Diabetic management and infection risk in total ankle arthroplasty.

BACKGROUND: As total ankle arthroplasty (TAA) increases in popularity nationwide for the management of end-stage arthritis, it is essential to understand ways to mitigate the risk of infection. Diabetes increases the risk of infection due to compromised immunity and impaired wound-healing mechanisms. However, there is limited research on how diabetic management, inclusive of medications and glucose control, may impact infection risks post-TAA. This study aims to demonstrate the impact of diabetic management on the occurrence of periprosthetic joint infection (PJI) following TAA. METHODS: This was a retrospective study of patients who underwent a TAA at a single academic institution from March 2002 to May 2022. Patients with diabetes who developed an intraarticular infection following TAA were propensity score matched (1:3) to diabetic patients who did not. Data collection included demographics, implant types, diabetic medications, and preoperative hemoglobin A1c. PJI was diagnosed based on Musculoskeletal Infection Society (MSIS) criteria. Statistical analyses assessed differences in medication use, glucose control, and infection rates between groups. RESULTS: Of the 1863 patients who underwent TAA, 177 patients had a diagnosis of diabetes. The infection rate in patients with diabetes (2.8%) was higher than the total cohort rate (0.8%). Five patients with diabetes developed a PJI at an average of 2.2 months postoperatively. This cohort (n = 5) was compared to propensity score-matched controls (n = 15). There was no significant difference in diabetic medication use. Patients who developed PJI had higher rates of uncontrolled diabetes (60.0% vs. 6.7%) and average A1c levels (7.02% vs. 6.29%) compared to controls. CONCLUSION: Our findings suggest that the elevated risk of PJI observed in individuals with diabetes subsequent to TAA may be attributed not solely to the presence of diabetes, but to inadequate glycemic control. Effectively managing blood glucose levels is imperative for achieving favorable outcomes following TAA. LEVEL OF EVIDENCE: III.

Preoperative incongruent subtalar joint predicts less favorable clinical outcome in total ankle arthroplasty.

BACKGROUND: This study aimed to determine the clinical effect of incongruent subtalar joint space on total ankle arthroplasty (TAA). METHODS: Thirty-four consecutive patients who underwent TAA were grouped according to the status of subtalar joint incongruency. A comparison of clinical and radiographic parameters between groups as well as multiple regression analysis was performed to identify contributing factors to the final functional outcome. RESULTS: The final American Orthopaedic Foot and Ankle Society (AOFAS) score was significantly higher in the congruent group compared to that of the incongruent group (p = 0.007). There were no significant differences between the two groups in measured radiographic angles. In multiple regression analysis, the female sex (p = 0.006) and incongruency of the subtalar joint (p = 0.013) were found to be significant contributing factors to the final AOFAS score. CONCLUSIONS: A thorough preoperative investigation should be taken into the state of the subtalar joint for TAA.

Isolated Subtalar Arthrodesis for Avascular Necrosis of the Talus.

Isolated subtalar arthrodesis has been attempted in talar avascular necrosis (AVN) patients to preserve the tibiotalar joint and potential revascularization. This article reports the efficacy of isolated subtalar arthrodesis in the setting of AVN. A retrospective review of subtalar arthrodeses was performed on a cohort of 12 patients with talar AVN who underwent subtalar arthrodesis. The primary outcome was radiographic fusion with secondary outcomes of subsequent procedures, recurrent pain, and perioperative complications. Radiographic fusion of subtalar arthrodesis occurred in 12 of 12 patients. Five of six patients with traumatic etiology went on to have secondary procedures. One of six patients with atraumatic etiology underwent a secondary procedure for advancement of tibiotalar arthritis. In the setting of atraumatic talar AVN, this small cohort demonstrates that isolated subtalar arthrodesis is a safe and reliable procedure with high fusion rates and low need for secondary procedures. (Journal of Surgical Orthopaedic Advances 28(2):132-136, 2019).

Role of Fresh Osteochondral Allografts for Large Talar Osteochondral Lesions.

