A Study of Tibial Cyst Formation in Modular Stemmed Total Ankle Arthroplasty: Exploring a Possible Relationship to Smooth and Porous Coating on the Stem Segments.

Vertical fixation through stemmed components has been a successful strategy in total ankle arthroplasty. Research in hip replacement surgery has demonstrated increased rates of stress shielding, aseptic loosening, thigh pain, and cystic formation around stemmed femoral implants extensively coated with porous surfaces. While some ankle prostheses have integrated porous coating technology with stemmed tibial implants, there is little to no research investigating the potential negative effects of bone bonding to the tibial stems and possible impact on tibial cyst formation. We performed a retrospective cohort study comparing the incidence of periprosthetic tibial cyst formation in smooth versus fully porous-coated stemmed tibial implants after undergoing total ankle implant arthroplasty. Radiographs were compared for postoperative rates of tibial cyst formation and bone bonding to the tibial stems. Relative risk for reoperation between the smooth and porous-coated implants was investigated. The smooth-stem group showed no incidence of tibial cyst formation nor signs of significant bone bonding to the tibial stems; however, the follow-up matched porous-coated group showed a rate of 63% of cystic formation with associated evidence of bone bonding on final radiographic follow-up (p < .01). Relative risk for reoperation was 0.74. Despite a higher incidence of tibial cyst formation in the stemmed ankle arthroplasty groups with porous coating, reoperation rates were similar. We theorize that the proximal bonding to the porous stem surface could impact the distal stems and result in the observed increase in cyst formation.

Comparison of Dynamic Versus Static Locked Retrograde Tibiotalocalcaneal Arthrodesis With Intramedullary Nail Fixation: Evaluation of the RAIN Database.

Hindfoot osteoarthritis (OA) or deformity involving the ankle and subtalar joint is a disabling condition. Tibiotalocalcaneal (TTC) fusion is an effective salvage option in pathologies where total ankle replacement is contraindicated. The purpose of this study is to compare the union rate of the ankle joint in proximal static versus dynamically locked retrograde intramedullary nail fixation for tibiotalocalcaneal arthrodesis. An institutional review board-approved comprehensive chart and radiographic review was performed. TTC arthrodesis performed in patients with OA, post-traumatic arthritis, or deformity corrected by retrograde nail were included. Patients with Charcot arthropathy, failed joint replacement, neuropathy, or avascular necrosis were excluded. The primary outcome was ankle joint union with secondary measure of mean time to fusion. A total of 60 patients met inclusion criteria with 30 in the static group (SG) and 30 in the dynamic group (DG). The average age of the static group (SG) and dynamic group (DG) was 56.9 and 54.1 years, respectively. Mean body mass index was 34.03 kg/m2 for SG and 33.43 kg/m2 for DG. The union rate of the ankle joint was slightly higher in the DG but not statistically significant [SG 83.3%, DG 86.6%, p > .05 (p = .83)]. Time to fusion (TTF) in SG was 111.6 days compared to 97.2 days in DG. Dynamically locked intramedullary nails allow continued compression across the arthrodesis site as fusions remodel. Time to union and union rate of the ankle joint was superior in the dynamic group but this was not statistically significant. In this cohort, union rates were excellent in both groups, and no statistically significant difference was seen in the number of nonunions.

The Medial Gastrocnemius Recession, an Alternative Surgical Treatment for Isolated Gastrocnemius Contracture: A Cadaver Study With Discussion Emphasizing Variable Conjoint Tendon Anatomy.

