Revision Total Ankle Arthroplasty Using a Novel Modular Fixed-Bearing Revision Ankle System.

INTRODUCTION: Large bone defects such as those encountered after failed total ankle replacement have previously been a relative contraindication to revision ankle replacement due to inadequate bone stock. We describe our experience and patient reported outcomes with a modular ankle replacement system with tibial and talar augments. METHODS: This is a retrospective case series analysis of patients who underwent a total ankle replacement using the INVISION system across 2 centers between 2016 and 2022. Patients completed the Manchester-Oxford Foot Questionnaire (MOXFQ), Ankle Osteoarthritis Scale (AOS), and EQ-5D pre-operatively and then post-operatively at 6 months, 1 year, 2 years, 3 years, and 5 years. Medical records were reviewed for complications and re-operations. X-rays were reviewed for lucencies and alignment. RESULTS: A total of 17 patients were included in the study; 14 men and 3 women with an average age at the time of surgery of 67.9 years (range 56-80 years). The average follow-up post-operatively was 40.5 months (range 7-78) at the time of this study. The indication for surgery was revision of failed total ankle replacement (TAR) in 16 and revision of failed ankle fusion in 1. An augmented tibia was used in 13, an augmented talus in 13, and both augmented tibia and talus in 9 cases. There were no early surgical complications. One patient required debridement and implant retention for late deep infection. No implants have been revised. The average MOXFQ score improved by 19.3 points at most recent follow-up. The average AOS score improved by 25.2 points. CONCLUSION: The early results of a modular augmented ankle arthroplasty system have shown satisfactory patient outcomes with a low complication and re-operation rate and present another option for patients with larger bone defects. This is a small series, and a larger series with long-term follow-up would be beneficial. LEVELS OF EVIDENCE: Level IV: Case series.

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.

Patient-Reported Outcomes in Total Ankle Arthroplasty: Patient Specific Versus Standard Instrumentation.

BACKGROUND: Total ankle arthroplasty (TAA) can now be performed using patient-specific instrumentation (PSI). Advantages include the ability to preoperatively plan and reduce the number of intraoperative surgical steps. The aim of this study was to compare PSI with standard instrumentation (SI) in a nonrandomized retrospective cohort study with respect to patient-reported outcome measures (PROMs). Secondary aims were to compare complications, reoperations, tourniquet time, fluoroscopy time, and postoperative alignment. METHODS: In all, 159 patients (111 men, 48 women) undergoing a total of 168 Infinity TAA (Stryker, Memphis, TN) using PSI (Prophecy, Stryker, Memphis, TN) or SI between 2014 and 2021 were included with a minimum follow-up of 12 months. The PROMs were obtained preoperatively and at 1 year, and included the Manchester-Oxford Foot Questionnaire (MOXFQ), Ankle Osteoarthritis Scale (AOS), and European Quality of Life 5 Dimension 3 Level (EQ-5D-3L). Coronal plane deformity correction was assessed using the midline tibiotalar angle (MTTA). Demographics, tourniquet time, and intraoperative fluoroscopy times were obtained from the hospital records. RESULTS: There were 61 TAAs in the PSI group and 107 TAAs in the SI group. There was no significant difference in total MOXFQ, AOS, or EQ-5D. There was a significantly reduced tourniquet time (PSI mean: 95.39 minutes, SI mean: 116.87 minutes, P < .001) and radiation exposure (PSI mean: 31 seconds, SI mean: 53 seconds, P < .001). Angular correction was more accurate in the PSI group (PSI mean: 1.29°, SI mean: 2.26°, P = .005). CONCLUSION: This study supports the use of PSI to decrease operative time, reduce intraoperative fluoroscopy, improve accuracy of implantation, and improve postoperative alignment in TAA. There was a significant difference (P = .032) in favor of PSI in the walking/standing domain of the MOXFQ at 12 months but no significant difference in overall PROMs. LEVELS OF EVIDENCE: Level III, Retrospective.

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.

Metal debris release is commonly seen from explanted total ankle replacements.