Osteochondral lesions of the talus, large or small, are challenging for the treating orthopaedic surgeon. These cartilage and bony defects can cause substantial pain and functional disability. Surgical treatment of small osteochondral lesions of the talus has been thoroughly explored and includes retrograde drilling, arthroscopic débridement and marrow stimulation, osteochondral autografting from cartilage/bone unit harvested from the ipsilateral knee (mosaicplasty), and autologous chondrocyte implantation. Although each of these reparative, replacement, or regenerative techniques has varying degrees of success, they may be insufficient for the treatment of large osteochondral lesions of the talus. Large-volume osteochondral lesions of the talus (>1.5 cm in diameter or >150 mm(2) in area) often involve a sizable portion of the weight-bearing section of the talar dome, medially or laterally. A fresh structural osteochondral allograft is a viable treatment option for large osteochondral lesions of the talus.

Equivalent pain relief with and without resection of the posterior tibial tendon in adult flatfoot reconstruction.

Transfer of the flexor digitorum longus (FDL) is indicated to compensate for the loss of posterior tibial tendon (PTT) function in the treatment of adult acquired flatfoot deformity (AAFD). The aim of this study was to determine the effect of PTT resection on pain relief following surgical treatment of stage II AAFD. A retrospective review of patients who underwent surgical treatment for stage II AAFD was performed. Patients were divided into two groups based on whether the degenerated PTT was resected or left in situ. A visual analog scale (VAS) score for pain was recorded for each patient preoperatively. Concomitant surgical procedures and the incidence of postoperative pain were also reported for each group. Deformity correction was assessed with standard weight-bearing radiographs. Thirty-four patients with a mean follow-up of 14 months were included in the study. There was no difference in preoperative VAS pain scores, and patients in both groups demonstrated excellent pain relief postoperatively. Five patients in the PTT resection group and one patient in the PTT in situ group reported lateral-sided foot pain postoperatively. Resection of the PTT did not significantly affect postoperative pain relief. Future prospective studies are needed to determine whether resection of the degenerated PTT is necessary at the time of surgery for stage II AAFD.

Heterotopic ossification following total ankle replacement: clinical significance and factors affecting its formation.

Little is known about the clinical significance of heterotopic ossification after total ankle replacement and the factors contributing to its occurrence. This study documented the incidence of heterotopic ossification in a large ankle arthroplasty series; identified potentially related patient, implant, and operative factors; and determined the strength of association of those factors with the clinical outcome. Ninety ankles in 88 primary ankle arthroplasty patients were followed for an average of 32.4 months. Scandinavian Total Ankle Replacement, Salto-Talaris, and INBONE ankle implants were used at the surgeon's discretion. Heterotopic ossification was measured and classified using methods previously described for total hip arthroplasty. Incidence, location, severity, predisposing factors, and outcomes were documented, and correlation between ossification severity and each examined factor was determined. Eighty percent and 95.6% of ankles showed heterotopic ossification on anteroposterior and lateral views, respectively, and 97.8% showed evidence on either anteroposterior or lateral views. Ossification grades 4 and 3 were most common, predominantly located at the medial gutter and posterior to the tibial component. No preoperative variables were associated with heterotopic ossification, but its presence on lateral radiographs correlated with insufficient coverage of the tibial or talar component. Only three ankles required heterotopic ossification resection because of recalcitrant pain. The incidence of heterotopic ossification following primary total ankle arthroplasty was higher in this series than previously reported.

Biomechanical comparison of prophylactic medial malleolar fixation in total ankle arthroplasty.

The purpose of this study was to compare the biomechanical properties of two common forms of prophylactic fixation of the medial malleolus during total ankle arthroplasty (TAA). Ten matched pairs of cadaveric lower extremities were fixed with a single cannulated cortical screw or a one-third tubular plate after preparation for TAA. Ten unmatched single cadaver lower extremities were used as the control. A transverse load was applied to the medial malleolus. Bone mineral density, peak loads at fracture, and fracture pattern were noted. There was no statistically significant difference in peak load to failure between either fixation cohorts or between the fixation cohort and the control cohort. There was a moderate positive correlation between bone mineral density and peak load for all three experimental groups. The peak load was significantly (p = .035) increased in male cadavers. Fractures occurred almost exclusively at the apex of the tibial and malleolar cuts with a vertical fracture pattern.

Younger Patients Undergoing Total Ankle Arthroplasty Experience Higher Complication Rates and Worse Functional Outcomes.