BACKGROUND: Gastrocnemius recession is a popular procedure utilized to treat chronic conditions related to isolated gastrocnemius contracture (IGC). Recent anatomical research detailing variable gastrocsoleus tendon morphology has raised important questions regarding the safety of some traditional recession procedures. Alternative gastrocnemius recession strategies may produce comparable dorsiflexion improvement results while avoiding the surgical risk related to conjoint tendon anatomical variability. METHODS: Ten matched cadaver pairs were randomized to receive either a medial gastrocnemius recession (MGR) procedure or a gastrocnemius intramuscular recession "Baumann" procedure. Postoperative dorsiflexion improvement was measured and then compared between groups. Detailed postoperative surgical dissections were performed to assess structures at risk, conjoint tendon morphology, and anatomical symmetry. RESULTS: Medial gastrocnemius recession and Baumann procedures were equally effective at producing significant increases in passive ankle dorsiflexion. No sural nerve injuries were observed. Thirty-five percent of specimens showed direct muscular fusion of at least a portion of the distal gastrocnemius muscular tissue to the adjacent soleus. CONCLUSION: The MGR procedure produced comparable dorsiflexion improvement results to the Baumann procedure in our cadaver model. Surgeons must account for certain conjoint tendon anatomical variants when surgically treating IGC as traditional recession methods risk tendo-Achilles overlengthening. LEVELS OF EVIDENCE: Level V: Cadaver Study.

Direct Plantar Approach to Plantar Plate Repair and Associated Wound Complications.

BACKGROUND: Lesser toe metatarsophalangeal joint (MTPJ) instability, secondary to plantar plate tear, has been the focus of numerous recent publications, the majority reporting on repair through a dorsal approach. A plantar approach has been described with the advantage of direct ligamentous repair or repair to bone, which follows conventional techniques employed throughout the body. Previous clinical studies have shown success in deformity correction and the longevity of both approaches. The proponents of the dorsal approach advocate that indirect repair of the plantar plate avoids perceived risks of complications with a plantar incision without evidence of superior outcomes. The purpose of this study was to investigate the safety and efficacy of the direct plantar approach to plantar plate repairs (PPRs) by reporting the rate of specific complications in a large clinical series. METHODS: This was the institutional review board (IRB) approved retrospective study of 204 PPRs in 185 patients (194 lesser MTP, 10 hallux MTP) with an average age of 56 and a mean body mass index (BMI) of 28. Surgical technique involved repair with absorbable braided suture (88%) versus suture anchor (12%) with or without MTPJ pinning (80%). Mean follow up was 53 weeks (range 5-170). Patients were screened for associated risk factors, including diabetes mellitus (8%), tobacco use (5%), neuropathy (1%), and additional concurrent procedures (96%). Complications were defined as superficial or deep infection, painful scars, and reoperation. Analysis was conducted using the Wilcoxon-Mann-Whitney test or Fisher's exact tests for continuous and categorical variables, respectively. Risk factors were analyzed using univariate logistic analysis to produce odds ratios (OR) with a 95% confidence interval (CI) and an inclusion criterion of a P-value, P > .2 for multivariate analysis as determined by Wald tests (significance at P < .05 for final modeling). RESULTS: Overall, there were 31 total complications (15%) demonstrated by 14 superficial infections (6.8%) and 17 painful scars (8.3%) along with three reoperations (1.4%). All reoperations were performed for deformity or instability, not scar revision. There were no deep infections. No increased odds of complications were found with suture anchor repair, MTPJ pinning, neuropathy, or diabetes. Patients that used tobacco had 7.5 (CI 1.66, 34.06) the odds of developing any wound complication compared with nonsmokers. Tobacco use was also found to significantly increase the odds of superficial infection by 9.8 (CI 2.08, 46.15). There was no increase in painful scars or reoperation in tobacco users. This study did not find an increased complication rate with additional ipsilateral procedures performed at the time of surgery. CONCLUSION: To our knowledge, this is the largest study evaluating the direct plantar approach to PPR as well as the evaluation of associated complications with the plantar incision. With low complication and minimal reoperation rates, the results of this study have demonstrated the clinical viability of plantar-based incisions. Previous studies have demonstrated the success of PPR and correction of deformity with a direct approach. This case series further demonstrates the safety and efficacy of plantar-based incisions, particularly for direct PPRs. LEVEL OF EVIDENCE: IV Retrospective Case Series. CATEGORY: Lesser Toes.

Total Ankle Arthroplasty Survivorship, Complication, and Revision Rates in Patients Younger Than 55 Years.

