Outcomes following total ankle total talus replacement: A systematic review.

BACKGROUND: Prosthetic substitution of the talus presents a significant challenge to the foot and ankle surgeon. The shear and compressive forces on the talus and its tenuous blood supply lead to high rates of avascular necrosis and eventual talar collapse. The purpose of this systematic review is to evaluate whether total ankle total talus replacement (TATTR) leads to improved clinical and radiographic outcomes with appropriate safety metrics in patients with a history of avascular necrosis or significant trauma. METHODS: We searched the concepts of talus, prosthesis, and arthroplasty in MEDLINE (PubMed), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Scopus (Elsevier) from the database's inception through March 9, 2023. Inclusion Criteria were 1) previous trauma to the talus, 2) post-traumatic arthritis to the tibiotalar joint, 3) avascular necrosis of talus, 4) multiple failed prior interventions, 5) degenerative osteoarthritis to the tibiotalar joint, and 6) inflammatory arthropathy to tibiotalar joint. Patients less than 18 years of age and manuscripts in non-English languages were excluded. RESULTS: Of the 7625 references, 16 studies met the inclusion criteria, yielding data from 136 patients (139 ankles). The studies varied in design, with case reports and retrospective case series being predominant. The overall weighted average modified Coleman Methodology Score (mCMS) was 70.4 out of 100, indicating moderate flaws in study design that may be subject to various forms of bias and possible confounders. Demographics showed a diverse range of etiologies, with alumina ceramic being the primary prosthesis material. Functional scores demonstrated improvements in dorsiflexion and plantarflexion, although patient-reported outcome measures (PROs) were inconsistently reported. Complications included fractures, heterotopic ossification, prolonged wound healing, and infections. Revision details were sparsely reported. CONCLUSION: TATTR is a promising treatment modality for improving short-term functional outcomes for patients with avascular necrosis or trauma-related issues. However, this systematic review underscores the need for standardized reporting, longer-term follow-ups, and further research to establish the procedure's efficacy and safety, particularly in comparison to other treatment modalities. LEVEL OF EVIDENCE: III, Systematic Review of Level IV Studies.

Outcomes after total ankle arthroplasty with an average follow-up of 10 years: A systematic review and meta-analysis.

BACKGROUND: The literature demonstrating positive outcomes after total ankle arthroplasty (TAA) is mounting. However, the long-term outcomes of TAA (≥ 10 years) remain minimally reported. The purpose of this systematic review and meta-analysis was to evaluate outcome metrics over multiple TAA studies with greater than 10 years of average follow-up. METHODS: TAA studies were searched in Medline, Embase, and Scopus from the date of inception to September 12, 2022. Inclusion criteria included 1) studies of patients that underwent uncemented TAA, and 2) studies with an average follow-up time of at least ten years. Manuscripts in non-English languages and isolated abstracts were excluded. We collected American Orthopaedic Foot and Ankle Score (AOFAS) and Visual Analog Scale (VAS) scores from the included studies for pooled meta-analysis. Due to the varying definition of survivability between studies, this metric was not assessed in our final evaluation. RESULTS: Our data included approximately 3651 patients (3782 ankles). Of the 25 studies with an average follow-up of 10 years included in the systematic review, 5 provided pre- and post-operative AOFAS means and 5 provided pre- and post-operative VAS means with associated measures of variability and were included in our meta-analysis. The weighted mean difference between pre-and post-operative AOFAS and VAS scores was -40.36 (95% CI -47.24 to -33.47) and 4.52 (95% CI: 2.26-6.43), respectively. The risk of bias was low to moderate for the included studies. CONCLUSION: Outcomes following TAA are favorable and indicate patient-reported outcome improvement over long-term follow-up. However, a significant amount of heterogeneity exists between studies. Future, prospective, randomized research should focus on standardizing outcome measures, survivorship, and complication reporting methodologies to allow for pooled meta-analyses of these important outcome metrics.

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.

An examination of negative one-star patient reviews for foot and ankle orthopedic surgery: A retrospective analysis.