BACKGROUND: Although many patients with posttraumatic ankle arthritis are of a younger age, studies evaluating the impact of age on outcomes of primary total ankle arthroplasty (TAA) have revealed heterogenous results. The purpose of the present study was to determine the effect of age on complication rates and patient-reported outcomes after TAA. METHODS: We retrospectively reviewed the records of 1,115 patients who had undergone primary TAA. The patients were divided into 3 age cohorts: <55 years (n = 196), 55 to 70 years (n = 657), and >70 years (n = 262). Demographic characteristics, intraoperative variables, postoperative complications, and patient-reported outcome measures were compared among groups with use of univariable analyses. Competing-risk regression analysis with adjustment for patient and implant characteristics was performed to assess the risk of implant failure by age group. The mean duration of follow-up was 5.6 years. RESULTS: Compared with the patients who were 55 to 70 years of age and >70 years of age, those who were <55 years of age had the highest rates of any reoperation (19.9%, 11.7%, and 6.5% for the <55, 55 to 70, and >70-year age groups, respectively; p < 0.001), implant failure (5.6%, 2.9%, and 1.1% for the <55, 55 to 70, and >70-year age groups, respectively; p = 0.019), and polyethylene exchange (7.7%, 4.3%, and 2.3% for the <55, 55 to 70, and >70-year age groups, respectively; p = 0.021). Competing-risk regression revealed a decreased risk of implant failure for patients who were >70 of age compared with those who were <55 years of age (hazard ratio [HR], 0.21 [95% confidence interval (CI), 0.05 to 0.80]; p = 0.023) and for patients who were 55 to 70 years of age compared with those who were <55 years of age (HR, 0.35 [95% CI, 0.16 to 0.77]; p = 0.009). For all subscales of the Foot and Ankle Outcome Score (FAOS) measure except activities of daily living, patients who were <55 years of age reported the lowest (worst) mean preoperative and postoperative scores compared with those who were 55 to 70 years of age and >70 years of age (p ≤ 0.001). Patients who were <55 years of age had the highest mean numerical pain score at the time of the latest follow-up (23.6, 14.4, 12.9 for the <55, 55 to 70, and >70-year age groups, respectively; p < 0.001). CONCLUSIONS: Studies involving large sample sizes with intermediate to long-term follow-up are critical to reveal age-related impacts on outcomes after TAA. In the present study, which we believe to be the largest single-institution series to date evaluating the effect of age on outcomes after TAA, younger patients had higher rates of complications and implant failure and fared worse on patient-reported outcome measures. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Comparison of Radiographic Talar Loosening Rates Between Salto-Talaris and INBONE II.

BACKGROUND: Despite substantial increase in total ankle arthroplasty (TAA) nationwide, there are few studies comparing flat-cut vs chamfer-cut talar systems in TAA with regard to radiographic aseptic loosening rates of the implant. METHODS: This retrospective study included 189 Salto-Talaris TAA and 132 INBONE II primary TAA with a minimum 1-year follow-up. Patient characteristics were obtained including gender, age at surgery, body mass index (BMI), smoking status, primary diagnosis, surgical time, and the presence of diabetes. Radiographic evidence for aseptic loosening was assessed. Statistical analysis was performed for comparison in outcomes between Salto-Talaris and INBONE II. RESULTS: The mean age of the study population was 63.5 ± 9.8 years at surgery. Mean follow-up was 4.9 ± 3.0 years. Radiographic aseptic loosening of the tibial implant showed no significant difference between the 2 groups: Salto-Talaris, 18%, and INBONE II, 18.9% (P = .829). Aseptic loosening of the talar implant also showed no significant difference between the 2 groups: Salto-Talaris, 1.6%, and INBONE II, 1.5% (P = .959). No variables, including the implant type, were found to contribute to the aseptic loosening rate of either the tibia or talus. CONCLUSION: In our cohort, we observed no difference in radiographic implant aseptic loosening between Salto-Talaris and INBONE II systems. LEVEL OF EVIDENCE: Level IV, retrospective case series study.

Association of Radiographic Soft Tissue Thickness With Revision Total Ankle Arthroplasty Following Primary Total Ankle Arthroplasty: A Minimum of 5-year Follow-up.