Total ankle replacement has become a viable alternative to ankle arthrodesis in the surgical management of advanced ankle arthritis. Total ankle replacement has generally been reserved for patients who are older and for those who will have a lower demand on the replacement. The purpose of the current study is to review patient outcomes, complications, and implant survival in patients younger than 55 years who underwent total ankle replacement at a single institution. A single-center chart and radiographic review was performed of consecutive patients who underwent total ankle replacement for treatment of end-stage ankle arthritis. All surgeries were performed by 1 of 5 fellowship-trained foot and ankle surgeons at a single institution. A total of 51 patients met inclusion criteria with a mean follow-up of 31.2 months (SD = 16.2). Implant survival was 94%, There were 7 major complications (13%) requiring an unplanned return to the operating room and 8 minor complications (15%) that resolved with conservative care. The results of this study show that total ankle replacement is a viable treatment option for patients younger than 55 years.Levels of Evidence: A retrospective case series.

The INFINITY Total Ankle Prosthesis: Outcomes at Short-Term Follow-up.

BACKGROUND: The INFINITY total ankle prothesis remains the most widely used fourth-generation total ankle arthroplasty (TAA) system in the United States. The purpose of the present study was to assess radiographic outcomes for INFINITY at short-term follow-up. METHODS: All patients who underwent primary TAA with INFINITY between August 2015 and June 2018 at a single institution and who were at least 1 year postoperative were included. A total of 55 ankles with a mean follow up 22 months (range, 12-43 months) met the criteria. Weightbearing radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 to 8 weeks postoperatively, and at the most recent follow-up. Medical records and charts were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook at el, respectively. RESULTS: Overall, INFINITY survivorship was 98.2%. Coronal and sagittal tibiotalar alignment improved after surgery (P < .001, P = .09, respectively), and was maintained during the latest follow-up (P = .62, P = .47, respectively). Only 1 ankle (1.8%) required early revision; while 5 (9.1%) indicated non-implant-related revision; 85.5% required no reoperation. In nineteen ankles (34.5%), postoperative periprosthetic lucency was observed; most were not progressive (17 ankles, 89.5%). Twelve complications (3 high grade, 3 intermediate, and 6 low grade) in 11 ankles (20%) were recorded according to the Glazebrook classification system. CONCLUSION: INFINITY survivorship was 98.2% at a mean of 1.8 years of follow-up, and only 1 ankle required prosthetic revision. Additional studies with longer follow-up are warranted for fourth-generation TAA prostheses. LEVELS OF EVIDENCE: Level IV: Case series.

The Role of Secondary Imaging Techniques for Assessing Bone Mineral Density in Elderly Ankle Fractures.

Elderly ankle fractures in the elderly represent a substantial healthcare burden. Dual-energy x-ray absorptiometry (DXA) is the gold standard for diagnosis of osteoporosis. However, there is emerging research regarding secondary imaging techniques to evaluate bone mineral density (BMD). The purpose of this systematic review was to summarize the role of secondary imaging techniques for measuring BMD in elderly ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Eight studies were included in the systematic review. Computed tomography (CT) may have a role in preoperative surgical planning, provide an explanation for injury patterns in elderly patients, and may be correlated with clinical outcomes. High-resolution peripheral quantitative CT may be better suited than DXA for the assessment of ankle fractures due to the resolution of the image and its ability to distinguish between bone compartments, as well as provide a more accurate estimation of bone quality. Quantitative ultrasound has shown promise as a tool for measuring BMD in patients with osteoporosis, but is not able to detect osteoporosis in patients with ankle fractures. This paper helps define the role of each modality in the spectrum of care in the evaluation of osteoporosis as it pertains to elderly ankle fractures.

The Safety Profile of Same-Day Outpatient Total Ankle Arthroplasty.

There has been significant change in the health care policy in the United States in recent years with an increasing focus on health care costs and patient satisfaction. One strategy of cost containment is to transition outpatient surgery away from high cost hospital environments. Total ankle arthroplasty has begun the evolution to outpatient settings; however, there is limited published literature on the results of outpatient total ankle arthroplasty (TAA). The purpose of the present study was to review the safety profile of same day outpatient TAA at an ambulatory surgery center. A review of consecutive patients who underwent same day outpatient TAA for end-stage ankle arthritis with a minimum of 12 months' follow-up was performed. The primary outcomes assessed were the incidence of perioperative adverse medical events, hospital admissions related to the procedure, and postoperative complications (minor and major). Univariate analyses were performed. Fifty-one patients who underwent same-day TAA between June 2016 and July 2018 were included; mean follow-up was 20.7 months (± 7.6). The mean age at time of surgery was 56.5 years (± 7.2), with a mean body mass index of 30.4 (± 5.3). Overall, there were no perioperative adverse medical events or hospital admissions related to the procedure. Five minor complications (9.8%) and 7 major (13.7%) were recorded. Of the major complications, only 1 required TAA revision. Implant survivorship during the most recent follow-up was 98%. The present study suggests that TAA can be performed safely in an outpatient ambulatory setting. Additional comparative studies with larger TAA cohorts and patient reported outcomes are warranted.

