Cost-Utility Analysis of Total Ankle Replacement Compared with Ankle Arthrodesis for Patients Aged 50-85 Years with End-Stage Ankle Osteoarthritis: The TARVA Study.

BACKGROUND: Patients with end-stage ankle osteoarthritis suffer from reduced mobility and quality of life and the main surgical treatments are total ankle replacement (TAR) and ankle fusion (AF). OBJECTIVES: Our aim was to calculate the mean incremental cost per quality-adjusted life-year (QALY) of TAR compared with AF in patients with end-stage ankle osteoarthritis, over 52 weeks and over the patients' lifetime. METHOD: We conducted a cost-utility analysis of 282 participants from 17 UK centres recruited to a randomised controlled trial (TARVA). QALYs were calculated using index values from EQ-5D-5L. Resource use information was collected from case report forms and self-completed questionnaires. Primary analysis was within-trial analysis from the National Health Service (NHS) and Personal Social Services (PSS) perspective, while secondary analyses were within-trial analysis from wider perspective and long-term economic modelling. Adjustments were made for baseline resource use and index values. RESULTS: Total cost at 52 weeks was higher in the TAR group compared with the AF group, from the NHS and PSS perspective (mean adjusted difference £2539, 95% confidence interval [CI] £1142, £3897). The difference became very small from the wider perspective (£155, 95% CI -  £1947, £2331). There was no significant difference between TAR and AF in terms of QALYs (mean adjusted difference 0.02, 95% CI -  0.015, 0.05) at 52 weeks post-operation. The incremental cost-effectiveness ratio (ICER) was £131,999 per QALY gained 52 weeks post-operation. Long-term economic modelling resulted in an ICER of £4200 per QALY gained, and there is a 69% probability of TAR being cost effective at a cost-effectiveness threshold of £20,000 per QALY gained. CONCLUSION: TAR does not appear to be cost effective over AF 52 weeks post-operation. A decision model suggests that TAR can be cost effective over the patients' lifetime but there is a need for longer-term prospectively collected data. Clinical trial registration ISRCTN60672307 and ClinicalTrials.gov NCT02128555.

Radiological outcomes following open versus percutaneous fixation versus arthroscopically assisted percutaneous fixation of calcaneal fractures: a ten-year retrospective observational study.

BACKGROUND: Calcaneal fractures are often major injuries associated with considerable morbidity. The optimal surgical management of displaced calcaneal fractures remains contentious with open, percutaneous and arthroscopically assisted percutaneous approaches all offering potential benefits for patients. The aim of this study was to assess which of these three separate surgical approaches to the management of displaced calcaneal fractures provides the best radiographic deformity correction. METHODS: This is a retrospective observational study of all calcaneal fractures undergoing operative fixation at a single major trauma centre in the UK. The primary outcome was pre- and post-operative assessment of the deformity correction using radiographic parameters (angle of Gissane and Bohler's angle). Secondary outcomes included fracture configuration, complications and re-operation rate. RESULTS: Between 01/01/2009 and 31/12/2019, 152 calcaneal fractures in 134 patients underwent operative management via either an open or percutaneous approach. One-way ANOVA testing of the pre- and post-operative radiographic parameters demonstrated that an open approach offered superior post-operative correction of Bohler's angle when compared to percutaneous alone (p < 0.05); however, there was no difference in post-operative angle of Gissane (p > 0.05). The mean follow-up for complication and re-operation data was 3.5 years (range 0.1-12.4). Overall complication rate following all surgical fixation was 7.2% with a further 32.2% requiring further long-term surgical intervention for subtalar arthritis or removal of metalwork. CONCLUSION: Arthroscopically assisted percutaneous fixation does not offer superior radiographic deformity correction compared to percutaneous technique alone. Open fixation yielded improved correction of Bohler's angle when compared to percutaneous alone; however, there was no difference in post-operative angle of Gissane. LEVEL OF EVIDENCE: III.

Two to Five-Year Outcomes of Total Ankle Arthroplasty with the Infinity Fixed-Bearing Implant: A Concise Follow-up of a Previous Report.

LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial.

BACKGROUND: End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF). OBJECTIVE: To determine which treatment is superior in terms of clinical scores and adverse events. DESIGN: A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307). SETTING: 17 National Health Service trusts across the United Kingdom. PATIENTS: Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure. INTERVENTION: Patients were randomly assigned to TAR or AF surgical treatment. MEASUREMENTS: The primary outcome was change in Manchester-Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible. RESULTS: Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was -5.6 (95% CI, -12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (-11.1 [CI, -19.3 to -2.9]). LIMITATION: Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques. CONCLUSION: Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%. PRIMARY FUNDING SOURCE: National Institute for Health and Care Research Heath Technology Assessment Programme.

Complications after revision surgery of malreduced ankle fractures.