Background: The incidence of primary total ankle arthroplasty (TAA) is rising, with a corresponding increase in revision surgeries. Despite this, research on risk factors for revision TAA following primary TAA remains limited. Radiographic soft tissue thickness has been explored as a potential predictor for outcomes in hip, knee, and shoulder arthroplasty, but its role in TAA has not been assessed. This study aimed to assess the predictive value of radiographic soft tissue thickness for identifying patients at risk of requiring revision surgery following primary TAA. Methods: A retrospective study was conducted on 323 patients who underwent primary TAA between 2003 and 2019. Radiographic measurements of soft tissue thickness were obtained from preoperative radiographs. Two novel radiographic measures of soft tissue thickness were developed and assessed (tibial tissue thickness and talus tissue thickness). Clinical variables including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, diabetes, smoking status, primary diagnosis, and implant type were recorded. Logistic regression analysis was used to assess the predictive value of soft tissue thickness and BMI for revision TAA. Results: The rate of revision surgery was 4.3% (14 of 323 patients). Patients requiring revision had significantly greater tibial tissue (3.54 vs 2.48 cm; P = .02) and talus tissue (2.79 vs 2.42 cm; P = .02) thickness compared with those not requiring revision. Both the tibial tissue thickness (odds ratio 1.16 [1.12-1.20]; P < .01) and the talus tissue thickness (odds ratio: 1.10 [1.05-1.15]; P < .01) measurements were significant predictors of revision TAA in multivariable logistic regression models. However, BMI was not a significant predictor of revision TAA. The two metrics demonstrated excellent interrater reliability. Conclusion: Greater soft tissue thickness was a better predictor of revision TAA compared with BMI. These findings suggest that radiographic soft tissue thickness may be a valuable tool for assessing the risk of the need for revision TAA following primary TAA. Further research is needed to validate and explore the potential impact on clinical practice. Level of Evidence: Level III, comparative study.

Revision Total Ankle Arthroplasty Using the INBONE II System.

BACKGROUND: The utilization of total ankle arthroplasty (TAA) for managing severe ankle osteoarthritis has become increasingly common, leading to a higher occurrence of revision TAA procedures because of failure of primary TAA. This study aims to examine the clinical results associated with revision TAA using the INBONE II system. Given the growing number of TAA revision procedures and a focus on motion-preserving salvage options, we evaluated our early experience with revision TAA. METHODS: A retrospective analysis was conducted on a group of 60 presumed noninfected patients who underwent revision TAA with the INBONE II system. Detailed information was collected on patient demographics, implant characteristics, concurrent procedures, and complications. The implant survival was estimated using Kaplan-Meier analysis. RESULTS: The study revealed high complication rates but generally fair clinical outcomes for revision TAA using the INBONE II system. Complications were observed in 22 patients (36.7%), including persistent pain (n = 6), nerve injury/impingement (n = 5), infection (n = 3), fracture (n = 3), implant failure (n = 3), impaired wound healing (n = 2), and osteolysis (n = 3). The 3-year survivorship rate from reoperation was 92.0% (82.7%-100.0%) whereas the 3-year survivorship rate from major complications was 90.4% (80.8%-100.0%). CONCLUSION: We report high complication rates but generally fair clinical results for revision TAA utilizing the INBONE II system.

Applications of the medial femoral condyle free flap for foot and ankle reconstruction.

BACKGROUND: Avascular necrosis (AVN) or persistent nonunion occurs in situations of poor vascular supply. Some specific situations that plague the foot and ankle surgeon are talus nonunion, talus AVN, navicular AVN, and failed ankle arthrodesis with bone loss. The medial femoral condyle (MFC) flap has emerged as a popular source of vascularized corticocancelous bone. We present a series of cases demonstrating the versatility of the MFC flap in complex foot and ankle pathology. METHODS: A retrospective review was completed of all MFC flaps used in the foot and ankle over the past 5 years. Five patients were identified (average age 48). Surgical indications included talar AVN and ankle arthritis, talar nonunion, and navicular AVN. All patients had undergone conventional bone grafting techniques, which failed, prior to being treated with a MFC free flap; this series of patients did not possess significant medical comorbidities. Fixation techniques included compression screw fixation, plate osteosynthesis, or fine wire external fixation. The average follow-up was 20 months (range 8 to 40 months). RESULTS: There was a 100% flap success rate with no returns to the operating room for thrombosis. The volume of the bone flaps was 5.6 cm(3) (range 1 cm(3) to 12 cm(3)). The average follow-up time was 20 months (range 8 to 40 months). All cases resulted in union, and full weight bearing status was achieved at a mean of 23.8 weeks (range 10 to 52 weeks) postoperatively. CONCLUSIONS: Vascularized bone transfer in the form of the MFC free flap was a valuable method for foot and ankle reconstruction. The MFC flap provided an alternative for those defects that were smaller then 3 cm in length. In our experience, for small bone defects requiring vascularized bone, the MFC flap is currently the ideal donor location supplanting the iliac crest. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Decision-Making and Management of Tarsal Coalition in the Young Adult Patient: A Critical Analysis Review.