Total Ankle Arthroplasty With Anatomic Lateral Ankle Stabilization (ATLAS) in Moderate and Severe Pre-operative Varus Alignment.

The purpose of the present study was to assess the early clinical and radiographic outcomes for patients who underwent TAA and Anatomic Lateral Ankle Stabilization (ATLAS) using synthetic graft for instability in moderate and severe preoperative varus alignment. Seven ankles with moderate or severe varus alignment underwent TAA with a 3rd generation prothesis (INBONE-2) and ATLAS using synthetic graft between September 2018 and February 2019 at a single institution, and were at least 1 year postoperative (mean 13.3 months, range 12-15). Medical records and charts were reviewed for revisions, reoperations, and complications. Weightbearing radiographs were assessed using tibiotalar alignment parameters preoperatively, and during the latest follow-up. Survivorship for INBONE-2 with ATLAS was 100%; recurrent instability was not observed. Symptomatic talonavicular joint arthritis was recorded for a single patient 12 months postoperatively; no revisions, or reoperations were performed. Coronal alignment improved significantly from 17.7 ± 9.3 (range, 10.1-33.6) to 2.3 ± 1.2 (range, 0.9-4.4) degrees (p < .006), and all ankles achieved neutral alignment in a single stage. Regarding sagittal alignment, 2 ankles (28.5%) were translated anteriorly and the rest were neutral (71.5%) preoperatively. Significant posterior translation was observed and during the latest follow-up, 4 ankles were neutral (57.1%) and 3 posterior (42.9%) (p < .009). Satisfactory outcomes were observed at a minimum of 1-year follow-up for patients with moderate or severe varus alignment who underwent TAA with INBONE-2 and ATLAS. ATLAS may afford advantages over previously described repair techniques. Comparative studies between the Brostrum-Gould and ATLAS are warranted.

Does Functional Neuromuscular Electrical Stimulation (NMES) Influence Calf Atrophy Following Achilles Tendon Surgery? Prospective Double-Blind Randomized Controlled Trial on the Use of Immediate Postoperative Electrical Muscle Stimulation to Preserve Muscle Function and Volume.

Surgical repair of the Achilles tendon can lead to prolonged calf atrophy and functional limitations, even with early weightbearing. The use of neuromuscular electrical stimulation (NMES) has been studied in muscle rehabilitation programs following anterior cruciate ligament repair. Accelerated recovery and pain reduction were noted. The aim of the present study was to evaluate the use of electrical stimulation on maintaining calf muscle cross-sectional area volume and improving patient reported outcome measures following Achilles tendon surgery. Randomized controlled clinical trial. Forty patients were enrolled. All patients had undergone repair of the Achilles tendon. A 4 lead NMES device was applied at time of surgery with both patient and surgeon blinded to activity of the device. All patients followed a standardized postoperative protocol. Group 1 consisted of 20 patients who received protocol specific NMES. Group 2 was the "sham device" control group, receiving subtherapeutic electrical stimulation. Preoperative and postoperative calf circumference (2, 6, 12 weeks) and magnetic resonance imaging (MRI) scans (2, 6 weeks) were conducted. Patient-reported functional outcome scores were measured. Of the 40 patients, 23 (57.5%) were male and 17 (42.5%) were female. The mean age was 48.9 years (11.1 standard deviation [SD]) with a mean body mass index of 32.2 kg/m2 (5.7 SD). Calf measurements for Group 1 (39.3 cm and 39.7 cm) were slightly higher compared Group 2 (38.4 cm and 39.2 cm) at 6 and 12 weeks postoperative. Functional scores were similar between Groups 1 and 2 at final follow-up. Foot/Ankle Computer Adaptive Test scores were 55.1 (6.9 SD) versus 58.4(8.6 SD), and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores were 82.3 (8.2 SD) and 83.9 (9.3 SD), respectively. The visual analog scale at 12-week visit for Groups 1 and 2 was 8.4 (9.3 SD) and 8.4 (9.1 SD), respectively. This prospective randomized controlled trial was undertaken to quantify and validate the effect and ability of NMES to minimize calf atrophy after acute or chronic repair. No statistically significant difference was found between active NMES and sham control group. There was a trend showing some maintenance of calf volume per MRI study.