BACKGROUND: Despite the questionable validity of online-based physician review websites (PRWs), negative reviews can adversely affect a provider's practice. Several investigations have explored the effect of extremely negative "one-star" reviews across subspecialties such as adult reconstruction, sports medicine, and orthopaedic traumatology; however, to date, no study has explored one-star reviews in foot and ankle surgery. The goal of this study was to characterize factors that contribute to extremely negative, one-star reviews for foot and ankle surgeons on Vitals.com. METHODS: A retrospective analysis of negative one-star reviews with corresponding patient complaints for foot and ankle surgeons (both orthopaedic surgeons as well as podiatrists) in the United States. Physicians included were selected within a 10-mile radius of the top ten largest cities in the United States. Data was stratified by patient type (e.g., those receiving surgery and those not undergoing surgical intervention) and binned according to type of patient complaint, as previously described. RESULTS: Of the 2645 foot and ankle surgeons identified in our initial query, 13.8% of surgeons contained one-star reviews eligible for analysis. Patient complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly 50% of the complaints related to surgical patients. CONCLUSION: In conclusion, complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly half of the complaints related to surgery. This data serves to inform practicing foot and ankle surgeons as to the influences behind patients leaving extremely negative reviews on PRWs. LEVEL OF CLINICAL EVIDENCE: IV.

Robotic Technology in Foot and Ankle Surgery: A Comprehensive Review.

Recent developments in robotic technologies in the field of orthopaedic surgery have largely been focused on higher volume arthroplasty procedures, with a paucity of attention paid to robotic potential for foot and ankle surgery. The aim of this paper is to summarize past and present developments foot and ankle robotics and describe outcomes associated with these interventions, with specific emphasis on the following topics: translational and preclinical utilization of robotics, deep learning and artificial intelligence modeling in foot and ankle, current applications for robotics in foot and ankle surgery, and therapeutic and orthotic-related utilizations of robotics related to the foot and ankle. Herein, we describe numerous recent robotic advancements across foot and ankle surgery, geared towards optimizing intra-operative performance, improving detection of foot and ankle pathology, understanding ankle kinematics, and rehabilitating post-surgically. Future research should work to incorporate robotics specifically into surgical procedures as other specialties within orthopaedics have done, and to further individualize machinery to patients, with the ultimate goal to improve perioperative and post-operative outcomes.

The Impact of Time and State Opioid Legislation on Opioid Prescription Filling in Total Ankle Arthroplasty.

Total ankle arthroplasty (TAA) is an increasingly utilized treatment for ankle arthritis, and opioids are commonly used as part of perioperative pain control. However, many states have enacted opioid-limiting legislation to reduce perioperative opioid prescribing. The aim of this study was to evaluate the impact of time and state legislation on perioperative opioid prescribing in TAA. This study is a retrospective, observational review of 90-day perioperative opioid prescribing in 1,829 patients undergoing TAA throughout the United States using a large insurance database. Initial and cumulative volumes and rates of opioid prescription filling were recorded along with baseline patient and operative characteristics. Dates of state legislation enactment were also recorded. Student t-tests, analysis of variance, and multivariable linear and logistic regression were utilized to analyze the impact of time and state legislation on opioid prescription filling. In the 90-day perioperative time period, initial and cumulative opioid prescription filling in oxycodone 5-mg equivalents has decreased significantly from 2010 (63.8 initial and 163.3 cumulative) to 2019 (41.1 initial and 67.2 cumulative). States with opioid-limiting legislation saw larger and more significant reductions in initial and cumulative opioid prescription filling preact to postact (63.3-50.6 with legislation vs 61.4-51.9 without legislation initial and 146.4-93.3 with legislation vs 125.1-108.6 without legislation cumulative). This study demonstrates that foot and ankle surgeons in states with opioid-limiting legislation have responded by significantly reducing 90-day perioperative opioid prescribing in TAA. These results encourage states without legislation to enact opioid-specific laws to reduce opioid prescribing.

The use of platelet-rich plasma in pathologies of the foot and ankle: A comprehensive review of the recent literature.

