Randomized Controlled Trial Comparing Early Mobilization vs Six Weeks of Immobilization in a Walking Cast Following Total Ankle Replacement.

Rehabilitation for patients after total ankle replacement traditionally involves weeks of immobilization in a plaster cast followed by progressive mobilization. In a small randomized trial, we compared teh outcomes of patients who received a 3-component cementless, unconstrained, mobile-bearing prosthesis and were initially immobilised in a plaster cast for 6 weeks to thoese who received the same prosthesis but were allowed to mobilise early. Gait, clinical, patient-reported, and radiologic outcomes were measured. The study included 20 patients, 10 in the plaster cast group and 10 in the early mobilization group, and the demographics of the groups did not differ significantly. All patients were followed-up for 24 months. There were no significant differences between the 2 groups 2 years after surgery in ankle dorsiflexion, spatiotemporal gait characteristics, American Orthopaedic Foot and Ankle Society ankle-hindfoot scores, Timed Up and Go Test times, WOMAC (pain, stiffness, function) scores, SF-36 (quality-of-life) scores, or patient satisfaction (pain relief, daily-living, recreational activities, and overall) (all p > .05). Bone mineral density decrease of the medial malleolus and increase at middle tibia, calculated with DEXA scans, was significantly better in early mobilization than plaster cast group at one and 2 years postoperatively, but this was also the case preoperatively. The lack of differences in outcomes suggests that early ankle mobilization may be a safe and reliable method to enhance recovery following ankle arthroplasty with a 3-component cementless, unconstrained, mobile-bearing prosthesis. Compared to traditional plaster casting, patients who are engaged in early mobilization after arthroplasty may enjoy similar functional, mobility, quality-of-life, pain relief, activity level, and satisfaction outcomes.

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.

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.

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.

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.

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.

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.

Outcome of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Lesser Toe Metatarsalgia.

BACKGROUND: As in all fields of surgery, advances in orthopaedic surgery develop toward less invasive surgical techniques. The advantages of smaller incisions include minimal soft tissue dissection allowing procedures to be performed as outpatient surgery. There is the assumption that this leads to a quicker recovery time permitting an earlier return to work. As with any new surgical technique, there is an associated learning curve. This study looked into the outcome of minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) performed at a University Hospital. METHODS: Thirty patients underwent minimally invasive surgery for DMMO. There were 13 males and 17 females with an average age of 60 years. More than one metatarsal osteotomy was done in all cases to facilitate the moulding of the metatarsal head to the correct alignment with full weight bearing. The outcome was measured with the Manchester-Oxford Foot Questionnaire (MOXFQ), patient-reported outcome (PRO), and visual analog scale (VAS) pain score. Minimum follow up was 1 year. RESULTS: At the final review, the average MOXFQ score was an excellent 31. Average improvement in VAS score was 3.5, which ranged from 10 to -7. The VAS was affected by 2 patients whose pain worsened after the operation. There were 4 complications, one each of nonunion, malunion, transfer metatarsalgia, and soft tissue ossification. CONCLUSION: The 3 most common complications of foot and ankle surgery are infection, wound dehiscence, and skin ulcer or blister. Intra-articular metatarsal osteotomies are commonly associated with stiffness due to scarring and consequently hammertoes. By reducing the soft tissue injury in minimally invasive surgery, these risks can be potentially minimized. Minimally invasive DMMO produced good patient satisfaction, functional improvement, and low complication rates in most cases. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Pre-operative echocardiogram in hip fracture patients with cardiac murmur--an audit.

BACKGROUND: All hip fracture patients with a cardiac murmur have an echocardiogram as a part of their preoperative work-up in our unit. We performed a retrospective audit to assess the impact of obtaining a pre-operative echocardiogram on the management of hip fracture patients. METHODS: All hip fracture patients (N = 349) between 01/06/08 and 01/06/09 were included in the study. 29 patients had pre-operative echocardiogram (echo group). A computer generated randomised sample of 40 patients was generated from N, 'non-echo' group. Data was obtained from medical records and the Hospital Information Support System (HISS). The groups were compared using Student's t test. Approval was obtained locally from the clinical governance department for this project. RESULTS: Age and gender distribution were similar in both groups. Indication for echo was an acute cardiac abnormality in 4 cases. 25 patients had echo for no new cardiac problem (indication being cardiac murmur in 23 patients and extensive cardiac history in 2 cases). Cardiology opinion was sought in 5 cases. No patient required cardiac surgery or balloon angioplasty preoperatively. Patients having pre-operative echo had significant delay to surgery (average 2.7 days, range 0-6 days) compared to 'non-echo' group (average 1.1 days, range 0-3 days), (p < 0.001). There was no significant difference in length of stay (p = 0.14) and mortality at 30 days (p = 0.41) between the groups. CONCLUSION: We have developed departmental guidelines for expediting echo requests in hip fracture patients with cardiac murmur. A liaison has been established with our cardiology department to prioritise such patients on the Echocardiography waiting list, to prevent unnecessary avoidable delay. Careful patient selection for pre-operative echocardiography is important to avoid unnecessary delay to surgery.

Medium term results of revision total hip replacement using radial impaction grafting and a collared textured stem.

Massive bone loss is a problem frequently encountered during revision hip surgery. Several ways of addressing the bone loss in proximal femur have been described with varying results. We present our results with the use of a radial impaction grafting technique and a collared textured component. 107 consecutive cases of Revision Total Hip Arthroplasty, who underwent radial impaction grafting and had a textured collared implant inserted for femoral deficiencies were assessed. The average follow up was seven years and four months (3 to 11 years). All the patients experienced a significant improvement in the clinical scores. Oxford Hip scores improved from an average of 41.2 (30 - 56) to 19.3 (12 - 32). Harris Hip scores improved from an average of 40.8 (28 - 65) to 83.4 (60 - 99). There were no cases of subsidence at follow up. Using revision for any cause as the end point the survivorship at an average of 88.8 months was 93.8%. Three revisions were performed for deep infection within the first year. There were three cases of peri-prosthetic fractures distal to the tip of standard length stems at an average of 8.4 months after surgery. We recommend the use of morsellised allografts with radial impaction grafting and textured, collared stems for selected cases with Paprosky type II and type III femoral defects. We also recommend use of long stems bypassing the tip of the previous implant with impaction grafting to avoid peri-prosthetic fractures.