Intermediate-Term Outcomes of a Third-Generation, 2-Component Total Ankle Prosthesis.

BACKGROUND: Short-term outcomes for the INBONE I and INBONE II tibial stems have been favorable. The INBONE-II talus has been shown to have lower reoperation and failure rates compared to its predecessor at short term follow-up. The purpose of the present study was to assess mid-term outcomes for the third generation, two component total ankle prosthesis at 5 to 9 years follow-up, evaluating both the tibial and talar components. METHODS: All patients who underwent primary total ankle arthroplasty (TAA) with INBONE-II between July 2010 and July 2014 at a single institution and who were at least 5 years postoperative were included. A total of 15 ankles with a mean follow-up of 85 months (range, 61-113 months) met the criteria. Radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 weeks postoperatively, and at the most recent follow-up. Medical records were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook et al, respectively. RESULTS: The survivorship of the prosthesis at a mean of 85 months was 93.7%. The coronal and sagittal tibiotalar alignments 6 weeks after surgery were 2.1 degrees (P = .081) and 36% (P = .15), respectively. Maintenance of this alignment was observed during the latest follow-up (P = .684 and P = .837, respectively). One ankle (6.7%) required early component revision, while 4 (26.7%) required a non-implant-related revision. Six complications (2 high grade, 1 intermediate, and 3 low) in 5 ankles (33.3%) were recorded according to the Glazebrook classification system. CONCLUSION: The present study is the first to report midterm follow-up after TAA with this third-generation, 2-component prothesis. High survivorship, maintenance of correction, and a low incidence of major complications were observed in this small case series. The most common complication overall was lateral gutter impingement, which accounted for the majority of the nonrevisional reoperations. LEVEL OF EVIDENCE: Level IV, case series.

Short- to Midterm Follow-up of Cemented Total Ankle Replacement Using the INBONE II: A Retrospective Chart Review.

Background: Total ankle arthroplasty is a viable option for the treatment of end stage ankle arthritis. The purpose of this study is to report on the mid-term results with a cemented total ankle prosthesis, the Inbone™ II implant over a 5 year period. Methods: A retrospective, single-center chart and radiographic review of all patients with end stage ankle arthritis treated with Inbone™ II TAR) as the primary index procedure from 12/1/2012 to 3/1/2017. Clinical data were evaluated at 3 month, 6 month, 1 year and subsequent intervals for the study period. Preoperative diagnosis, pertinent patient demographics adjunctive procedures, implant associated complications, subsequent surgeries, and revisions were recorded. Results: 121 total ankles met our inclusion criteria. Patients had an INBONE™ II TAR implant placed with bone cement with a minimum of a 12 months follow up. Average age was 62.88 (range, 32-87) years, average body mass index was 32.74 (range, 21.8-56.04) kg/m2 and average follow up was 28.51(range, 12-69) months. Using the COFAS complication classification there were 14 minor, 11 moderate, and 5 major complications. 6/121 (5.0%) revisions which included: polyethylene exchange, device explant/fusion, and antibiotic spacer in situ. No complications over the course of this study ended in amputation. Conclusion: Total Ankle Arthroplasty utilizing the cemented INBONE™ II yielded good midterm results with regards to minor, moderate, and major complications. Rate of revision 6/121 (5.0%) was within the reported range with only 5 patients converted to fusion during the study period resulting in a 95% survivability at mid-term follow up.Levels of Evidence: Level IV: Retrospective case series.

Bone Mineral Density Testing in Patients Undergoing Total Ankle Arthroplasty: Should We Pay More Attention to the Bone Quality?