Ankle fractures are common orthopedic injuries requiring reduction and cast immobilization or fixation. Fractures fixed in a malreduced (misaligned) position can require revision surgery. However, because this has been a relatively rare occurrence, little is known about the complications that can occur after such surgery. We reviewed all adult closed ankle fractures that underwent revision surgery for technical failure in a regional trauma hospital from January 2007 to January 2010. Those with open fractures and those who required external fixation at any point in their treatment were excluded. Nine patients underwent revision surgery during the study period. Of these 9 patients, 3 (33%) developed a deep infection, all with positive microbiology cultures for methicillin-sensitive Staphylococcus aureus. Each of these patients underwent removal of the metalwork and wound debridement, followed by plastic surgery free flap coverage. In addition to the 3 infection cases, those with noninfected complications included 1 patient (11%) with chronic regional pain syndrome, 1 (11%) with failure of plate fixation, and 1 (11%) with persistent pain requiring arthroscopy and debridement. The overall incidence of complications was 66.67% in this group of 9 patients who had undergone revision surgery for the treatment of a malreduced malleolar ankle fracture. Although our observational study involved a small subset of patients who had undergone surgical repair for ankle fracture, we suggest that if revision surgery will be undertaken, the high incidence of infection and the potential need for plastic surgery should be highlighted during the consent process before the original, open reduction internal fixation procedure.

The role of ankle arthroscopy in acute ankle injuries of the athlete.

This article discusses the role of ankle arthroscopy in the acute management of ankle trauma in athletes. The rate of intra-articular pathology associated with ankle trauma is high and arthroscopic treatment often has an important role to play. Its major role is in the assessment and treatment of joint surface damage, syndesmotic instability, and intra-articular fractures.

Tibiotalocalcaneal arthrodesis with a curved, interlocking, intramedullary nail.

BACKGROUND: Tibiotalocalcaneal fusion with a straight rod has a risk of damaging the lateral plantar neurovascular structures and may interfere with maintaining normal heel valgus position.We report the results of a prospective study of tibiotalocalcaneal (TTC) arthrodesis with a short, anatomically curved interlocking, intramedullary nail. MATERIAL AND METHODS: Forty-five arthrodesis in 42 patients, performed between Jan 2003 and Oct 2008, were prospectively followed. The mean followup was 48 (range, 10 to 74) months. The main indications for the procedure were failed ankle arthrodesis with progressive subtalar arthritis, failed ankle arthroplasty and complex hindfoot deformity. The outcome was measured by a combination of pre and postoperative clinical examination, AOFAS hindfoot scores, SF-12 scores and radiological assessment. RESULTS: Union rate was 89% (40/45). Eighty-two percent (37/45) reported improvement in pain and 73% (33/45) had improved foot function. Satisfactory hindfoot alignment was achieved in 84% (38/45). Postoperatively there was a mean improvement in the AOFAS score of 37. Complications included a below knee amputation for persistent deep infection, five nonunions, and three delayed unions. Four nails, six proximal and six distal locking screws were removed for various causes. Other complications included two perioperative fractures, four superficial wound infections and one case of lateral plantar nerve irritation. CONCLUSION: With a short, anatomically curved intramedullary nail, we had a high rate of tibiotalocalcaneal fusion with minimal plantar neurovascular complications. We believe a short, curved intramedullary nail, with its more lateral entry point, helped maintain hindfoot alignment.

Fixation of ankle fragility fractures by tibiotalocalcaneal nail.

INTRODUCTION: Fragility fractures of the ankle are difficult to treat by conventional fixation due to poor bone quality, compromised soft tissues, and inherent instability. Conservative management of these patients also has its problems. MATERIALS AND METHODS: We retrospectively reviewed 13 patients who underwent intramedullary nailing through the tibiotalocalcaneal joints in an attempt to achieve the dual aims of fracture control and early mobilisation. The Olerud and Molander scale was used as outcome measures. RESULTS: There were 12 females and 1 male with a mean age of 78.9 (range 64-93). Half of the patients were discharged from hospital within the first 2 weeks after the operation. All achieved a comparable function to their pre-operative state. The mean follow-up period was 11 months (range of 2-62 months). Six are now deceased from unrelated causes. The mean Olerud and Molander score was 50 (range 30-65). All the radiographs showed evidence of fracture union with no changes in the overall alignment of the joint. CONCLUSION: Given the low survivorship of this frail group of patients the main objectives are achieving early mobilisation whilst maintaining good fracture position. In our experience, tibiotalocalcaneal nailing is a very useful and successful way of treating fragility fractures of the ankle because it has a low risk of complications and restores function with impressive patient satisfaction. The potential benefits of this technique, we believe, outweigh the disability ensued from subtalar joint fusion.

Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail. The results of 52 procedures.

BACKGROUND: The purpose of this study was to report the results of 52 combined subtalar and ankle arthrodesis using an intramedullary nail. METHODS: Retrospective review identified 49 patients who had 52 combined ankle and subtalar arthrodeses with an ACE retrograde locked intramedullary humeral nail (DePuy-Ace), Warsaw, IN). Most procedures included bone grafts from the fibula, proximal tibia, or iliac crest or femoral head allograft. Intraoperative complications included one fractured tibia and one fractured medial malleolus. The procedure was done mainly for the treatment of combined ankle and subtalar arthritis (31) or complex hindfoot deformities (12). Outcome was assessed by a combination of chart review, clinical examination, and telephone questionnaire. Followup averaged 34 (8 to 73) months. RESULTS: At followup 82% of patients were satisfied with the results of surgery, 82% reported improvements in pain levels, and 67% reported improved foot function. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 63. Postoperative complications included deep infection, amputation, stress fracture, nonunion, and prominent hardware. CONCLUSION: Hindfoot arthrodesis with intramedullary nailing is an effective technique for treating complex foot deformities and often is the only alternative to amputation. Patient satisfaction is high, but the procedure is demanding and complications are frequent.