Platelet-rich plasma (PRP) is an autologous serum containing higher concentrations of platelets and growth factors above normal blood. The process of obtaining PRP involves the extraction of blood from the patient which is then centrifuged to obtain a concentrated suspension of platelets. PRP continues to evolve as a potential treatment modality with many applications in orthopaedic surgery. The therapeutic components of PRP possess numerous theoretical regenerative properties. The present manuscript outlines how PRP is prepared, noting the tremendous variability between preparation protocols. Given the growing body of evidence examining the use of PRP in pathologies of the foot and ankle, we assess its efficacy as it relates to our field. Specifically, we evaluate the literature in the past five years regarding the role of PRP in treating plantar fasciitis, Achilles tendinopathy, insertional Achilles tendinitis, Achilles tendon ruptures, osteochondral lesions of the talus, hallux rigidus, and ankle osteoarthritis.

Analyzing the quality and educational value of Achilles tendinopathy-related videos on TikTok.

BACKGROUND: Social media platforms, like TikTok, have become popular options for the consumption and distribution of healthcare information. Due to the lack of scientific oversight, the consistency of healthcare-related videos has become a focus of the current literature. However, orthopaedic surgery has lagged behind other specialties in acknowledging the widespread utilization of TikTok videos for medical information. This study aims to assess the quality and educational benefits of Achilles tendinopathy-related TikTok videos. METHODS: TikTok was queried using the hashtags "#achillestendonexercises", "achillestendonitisexercises", "achillestendinosisexercises", and "achillestendinopathyexercises". 100 videos (25 for each term) were included after applying the exclusion criteria. The number of views, likes, shares, comments, and favorites was recorded. The content was graded using DISCERN (a well-validated informational analysis tool) and ATEES (a self-designed tool for exercise evaluation). RESULTS: The total number of views of the 100 videos was 1647,148, with a median of 7562.5 (IQR = 2,281- 19,575). The videos collectively received 73,765 likes, 1125 comments, 14,491 favorites and 6897 shares with a median of 283 (IQR= 73.8-957.8), 7 (IQR= 1.8-16.0), 61.5 (IQR= 8.8-184.3), and 18.5 (IQR= 2.0-49.8), respectively. General users uploaded slightly less (48%) when compared to healthcare professionals (52%). Healthcare professionals had more videos graded as "very poor" (43.4%) in comparison to the general users (36.2%). General users had more videos graded as "poor" (63.8%) in comparison to healthcare professionals (54.7%). However, there were no significant differences between the groups on either of the video grading scales. CONCLUSION: Although TikTok is a powerful tool for information distribution, the educational value of the videos related to Achilles tendinopathy exercises was poor. With only 1% of videos receiving a grade of 'fair,' and no videos reaching a score of 'good' or 'excellent', healthcare professionals should be aware of the high viewership of low-quality content easily accessible on TikTok.

Chronic Achilles Tendon Ruptures: From Bracing Treatment to Complex Reconstruction.

The optimal management of chronic Achilles tendon injuries continues to be debated. The tension-length relationship and intrinsic viscoelasticity of the native tendon that allows efficient propulsion during ambulation are difficult to restore once the tendon has been injured. Missed or misdiagnosed injuries or failure of surgical or nonsurgical management of acute Achilles tendon ruptures can lead to the tendon healing in an elongated position or lack of healing altogether. This condition results in persistent weakness, pain, and functional debilitation for the patient. Understanding the tendon and muscle properties will inform the choice of treatment. Nonsurgical treatment options are primarily bracing treatment and physical therapy. Surgical treatment options involve direct repair, reconstruction with local tissue, allograft or autograft, and tendon transfer. Various options and techniques for reconstruction are described to assist in optimizing management of this challenging clinical problem.

Outcomes following total talus replacement: A systematic review.