Total ankle arthroplasty (TAA) has become one of the standard treatments for end-stage ankle arthritis. Long-term TAA survivorship is reported from 63% to 95%, with aseptic loosening being the most common mode of failure. Several studies have shown that low bone mineral density (BMD) of the hip affects the longevity of prosthetic implants. The role of Dual energy X-ray absorptiometry for TAA has not been established. The purpose of this review was to define the role of BMD in TAA outcomes and the role of Dual energy X-ray absorptiometry in measuring periprosthetic BMD. There is a paucity of information and published literature regarding the relationship between BMD and TAA. From attempting this systematic review, we hope to highlight that much of the focus in total ankle arthroplasty has emphasized implants and relatively little has focused on the quality of bone into which the prostheses are implanted.

Structures at Risk During Percutaneous Extra-Articular Chevron Osteotomy of the Distal First Metatarsal.

Background. Minimally invasive surgery of the forefoot has regained popularity as an alternative to traditional open procedures. Minimally invasive hallux valgus surgery has been shown to be effective and reproducible for the treatment of mild to moderate hallux valgus. The aim of this study is to identify vital structures that are at risk for iatrogenic damage while performing a minimally invasive distal chevron osteotomy due to limited direct visualization. Methods. Ten fresh-frozen below knee cadavers were used for this study. A minimally invasive distal chevron osteotomy and medial eminence resection with a 2.2 mm × 22 mm Shannon burr was performed on each cadaver. Each specimen was dissected to expose the potential structures at risk for injury during the procedure. Structures evaluated included the medial neurovascular bundle, first metatarsophalangeal joint capsule, extensor hallucis longus tendon, flexor hallucis longus tendon, abductor hallucis tendon, and the sesamoid apparatus. Results. Ten specimens were evaluated. The dorsal medial cutaneous nerve was directly injured in 5 of the 10 cadaver specimens and intact/uninjured in the remaining 5 specimens. The flexor hallucis longus, extensor hallucis longus, adductor tendon, sesamoid apparatus, and first metatarsophalangeal joint capsule were uninjured in all specimens. Conclusion. Minimally invasive chevron distal osteotomy and medial eminence resection has a high learning curve. The resection of the medial eminence may iatrogenically injure the dorsal medial cutaneous nerve. The incidence is higher in this study than prior reported cadaveric studies and may warrant extra care to protect vital structures.Level of Evidence: Level IV: Cadaver study.

Risk Factors for Early Failure of Fourth Generation Total Ankle Arthroplasty Prostheses.

A number of 2-component, fourth generation total ankle arthroplasty (TAA) prostheses have been introduced to the market in the past few years, as the popularity and indications for TAA have continued to expand. The purpose of the present study was to identify independent risk factors for the early failure of fourth generation TAA prostheses. A total of 97 ankles underwent TAA with a fourth generation prostheses (INFINITY, CADENCE) between August 2015 and June 2018 at a single institution and were at least 6 months postoperative (mean 18.3 months, range 6-43). The primary outcome assessed was the need for revision surgery, defined as removal of 1 or both metal components for any reason, excluding infection. Baseline patient demographics, characteristics, radiographic alignment parameters, and distal tibia cortical bone thickness (CBT) were assessed. Revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook et al, respectively. Univariate and multivariate analyses were performed. Three ankles (3.1%) underwent revision surgery for aseptic loosening at a mean of 24.3 (range, 16-31) months; all had a CBT <4 mm. Independent predictors for reoperation were CBT <4 mm, presence of diabetes, and ipsilateral hindfoot fusion (p = .04). No associations were identified for purported risk factors (age, body mass index, and coronal deformity). The present study is the first to suggest a potential relationship between reduced CBT of the distal tibia, and TAA failure. Additional studies are warranted to better understand the role of bone density in TAA survivorship.

Anterior Ankle Incision Wound Complications Between Total Ankle Replacement and Ankle Arthrodesis: A Matched Cohort Study.