¼ Tarsal coalitions most commonly affect the calcaneonavicular and talocalcaneal joints in up to 13% of the general population. They alter the mechanics of the subtalar joint, limiting inversion and eversion, and place excessive stress on neighboring joints causing pain, recurrent ankle sprains, and/or progressive pes planus during the adolescent growth spurt.¼ While many coalitions are identified on radiographs, advanced imaging with computed tomography or magnetic resonance imaging is sometimes required. These advanced imaging modalities also serve an essential role for surgical planning to quantify coalition involvement, identify fibrous or cartilaginous coalitions, and aid in determining the degree of deformity within the foot.¼ Surgical treatment is reserved for feet with persistent activity-related pain not relieved by prolonged attempts at nonoperative management, which include nonsteroidal anti-inflammatory drugs, shoe orthotics, and periods of non-weight-bearing in a cast. These conservative modalities may be successful in up to 85% of cases.¼ For adolescent patients, recent surgical options attempt to avoid arthrodesis and focus on coalition resection and interposition grafting with or without deformity correction. The ultimate decision is based on the location of the pain, the size and histology of the coalition, the health of the posterior subtalar facet, the degree of flatfoot deformity, and the presence of degenerative changes in the subtalar and/or adjacent joints.¼ While many studies focus on subtalar motion and gait kinematics, the critical outcomes remain pain relief and future need for arthrodesis, which may be related not only to resection of the coalition but assessment of deformity, including after the resection has been performed.

Biomechanical Comparison of Nonlocked Minimally Invasive and Locked Open Achilles Tendon Simulated Rupture Repairs.

BACKGROUND: Open repair of Achilles tendon ruptures is associated with a risk of infection and other wound complications. Although percutaneous repairs reduce these complications, they may increase the risk of nerve injury. This study was designed to determine whether a percutaneous nonlocking repair can approach the gapping resistance offered by a standard open repair under conditions approximating typical postoperative physiotherapy. METHODS: Ten pairs of cadavers Achilles tendons were transected in situ 5 cm above the insertion. One tendon from each pair was repaired using an open 4-strand Krackow locking loop, and the contralateral tendon was repaired with the Achillon system using the same suture material. Displacement transducers were attached to the medial, lateral, anterior, and posterior aspects of the tendon, spanning the repair. Each tendon underwent 1000 tensile loading cycles to 86.5 N, simulating passive ankle range-of-motion physiotherapy. Gapping was documented on the 1st, 50th, 100th, 500th, and 1000th cycles. The ultimate tensile strength of each repaired tendon was then measured by distracting until gross failure occurred. RESULTS: Gapping of the percutaneous repairs exceeded that of conventional open repairs on the first, 500th, and 1000th load cycles. All 10 conventionally repaired tendons withstood 1000 load cycles without gross failure, but 4 of 10 percutaneous minimally invasive repairs failed, one on the 9th load cycle and the others between the 100th and 500th cycles. On average, tendons repaired with the open technique withstood 66% greater tensile load in failure testing than those repaired with the percutaneous technique. CONCLUSION: Open Krackow Achilles tendon repairs may better withstand more aggressive postoperative physiotherapy than nonlocked percutaneous repairs. CLINICAL RELEVANCE: The study suggests that surgeons should consider locking suture approaches to avoid loss of repair integrity with early motion.

Republication of "Osteochondral Lesions of the Talus: Current Concepts in Diagnosis and Treatment".

Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. They require a strong plan. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment required to achieve a satisfactory result. In general, operative treatment is reserved for patients with displaced OLTs or for patients who have failed nonoperative treatment for 3 to 6 months. Operative treatments can be broken down into cartilage repair, replacement, and regenerative strategies. There are many promising treatment options, and research is needed to elucidate which are superior to minimize the morbidity from OLTs.

Total Ankle Arthroplasty: Does Obesity Matter?