INTRODUCTION: The treatment of pathologic changes to the talus and surrounding joints presents a unique challenge to the foot and ankle surgeon. The purpose of this systematic review is to summarize the literature for unconstrained (no surrounding fusion or replacement) total talus replacement (TTR) and evaluate whether it leads to improved clinical and radiographic outcomes and appropriate safety metrics. METHODS: Concepts of talus and arthroplasty were searched in MEDLINE, Embase, CINAHL Complete, and Scopus from 2005 to 2021. Inclusion Criteria were 1) previous trauma to the talus, 2) post-traumatic or degenerative arthritis to the tibiotalar joint, 3) avascular necrosis of talus, 4) multiple failed prior interventions, and 5) inflammatory arthropathy to tibiotalar joint. Manuscripts in non-English languages or those with concomitant total ankle arthroplasty or revision arthroplasty were excluded. RESULTS: Twenty-two studies of 191 patients (196 ankles) were included. Nineteen studies utilized third generation implants, two studies used first generation (n = 9) and one study used second generation implants (n = 14) made largely of ceramic (n = 84), cobalt chrome (n = 49), or titanium (n = 24). Patient-reported outcome measures were favorable in all described categories (Table 4) with ten studies reporting an average postoperative change of + 2.92° of dorsiflexion and - 2.05° plantarflexion at final follow-up. The most common adverse outcome was adjacent joint arthritis with five studies reporting some degree of postoperative, degenerative changes in the surrounding joints (n = 52). CONCLUSION: TTR is an alternative to joint sacrificing procedures to maintain range of motion through the tibiotalar joint and allow for maintenance of normal foot and ankle biomechanics. Despite promising early- and mid-term outcomes, future, prospective, randomized research should be conducted to better assess survivorship and complication rates with direct comparison of TTR to existing forms of salvage options for advanced talar pathology. LEVEL OF EVIDENCE: III, Systematic Review of Level IV Studies.

Histologic grading correlates with inflammatory biomarkers in tibialis posterior tendon dysfunction.

BACKGROUND: It has been theorized that tibialis posterior tendon dysfunction (TPTD) is a degenerative process unrelated to inflammation. The purpose of this study was to determine if inflammatory cytokines, matrix metalloproteases (MMPs), and glutamate were elevated in diseased tibialis posterior tendons (TPTs). METHODS: Matched diseased TPT, TPT insertion, and flexor digitorum longus (FDL) samples were collected from 21 patients. The samples were individually incubated in media, which was analyzed for inflammatory cytokines, MMPs, and glutamate. Histology and statistical analyses were performed. RESULTS: Diseased TPT and TPT insertion were significantly elevated compared to transferred FDL in eight inflammatory markers (p < 0.005). Only the diseased TPT was significantly elevated compared to the transferred FDL tendons for glutamate (p < 0.01). Histologic grading correlated with inflammatory cytokine levels. CONCLUSION: Diseased TPT and TPT insertion demonstrated significantly elevated levels of inflammatory markers compared to the transferred tendons used as controls, suggesting a role for inflammation in the disease process. The amount of inflammation correlated with increased tendon degradation. LEVEL OF EVIDENCE: Level III.

Increasing age and modifiable comorbidities are associated with short-term complications after open reduction and internal fixation of ankle fractures.

BACKGROUND: Ankle fractures are common orthopedic injuries with complication rates fixation of up to 40%. Limited evidence exists in the literature regarding complications in the elderly population, and moreover, these studies frequently define elderly arbitrarily at 60-65 years old. The purpose of the present study was to utilize a large, validated database to evaluate whether there is an inflection point of age when postoperative complications after an ankle fracture significantly increase. METHODS: A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent fixation of an ankle fracture between 2012 and 2018 was performed. Patients were identified within the database using the Current Procedural Terminology codes. Appropriate statistical analysis was performed with p value less than 0.05 considered statistically significant. RESULTS: A total of 27,633 fractures were including and comprised of 221 posterior malleolar, 1567 medial malleolar, 8495 lateral malleolar, 10,175 bimalleolar, and 7175 trimalleolar. A total of 1545 complications were encountered (5.6%). There was a statistically significant association between increasing age and complications (OR = 1.03; p < 0.001). Further analysis shows the largest spike in complications within the age 78 + bracket. There were no overall interaction effects between age and fracture subtype (p = 0.223). CONCLUSION: ORIF of ankle fractures is a common orthopedic procedure performed on patients of all ages, with complications ranging in severity. In order to best counsel patients on their individual postoperative risks, large datasets are often necessary to prognosticate. This study found that postoperative complications increase with advanced age. The incidence of complications did not spike for patients around the age of 65, but rather followed an incremental linear pattern with the largest increase in odds ratio occurring at age 78 and above. Complication rate was not associated with specific fracture type based off of ICD codes.

Fresh Osteochondral Allograft Transplantation for Osteochondral Lesions of the Talus: A Systematic Review.