The anterior incision is commonly used for total ankle replacement (TAR) and ankle arthrodesis. Historically, the anterior incision has demonstrated a high incidence of complications. The purpose of this study was to evaluate anterior incisional healing and soft tissue complications between TAR and ankle arthrodesis with anterior plate fixation.This was an IRB-approved retrospective review of wound healing and other complications among 304 patients who underwent primary TAR (191 patients) or ankle arthrodesis (113 patients) via the anterior approach over a 4-year period. The operative approach, intraoperative soft tissue handling, and postoperative protocol for the first 30 days were the same between groups. The mean follow-up was 11.8 months. To diminish the effect of selection bias, a subgroup analysis was performed comparing 91 TAR patients matched to an equal number of demographically similar ankle arthrodesis patients. Overall, 19.7% of patients experienced delayed wound healing greater than 30 days. Although the TAR and arthrodesis subgroups had dissimilar demographics, there was no difference in outcomes. Between matched pairs, no statistically significant differences were observed; however, trends were identified with matched cohort groups when compared to the overall patient series. These trends toward statistically significant differences in delayed wound healing and incidence of wound care in the matched cohort groups warrants further investigation in larger series or multicenter study. Further work is needed to identify the modifiable risk factors associated with the anterior ankle incision.

Association Between Bone Mineral Density and Elderly Ankle Fractures: A Systematic Review and Meta-Analysis.

Ankle fractures are becoming increasingly more common in the elderly population and present a significant burden to the United States health care system. Many factors have been associated with fragility ankle fractures including age, gender, body mass index, diabetes, tobacco use, and osteoporosis. However, the literature is inconsistent regarding the relationship between ankle fractures and osteoporosis. The primary aim of this meta-analysis was to quantify the relationship between bone mineral density (BMD) in elderly patients with ankle fractures compared with BMD in elderly patients without ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Data were combined using standard meta-analysis methods. Seven studies were used in the final analysis. A small-pooled effect size was found indicating the control group had increased BMD regardless of measurement used (95% confidence interval 0.09-0.58; I2 = 98.39%). Lower femoral neck BMD showed a small-pooled effect size (femoral neck 0.36; 95% confidence interval 0.00-0.73; I2 = 94.91%) with the ankle fracture cohort. This is the first meta-analysis to quantify the relationship between BMD and ankle fractures in the elderly population. Elderly ankle fractures showed a significant association with femoral neck BMD. The current data can be used in orthopedic clinics and Fracture Liaison Service programs to assign the appropriate subgroup of ankle fracture patients to investigative and treatment groups, assess fracture risk, and serve as an indication for secondary fracture prevention by stimulating an osteoporosis prevention workup. There may be a role for a team approach to fracture care including metabolic optimization.

Surgical Treatment of Subtalar Joint Instability: Safety and Accuracy of a New Technique in a Cadaver Model.

New surgical strategies to treat symptomatic subtalar joint (STJ) instability are evolving. We modified a previously described reconstruction strategy and then refined our new surgical technique through simulated surgery and subsequent cadaver dissections. Our purpose was to show that a tunnel intended to facilitate STJ stabilization surgery could safely be drilled across the footprints of the interosseous talocalcaneal ligament (ITCL). A percutaneous fluoroscopically guided tunnel for the purpose of ITCL reconstruction was created in 10 cadaveric below-knee specimens. Accuracy of the tunnel with relation to the anatomic boundaries of the ITCL attachment sites as well as damage to relevant structures at risk were recorded. Two sets of 5 surgeries were performed to assess for improvement in technique. Mean distances from the tunnel to the ITCL on the calcaneus improved between groups 1 and 2: 4.04 and 1.80 mm, respectively (p = .04). Mean distances from the tunnel to the ITCL on the talus improved between groups 1 and 2: 6.2 and 1.8 mm, respectively (p = .08). With information obtained from this study, an osseous tunnel can be safely placed within 2 mm of the ITCL footprints.

Outcomes of the Extended Z-Cut Osteotomy for Correction of Adult Acquired Flatfoot Deformity.