This study aimed to characterise the damage mechanisms present on the metal components used in various contemporary total ankle replacements. Twenty-seven explanted total ankle replacements comprising 8 different designs (3 fixed bearing and 5 mobile bearing) were analysed using various explant analysis techniques. Pitting and scratching were the most commonly observed wear features. Microscopic analysis revealed metallic pitting on 52% of tibial components and 95% of talar components. Pitting was identified on more cobalt-chromium than titanium alloy tibial components (63% versus 0%). Non-contact profilometry confirmed the presence of pitting, with significant (p < 0.05) differences in the measured average surface roughness values of pitted and unpitted areas for tibial and talar components. There was macroscopically visible sliding plane scratching, indicating the presence of hard third body particles, on 78% of talar components. Changes to the non-articulating surfaces coatings in terms of coating loss and/or changes in reflectivity was identified visually on 80% of metal components. Scanning electron microscopy with energy dispersive X-ray spectroscopy identified metallic embedded debris in 19% of polyethylene inserts. This explant study demonstrates the release of metal debris from both the metallic tibial and talar component articulating surfaces and non-articulating surface coatings of various contemporary total ankle replacements. Metal particulate debris release from total ankle replacements may be more common than previously recognised. Metal debris should be considered in further study into the aetiology of failed total ankle arthroplasty.

Perceived barriers and facilitators of day-case surgery for major foot and ankle procedures? A cross-sectional survey of United Kingdom surgeons.

BACKGROUND: Advances in minimally invasive surgery and improved post-operative pain management make it possible to consider performing even major foot/ankle operations as day-case. This could have significant benefits for patients and the health service. However there are theoretical concerns about post-operative complications and patient satisfaction due to pain. AIM: To scope the current practice of foot and ankle surgeons on day-case surgery for major foot and ankle procedures in the United Kingdom (UK). METHODS: An online survey (19 questions) was sent to UK foot and ankle surgeons via the British Orthopaedic Foot & Ankle Society membership list in August 2021. Major foot and ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge, with day surgery as the intended treatment pathway. RESULTS: 132 people responded to the survey invitation with 80% working in Acute NHS Trusts. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. 78% felt that there was scope to perform more procedures as day-case at their centre. Post-operative pain (34%) and patient satisfaction (10%) was not highly measured within their centres. Lack of adequate physiotherapy input pre/post-operatively (23%) and lack of out of hours support (21%) were the top perceived barriers to performing more major foot and ankle procedures as day-case. CONCLUSION: There is consensus among UK surgeons to do more major foot/ankle procedures as day-case. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. There is a need for nationally agreed protocols to optimise the delivery of and measurement of outcomes in this type of surgery. At a local level, the provision of physiotherapy and out of hours support should be explored at sites where this is a perceived barrier.

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.

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

AIMS: This is a multicentre, non-inventor, prospective observational study of 503 INFINITY fixed bearing total ankle arthroplasties (TAAs). We report our early experience, complications, and radiological and functional outcomes. METHODS: Patients were recruited from 11 specialist centres between June 2016 and November 2019. Demographic, radiological, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Questionnaire, and EuroQol five-dimension five-level score) were collected preoperatively, at six months, one year, and two years. The Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system was used to stratify deformity. Early and late complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts, and/or subsidence. RESULTS: In all, 500 patients reached six-month follow-up, 420 reached one-year follow-up, and 188 reached two-year follow-up. The mean age was 67.8 years (23.9 to 88.5). A total of 38 patients (7.5%) presented with inflammatory arthritis. A total of 101 (20.0%) of implantations used patient-specific instrumentation; 167 patients (33.1%) underwent an additional procedure at the time of surgery. A total of seven patients died of unrelated causes, two withdrew, and one was lost to follow-up. The mean follow-up was 16.2 months (6 to 36). There was a significant improvement from baseline across all functional outcome scores at six months, one, and two years. There was no significant difference in outcomes with the use of patient-specific instrumentation, type of arthritis, or COFAS type. Five (1.0%) implants were revised. The overall complication rate was 8.8%. The non-revision reoperation rate was 1.4%. The 30-day readmission rate was 1.2% and the one-year mortality 0.74%. CONCLUSION: The early experience and complications reported in this study support the current use of the INFINITY TAA as a safe and effective implant in the treatment of end-stage ankle arthritis. Cite this article: Bone Joint J 2021;103-B(7):1270-1276.