BACKGROUND: There is limited data evaluating the effect of obesity on outcomes following total ankle arthroplasty (TAA), especially in adequate sample sizes to detect impacts on patient-reported outcomes (PROs). The purpose of this study was to assess the effect of obesity on complication rates and PROs. METHODS: This was a single-institution, retrospective study of 1093 primary TAA performed between 2001 and 2020. Minimum follow-up was 2 years. Patients were stratified by body mass index (BMI) into control (BMI = 18.5-29.9; n = 615), obesity class I (BMI = 30.0-34.9; n = 285), and obesity class II (BMI > 35.0; n = 193) groups. Patient information, intraoperative variables, postoperative complications, and PRO measures were compared between groups using univariable statistics. Multivariable Cox regression was performed to assess risk for implant failure. Mean follow-up was 5.6 years (SD: 3.1). RESULTS: Compared to control and class I, class II patients had the lowest mean age (P = .001), highest mean ASA score (P < .001), and greatest proportion of female sex (P < .001) and Black/African American race (P = .005). There were no statistically significant differences in postoperative complications (infection, implant failure, or impingement) across the BMI classes (P > .05).Preoperatively, class II had lower (worse) mean scores for Foot and Ankle Outcome Score pain and ADL subscales than controls (post hoc pairwise P < .001 for both). At final follow-up, both class II and class I had lower (worse) mean Short Musculoskeletal Function Assessment (post hoc pairwise P < .001 and P = .030, respectively) and 36-Item Short Form Health Survey scores (post hoc pairwise P < .001 and P = .005, respectively) than controls. CONCLUSION: At midterm follow-up, obesity was not associated with increased rates of complications after TAA. Patients with obesity reported worse musculoskeletal function and overall quality of life after TAA but there was no differential improvement in PROs across BMI classes. To our knowledge, this is the largest single-institution study to date examining the effect of obesity on outcomes after primary TAA. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

A Propensity Score Matched Exploration of Infection in Primary Total Ankle Arthroplasty.

BACKGROUND: Infection is a serious complication of primary total ankle arthroplasty (TAA) and can lead to implant failure and revision surgery. Various demographic, comorbidity, and surgical factors have been associated with an increased risk of infection. However, the evidence base remains limited, and further research is needed regarding infection in TAA. This study aims to analyze risk factors of infection and explore outcomes following infected TAA. METHODS: A retrospective cohort study was conducted using data from a single institution from 2002 to 2022. Patients who underwent primary TAA and had subsequent infection were identified through annual registry surveillance and matched using propensity score matching (PSM) based on various demographic, comorbidity, and surgical factors. Demographics were compared between the matched groups using Mann-Whitney U test and Fisher exact test. The outcomes following infection were identified and summarized using descriptive statistics. RESULTS: A total of 1863 patients who underwent primary TAA were identified, and 19 were diagnosed with an infection. The identifiable overall infection rate was 1.0%. After PSM, there were no significant differences in the difference in age, gender, BMI, and smoking status between the infected and control cohort. There was a statistically significant increase in the rate of diabetes in the infected cohort. The subsequent surgical intervention resulted in limb salvage in 18 (94.7%) cases. Out of the total number of cases, 2-stage revision to total ankle replacement was performed in 7 cases, whereas revision to arthrodesis and isolated polyethylene exchange were each carried out in 4 cases. One patient had to undergo amputation; however, at the time of the most recent follow-up, all patients were found to be free of infection. CONCLUSION: This study demonstrated high rates of a history of smoking and diabetes in the infected TAA cohort. The diabetes rate in the infected group was significantly higher than the noninfected controls. Two-stage revision to total ankle replacement was performed in 7 cases, and revision to arthrodesis and isolated polyethylene exchange were each carried out in 4 cases. Overall, a high rate of limb salvage was reported. LEVEL OF EVIDENCE: Level III, case-control study.

Vascularized pedicle bone grafting for nonunions of the tarsal navicular.

