76 consecutive patients meeting inclusion and exclusion criteria were retrospectively analyzed. All patients had a minimum of 24 months of follow-up. Intraoperative parameters, preoperative and postoperative subjective outcome scores, radiographic parameters, and complications were recorded and evaluated. RESULTS: There were significant learning curve effects on various surgical and postoperative parameters. Surgical time decreased with the curve stabilizing after the 16th patient. With regard to patient outcomes, a learning curve was identified for the VAS, AOFAS, and SF-12 MCS scores. The number of patients required to stabilize these curves were 21, 13, and 16, respectively. Alignment as measured by alpha and gamma angles also improved with experience, with the curves stabilizing at 18 and 15 patients, respectively. There was a larger number cases required for complication rates, with the curve stabilizing after the 39th patient. No significant learning curve was found for ankle ROM, SF-12 PCS, beta angle, tibio-talar ratio (TTR), or tibio-talar surface angle (TTS). CONCLUSIONS: This study demonstrates a significant learning curve with respect to operative time, patient outcomes, and radiographic parameters. Extrapolating this information, we urge surgeons to adequately familiarize themselves with any new implant through a training program in a high-volume center. LEVEL OF EVIDENCE: IV, case series.

Clinical Outcomes and Return to Sport After Minimally Invasive Reconstruction of the Lateral Ligament Complex with Semitendinosus Tendon Autograft in Chronic Lateral Ankle Instability.

BACKGROUND: Ankle sprains are common, affecting especially the lateral ligament complex of the ankle, often leading to chronic symptoms and instability. Many procedures have been described for chronic ankle instability. This study analyzes clinical outcomes and return to sport in patients who underwent minimally invasive reconstruction of the lateral ligament complex of the ankle with a semitendinosus tendon autograft. METHODS: Twenty-three patients (mean age, 33.9 years) with grade 3 lesions of both the anterior talofibular and calcaneofibular ligaments underwent minimally invasive reconstruction of the anterior talofibular and calcaneofibular ligaments with an ipsilateral semitendinosus tendon autograft. They were retrospectively reviewed, and return to sport was evaluated with the Halasi ankle activity scale. RESULTS: Mean follow-up was 30 months (range, 26-53 months). The mean American Orthopaedic Foot and Ankle Society score increased from 68.6 to 95.3. The average visual analog scale score decreased from 3.6 to 1.3. The Halasi score changed from 5.0 to 5.1. Except for the Halasi score, the differences were significant (P < .001). Nineteen patients judged the received treatment as excellent, 2 as good. No revision procedures were performed. No major complications were reported. CONCLUSIONS: This study confirms good clinical and sport outcomes after minimally invasive reconstruction of the lateral ligament complex of the ankle with a semitendinosus autograft.

Precision of Bone Mineral Density Measurements Around Total Ankle Replacement Using Dual Energy X-ray Absorptiometry.

INTRODUCTION: Joint prosthesis survival is associated with the quality of surrounding bone. Dual-energy X-ray absorptiometry (DXA) is capable to evaluate areal bone mineral density (BMD) around different prosthetic implants, but no studies evaluated periprosthetic bone around total ankle replacement (TAR). Our aim is to determine the precision of the DXA periprosthetic BMD around TAR. METHODOLOGY: Short-term precision was evaluated on 15 consecutive patients. Each ankle was scanned 3 times both in the posteroanterior (PA) and lateral views with a dedicated patient positioning protocol. Up to four squared regions of interest (ROIs) were placed in the periprosthetic bone around tibial and talar implants, with an additional ROI to include the calcaneal body in the lateral scan. Coefficient of variation (CV%) and least significant change were calculated according to the International Society for Clinical Densitometry. RESULTS: The lateral projection showed lower mean CV values compared to the PA projection, with an average precision error of 2.21% (lateral scan) compared to 3.34% (PA scans). Overall, the lowest precision error was found at both "global" ROIs (CV = 1.25% on PA and CV = 1.3% on lateral). The highest CV value on PA was found at the medial aspect of talar side (ROI 3; CV = 4.89%), while on the lateral scan the highest CV value was found on the posterior aspect of talar side (ROI 2; CV = 2.99%). CONCLUSIONS: We found very good reproducibility BMD values of periprosthetic bone around TAR, that were comparable or even better compared to other studies that evaluated periprosthetic BMD around different prosthetic implants. DXA can be used to precisely monitor bone density around ankle prostheses, despite further long-term longitudinal studies are required to assess the clinical utility of such measurements.

Total ankle replacement: is pre-operative varus deformity a predictor of poor survival rate and clinical and radiological outcomes?

PURPOSE: The objective of this study was to compare survival rate and clinical and radiological outcomes of a cementless mobile-bearing total ankle replacement (TAR) between two groups of patients, affected by end-stage ankle arthritis, with or without a pre-operative varus deformity. METHODS: A total of 81 patients (81 ankles) were included in the study and divided in two groups. Group A, "varus" group, includes 11 patients with pre-operative varus deformity of more than 10 ° and group B, "neutral" group, includes 70 patients, with a varus/valgus deformity of less than 10 °. American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), and Short Form (SF)-12 score were used to compare clinical outcomes. Radiological parameters, complications, and survival rate at last follow-up were also recorded. RESULTS: In both groups, all clinical and radiological parameters improved after surgery (p < 0.05) without statistically significant difference. Complications were similar between two groups. Overall in three cases, an implant revision was necessary: 1 in group A (9%) at 3.1 years follow-up and 2 (3%) in group B at 3.8 years, without statistically significant difference (p > 0.001). CONCLUSIONS: Severe varus malalignment should not be considered a contraindication for a mobile-bearing TAR. Nevertheless, TAR in severe deformity should be performed only by experienced surgeons.