The Hintegra total ankle replacement: survivorship, failure modes and patient reported outcomes in seventy consecutive cases with a minimum five year follow-up.

PURPOSE: The Hintegra total ankle replacement (TAR) has been widely used worldwide for ankle arthroplasty since its introduction in 2000. The implant survivorship, patient reported outcomes, rate of periprosthetic cyst formation and reoperation rates are variably reported. The purpose of this study is to determine the functional outcomes and survivorship of the Hintegra TAR, in consecutive cases by multiple surgeons in a single UK institution, with a minimum of five year follow-up. METHODS: A retrospective review of prospectively collected data for 70 consecutive Hintegra TAR cases performed between 2010 and 2014. Data collected included patient demographics, complications, reoperations, revisions and patient reported outcome measures (PROMS: AOS, MOX-FQ, pain VAS and EQ-5D 3L). RESULTS: Seventy patients underwent Hintegra TAR (54 male/16 female) with an average age of 69 (range 48-84 years). Mean follow up was 76 months (range 60-104), 10 patients died during the follow-up. Implant survivorship was 81.7% at most recent follow-up. The commonest radiographic finding was periprosthetic cysts (n = 28, 40%): size range (7-40 mm). Nine patients required re-operation: six periprosthetic cyst debridement and grafting at a mean of 61 months (range 27-91), one lateral gutter debridement, one periprosthetic fracture and one debridement for deep infection. PROMS data was available for the majority of patients. Mean final follow-up scores were total AOS 35 (range: 0-97), MOX-FQ 36 (range: 2-93), pain VAS 34.6 (range: 0-100) and EQ-5D 3L Index 0.69 (range: 0.08-1.00). CONCLUSION: Our experience demonstrates implant survivorship similar to other TAR studies. We have identified a high incidence of periprosthetic cysts and would recommend ongoing surveillance of these patients.

A Multicenter Retrospective Cohort Study of First Metatarsophalangeal Joint Arthrodesis.

In this multicenter study, we evaluated commonly used methods of fixation and 2 methods of joint preparation for first metatarsophalangeal joint fusion, in terms of radiological union and revision rates. Included were 409 consecutive fusions in 385 patients. The overall union rate was 91.4% (34/409). About 29.4% (10/34) of our nonunions were symptomatic. Preoperative hallux valgus showed a statistically significant relation to nonunion (odds ratio [OR] = 9.33, p = .017). Other potential contributing factors like gender (OR 1.9, p = .44), diabetes (OR = 0, p = .99), steroid use (OR = 2.07, p = .44), inflammatory arthritis (OR = 0, p = .99), and smoking (OR = 2.69, p = .34) did not attain statistical significance. Further, the methods of fixation like solid screws (OR = 0, p = .99), plate (OR = 3.6, p = .187), or cannulated screws (OR = 0.09, p = .06) showed no correlation with incidence of nonunion. We compared 2 techniques of joint preparation and found no significant difference in union rates (chi-square = 1.0426, p = .30). Our crude comparison of costs showed the average saving to the trust per year could be 33,442.50£ by choosing screws over plates. To conclude, only hallux valgus had a statistically significant relation to nonunion. All other variables had no significant impact on the union. Solid screw seems to be economically the most viable option and a valid alternative.

Outcomes of revision surgery for failed total ankle replacement: revision arthroplasty versus arthrodesis.