BACKGROUND: Osteonecrosis and nonunions of the tarsal navicular remain a challenging clinical problem. This article presents a series of patients treated with local vascularized pedicle bone grafting to the navicular. The purpose of this study was to determine the early clinical and radiographic outcomes of this technique. METHODS: Patients who underwent local vascularized pedicle bone grafting for osteonecrosis of the navicular from 2002 to 2007 were included in this study. The Ankle Osteoarthritis Scale (AOS), the Revised Foot Function Index (FFI-R), and the Short-Form 36 (SF-36) outcomes questionnaires were administered at most recent followup. Postoperative imaging was reviewed for evidence of healing. Eight patients with a mean age of 47.5 (range, 18 to 68) years were included in this study. The mean followup time was 61 (range, 32 to 72) months. RESULTS: Two patients underwent concomitant talonavicular arthrodesis. Two patients underwent additional procedures to address continued nonunion of the navicular. Neither patient elected to complete the outcomes questionnaires. The mean postoperative FFI score was 35.2 (range, 16.6 to 59). SF-36 subscales were as follows: bodily pain, 53; general health, 55; mental health, 75; physical function, 56; role emotional, 61; role physical, 37.5; social function, 71; and vitality, 56. The mean postoperative AOS pain score was 27.9 (range, 0 to 46.2) and the average disability score was 31.4 (range, 0 to 78.2). Postoperative imaging revealed consolidation and full healing in six of eight patients. CONCLUSION: Vascularized pedicle bone grafting is a treatment option for patients with chronic nonunion or osteonecrosis of the navicular. Additionally, it may serve as an adjunct procedure to provide increased vascularity to talonavicular arthrodesis in cases of navicular osteonecrosis and talonavicular arthritis.

J. Leonard Goldner Award 2011: changes in pain, function, and gait mechanics two years following total ankle arthroplasty performed with two modern fixed-bearing prostheses.

BACKGROUND: Total ankle replacement (TAR) continues to grow as an alternative to arthrodesis for patients who suffer from end-stage ankle arthritis. The purpose of this study was to examine changes in gait mechanics from before surgery to 1 and 2 years after surgery in patients who received a fixed-bearing TAR. METHODS: Fifty-one patients with a primary fixed-bearing TAR and no complications requiring further surgery were identified from a database and enrolled in this non-randomized study. Subjects were examined preoperatively, and at 1 and 2 years postoperatively. Three-dimensional joint mechanics and ground reaction forces (GRF) were collected during level walking. The Four Square Step Test, Timed Up and Go (TUG), VAS, and the AOFAS-Hindfoot score were assessed for each subject at each time point. RESULTS: TUG, VAS and AOFAS-Hindfoot score along with all measured kinetic parameters demonstrated significant improvements across all of the time points (p < 0.05). Four Square Step Test time was significantly improved between the preoperative and 2-year postoperative time point (p < 0.05). Measured ankle dorsiflexion angles did not demonstrate significant change between any time points. CONCLUSIONS: All of the observed changes suggest improved or maintained functioning in patients who received a TAR with the greatest improvement occurring within the first year. Sagittal plane ankle range of motion and dorsiflexion angle at heel strike were unchanged across all of the time points. The results of this study indicate that patients with end-stage osteoarthritis demonstrate improvements in pain and gait up to 2 years following surgery while maintaining ankle range of motion.

Magnetic resonance imaging features of osteochondral lesions of the talus.

BACKGROUND: Osteochondral lesions of the talus (OLT) traditionally have been thought to occur anterolaterally or posteromedially. Recent studies utilizing magnetic resonance imaging (MRI) have questioned this teaching. The purpose of this study was to use MRI to describe the location, frequency, and morphology of OLT and determine if any correlations exist between lesion location and other data points. METHODS: The location, frequency, and size of OLT based on a nine-zone grid were recorded on 77 MRI examinations. Lateral ligaments were inspected for evidence of injury. Stability of the lesions was assessed based on four MRI criteria: presence or absence of cartilage defects, edema-like signal abnormality, T2 bright rim, and/or subchondral cysts. Demographic data including patient age, injury mechanism, and chronicity were recorded. An ANOVA model was used to determine if statistical differences existed between lesion size and location. Pearson correlation coefficients were used to examine any association between lesion location and demographic data. RESULTS: Most of the lesions were located medially and centrally on the talar dome (54.5%), with the second highest frequency found laterally and centrally (31.2%). With the numbers available there was no statistical difference between the size of the lesions based on location. No strong correlations were found between lesion location and demographic data. CONCLUSION: This study refutes traditional teachings regarding the location of OLT and supports recent studies showing that most lesions are located medially and centrally on the talar dome.