BACKGROUND: Medial displacement calcaneus tuberosity osteotomy and anterior process lengthening calcaneus osteotomy are traditional single-plane osteotomy techniques used in adult acquired flatfoot deformity reconstruction. More recently, 3-plane step-cut osteotomies were described for each of these and shown to offer improved rotational stability via the horizontal limb. However, a major technical challenge is achieving a sufficiently long horizontal limb to correct deformity through lengthening without losing bony apposition. Combining the anterior process and tuberosity step-cuts using an elongated horizontal limb alleviates this technical challenge, creates a very large surface area for bony healing, and utilizes a single incision. We hypothesized that the Z-cut osteotomy would achieve clinical and radiographic flatfoot deformity correction with a high union rate. METHODS: This was an institutional review board-approved retrospective study of 16 patients who underwent Z-cut osteotomy for the treatment of moderate to severe symptomatic adult acquired flatfoot deformity, stage IIA/B. The mean radiographic follow-up was 8.8 months, while the mean clinical follow-up was 2.36 years. Radiographic correction was assessed via weightbearing radiographs taken preoperatively and at a mean of 26 ± 2 weeks postoperatively. Measurements included Meary's angle (talo-first metatarsal angle), talonavicular (TN) joint uncoverage percentage, TN incongruency angle, medial cuneiform to fifth metatarsal height, and calcaneal pitch. Union rates and clinical outcomes via the Foot Function Index (FFI) score were assessed preoperatively and at a mean of 29 months following surgery. Paired t test was used to compare both clinical and radiographic outcomes with statistical significance set at P < .05. RESULTS: Fifteen of 16 patients returned an FFI questionnaire with a mean improvement of 52.1 to 10.3 (P = .002). The calcaneal pitch improved from 12.7 to 15.2 degrees (P = .002), the medial cuneiform-fifth metatarsal distance improved from 12.8 to 18.5 mm (P = .002), the TN coverage angle improved from 21.3 to 9.1 degrees (P < .001), the TN uncoverage percentage improved from 32.9% to 20.3% (P < .001), and the TN incongruency angle improved from 41.4 to 19.9 degrees (P < .001). Deformity correction was well maintained in 13 of 16 patients at final follow-up. The union rate of the osteotomy was 100%. Three patients had symptomatic hardware initially; 1 patient required removal of hardware. One patient developed a superficial infection that cleared. Another patient developed peroneal tendonitis, which resolved with corticosteroid injection. CONCLUSION: The Z-cut osteotomy is a novel, technically simplified, single-incision, single-osteotomy alternative to the previously described double calcaneus osteotomy techniques for reconstructing flexible moderate to severe adult acquired flatfoot deformity that offers comparable short-term clinical and radiographic outcomes with acceptably low complications. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Medial Structure Injury During Suture Button Insertion Using the Center-Center Technique for Syndesmotic Stabilization.

BACKGROUND: The center-center technique for syndesmosis fixation has been described as an improved and reliable technique for proper reduction of the syndesmosis during ankle fracture repair. Concurrently, the use of flexible fixation with a suture button is becoming an established means of syndesmosis stabilization. The purpose of this cadaveric study was to assess for medial structure injury during the placement of a suture button using the center-center technique for ankle syndesmosis repair at 3 insertion intervals. METHODS: Simulated open syndesmosis repair was performed on 10 cadaveric specimens. Three intervals were measured at 10 mm, 20 mm, and 30 mm proximal to the level of the distal tibial articular surface along the fibula. Proper longitudinal alignment of the center-center technique was completed under fluoroscopic guidance and was marked on the medial aspect of the tibia. The 3 intervals were drilled in the appropriate technique trajectory. The suture button was subsequently passed through each drill-hole interval. A single observer used a digital caliper to measure the distance from each suture button aperture with respect to the tibialis anterior tendon, tibialis posterior tendon, and greater saphenous vein and nerve. RESULTS: A total of 30 interval measurements (10 cadavers with 3 suture button segments each) were used for data analysis. Direct impingement on the greater saphenous vein was seen in 11 of 30 (36.6%) interval measurements. Six of the 11 (54.5%) observed saphenous structure impingement events occurred at the 10-mm drill hole. CONCLUSION: The results of the present study suggest that the use of the center-center technique for syndesmosis repair with suture button fixation risks preventable injury to the greater saphenous neurovasculature. CLINICAL RELEVANCE: To understand the medial ankle anatomy, as it pertains to insertion of flexible syndesmotic fixation in a cadaveric model, to aid in prevention of clinical iatrogenic injury.