PURPOSE: To compare the short-term outcomes of surgical management of failed ankle arthroplasty with revision ankle arthroplasty and conversion to arthrodesis. METHODS: Single-centre retrospective review of revision procedures for failed ankle arthroplasty between January 2012 and June 2019. Implant survival, union rates, and PROMS data-Pain Visual Analogue Score (VAS), Ankle Osteoarthritis Score (AOS) and Manchester-Oxford Foot Questionnaire (MOxFQ)-were compared between the two groups. RESULTS: Twenty-nine patients (31 ankles) underwent surgical management for failed ankle arthroplasty, with either revision arthroplasty (n = 21) or arthrodesis (n = 10). Revision arthroplasty had 87% survival at four years. Arthrodesis had an overall union rate of 80%. Two-year PROMS showed greater results for the revision arthroplasty group compared with that for arthrodesis group (Pain VAS 10 vs 50, p = 0.03; total AOS 12 vs 87, p = 0.04; average MOxFQ 17 vs 73.5, p 0.02). CONCLUSION: Revision arthroplasty demonstrates good short-term survival data with improvements in PROMS compared with arthrodesis. Further long-term follow-up is required to monitor if these benefits continue.

Should the Tibiotalar Angle Be Measured Using an AP or Mortise Radiograph? Does It Matter?

Understanding the tibiotalar angle (TTA) is key to planning for deformity correction. The TTA is an important radiographic tool to determine alignment or malalignment of the ankle and hindfoot. Two methods of measuring the TTA have been described: the midline TTA (MTTA) and the lateral TTA (LTTA). The aim of this study was to compare the 2 angles as measured on mortise and anteroposterior (AP) radiographs in a series of normal and pathological cases. A radiographic review was performed of sequential ankle AP and mortise radiographs taken between January 2016 and September 2017 across 4 specialist orthopedic centers. Patients were categorized into a normal group, where patients had normal radiological appearances, and an arthritis group, where patients had radiographic arthritis. The MTTA and the LTTA were measured. The overall mean ± standard deviation MTTA was 88.7° ± 5.1°, and mean LTTA was 87.5° ± 5.2° (p < .01). There was no statistically significant difference between the MTTA and LTTA in the normal group or on AP radiographs alone (p = .09). There was a statistically significant difference between the MTTA and LTTA in the arthritis group (p < .01) and when measured on mortise radiographs (p = .02). The MTTA had no difference when measured on the AP and mortise radiographs. There was a statistically significant difference in the LTTA between AP and mortise radiographs (p = .04). We have shown the MTTA to be a reliable and reproducible tool in all patients, on AP and mortise radiographs. The type of radiograph does not alter the measurement of deformity. In contrast, we have shown the LTTA to be unreliable and statistically different when measured on AP and mortise radiographs.

A Feasibility Study Comparing Platelet-Rich Plasma Injection With Saline for the Treatment of Plantar Fasciitis Using a Prospective, Randomized Trial Design.

Platelet-rich plasma (PRP) has been advocated for treatment of plantar fasciitis but there are few good-quality clinical trials to support its use. We conducted a feasibility study of PRP versus saline for treatment of plantar fasciitis. Patients with 6 months or more of magnetic resonance imaging-proven plantar fasciitis, who had failed conservative treatment were invited to participate in the study. Patients were block randomized to either PRP or an equivalent volume of saline. The techniques used for injection and rehabilitation were standardized for both groups. The patient and assessor were blinded. Visual analogue scale (VAS) for pain and painDETECT score were recorded preoperatively and at 6 months follow-up. From 35 patients approached, 28 (19 female, mean age 50 years) were recruited, with 14 randomized to each arm. At 6 months, 8 patients (28.6%) were lost to follow-up. There was a significant change in VAS score from baseline to follow-up in both intervention (mean change 37.2, P = .008) and control (mean change 42.2, P = .003) groups. There was no correlation between preoperative painDETECT score and change in VAS. Recruitment and loss to follow-up rates were relatively high. Both treatments resulted in a similar, significant, improvement in symptoms. Levels of Evidence: Level II.

How Knowledge Relates to Confidence in Orthopedics and Emergency Medicine Regarding Return to Sport and Rehabilitation in Foot and Ankle Trauma.

OBJECTIVE: The aim of this study was to survey the knowledge of registrars in emergency medicine and orthopedics on 5 common injuries to the foot and ankle and compare this knowledge, and self-reported confidence in giving it, with that of consultants and physiotherapists of various levels of experience. DESIGN: An online survey was used to gather the information using scenario-based open and closed questions. PARTICIPANTS: A total of 102 health care professionals, who regularly deal with sports injuries, were recruited. These included consultant orthopedic surgeons with a subspecialty interest in foot and ankle surgery, orthopedic surgeons in other specialties, extended scope physiotherapy practitioners (ESPs) in foot and ankle and general musculoskeletal practice, emergency medicine consultants, emergency medicine registrars, orthopedic registrars, senior physiotherapists, and junior physiotherapists. SETTING: The participants were drawn from various health care institutions in the North East of England. RESULTS: Consultant foot and ankle surgeons and extended scope practitioners in foot and ankle both scored significantly on knowledge of rehabilitation program design than either set of registrars. For 2 of the case scenarios, there was a significant difference in scores between either orthopedic consultants or ESPs and registrars (p < 0.05). For total score, there was a trend for extended scope practitioners to score higher than both sets of registrars, but this did not reach significance. Correlation coefficients for knowledge and self-reported confidence ranged between 0.009 and 0.33, demonstrating only weak positive linear correlation between scenario score and reported confidence in advice given. CONCLUSIONS: The most significant area of gaps in knowledge among the 2 groups of registrars was in the specifics of rehabilitation programs. There was markedly higher confidence with greater seniority. Registrars in emergency medicine and orthopedics are likely to benefit from case-based teaching in sports injury rehabilitation.

Arthroscopic versus open ankle arthrodesis: a multicenter comparative case series.

BACKGROUND: Ankle arthrodesis results in measurable improvements in terms of pain and function in patients with end-stage ankle arthritis. Arthroscopic ankle arthrodesis has gained increasing popularity, with reports of shorter hospital stays, shorter time to solid fusion, and equivalent union rates when compared with open arthrodesis. However, there remains a lack of high-quality prospective data. METHODS: We evaluated the results of open and arthroscopic ankle arthrodesis in a comparative case series of patients who were managed at two institutions and followed for two years. The primary outcome was the Ankle Osteoarthritis Scale score, and secondary outcomes included the Short Form-36 physical and mental component scores, the length of hospital stay, and radiographic alignment. There were thirty patients in each group. RESULTS: Both groups showed significant improvement in the Ankle Osteoarthritis Scale score and the Short Form-36 physical component score at one and two years. There was significantly greater improvement in the Ankle Osteoarthritis Scale score at one year and two years and shorter hospital stay in the arthroscopic arthrodesis group. Complications, surgical time, and radiographic alignment were similar between the two groups. CONCLUSIONS: Open and arthroscopic ankle arthrodesis were associated with significant improvement in terms of pain and function as measured with the Ankle Osteoarthritis Scale score. Arthroscopic arthrodesis resulted in a shorter hospital stay and showed better outcomes at one and two years.

The outcome of carpal tunnel decompression in elderly patients.

PURPOSE: To determine the outcomes of carpal tunnel decompression in elderly patients and whether outcomes can be predicted by the severity of presurgical nerve conduction study results. METHODS: We performed a retrospective study of all patients over 70 years of age who had elective carpal tunnel release at Dunedin Hospital between April 1999 and April 2002 with a minimum of 1-year follow-up evaluation. A grading system for presurgical nerve conduction studies was formulated that scored patients from 1 to 6 according to severity. Patients were evaluated by a mailed questionnaire (Symptom Severity Score) with follow-up telephone calls to nonresponders. RESULTS: Eighty-three carpal tunnel release procedures performed in 70 patients were included in the study. Eighty percent had marked to severe neurophysiologic changes (grades 4-6). The median postsurgical Symptom Severity Score was 1.3 (inter-quartile range, 1.1-1.7). Patients expressed satisfaction with the outcome of the surgery in 78 of 83 cases (94%). There was a significant relationship between presurgical nerve conduction grade and postsurgical Symptom Severity Score. CONCLUSIONS: This study shows that elderly patients have low postsurgical symptom scores and express high levels of satisfaction after surgery for carpal tunnel syndrome. There was a significant relationship between severity of neurophysiologic abnormalities and a higher Symptom Severity Score after surgery. Severe abnormality, however, should not exclude elderly patients from surgery.