Osteochondral lesions of the talus (OLTs) are difficult to treat. Despite a multitude of interventions, there are no generally-agreed-upon guidelines regarding treatment. The objective of this study was to conduct a systematic review of clinical outcomes after fresh osteochondral allografts transplantation of the talus. PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, and Medline were searched using PRISMA guidelines. Studies that evaluated outcomes after fresh osteochondral allograft transplantation for OLTs were included. Clinical outcomes, according to standardized scoring systems, such as the American Orthopaedics Foot & Ankle Society (AOFAS) Ankle/Hindfoot Scale and the Visual Analog Scale (VAS) were compared across studies. The literature search yielded 12 eligible studies with a mean Coleman Methodology Score of 68.1 (57-79). A total of 191 patients were included with an average age of 37.5 (17-74) years and average follow-up of 56.8 (6-240) months. The AOFAS Ankle/Hindfoot score was obtained pre- and postoperatively in 6 of the studies and had significant improvements in each (p < .05). Similarly, the VAS pain score was evaluated in 5 studies and showed significant decreases from pre- to postoperatively (p < .05). While there were no reported short-term complications, 21.6% of patients required minor subsequent procedures, most commonly arthroscopic debridement and hardware removal. The aggregate graft survival rate was 86.6%. Based on these findings, osteochondral allograft transplantation for OLTs results in positive outcomes with high rates of graft survival and patient satisfaction at intermediate follow-up.

Adverse events involving hallux metatarsophalangeal joint implants: Analysis of the United States Food and Drug Administration data from 2010 to 2018.

BACKGROUND: The prevalence of osteoarthritis of the hallux metatarsophalangeal joint (MTPJ) is 1 in 40 people over the age of 50. Surgical treatment options for MTPJ arthritis include joint preservation, joint resurfacing, and arthrodesis. Hallux MTPJ implants have evolved over the past several decades, but are associated with various complications. The aim of this study was to examine the MAUDE database to determine reported adverse events for hallux MTPJ implants. MATERIALS AND METHODS: The US Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2010 to 2018 to review voluntary reported adverse event reports for approved implants within the United States. We recorded the type of adverse event and excluded duplicate reports and those extracted from already published literature. RESULTS: Among 64 reported hallux MTPJ implant adverse events, the most common modes of adverse events were component loosening (34%), infection (14.1%), component fracture (9.4%), inflammation (9.4%), and allergic reaction (7.8%). Regarding implant type, Cartiva SCI had the highest percentage of adverse events (23.4%), followed by Arthrosurface ToeMotion (20.3%), Ascension MGT (12.5%), Arthrosurface HemiCAP® (10.9%), Futura primus (9.4%), and Osteomed Reflexion (6.3%). There was an increase in reported adverse events after 2016. The MAUDE database does not report the total incidence of implant insertion. CONCLUSION: Our study of the MAUDE database demonstrated that component loosening and infection are the most common modes of adverse events for hallux MTPJ implants. Cartiva accounted for one-fourth of the implant-related adverse events during our study period, followed by ToeMotion, and Ascension MGT implants. Continued reporting of adverse events will improve our understanding on short and long-term complications of various hallux MTPJ implants. LEVEL OF EVIDENCE: Level IV; Case Series from Large Database Analysis; Treatment Study.

Total ankle arthroplasty and ankle arthrodesis in rheumatic disease patients: An analysis of outcomes and complications using the National Inpatient Sample (NIS) database.

INTRODUCTION: Rheumatoid arthritis (RA), can manifest as an inflammatory arthropathy in the ankle. As a result, this study sought to examine the role of RA with respect to complications in patients undergoing either total ankle arthroplasty or ankle arthrodesis by utilizing the National Inpatient Sample to assess for correlations. METHODS: Admissions for TAA and AA were extracted from the National Inpatient Sample using primary ICD-9-CM diagnosis codes. Patients aged 18-65 years with a duration of hospital stay of >3 days and isolated complications were included. Multivariable regression was then performed within matched groups to determine differences. RESULTS: There was decreased risk of myocardial infarction, pulmonary embolism, surgical site infection, and urinary tract infection in patients with RA. Postoperative development of pneumonia was seen at a higher rate in patients with RA. CONCLUSION: RA is not associated with a markedly increased complication burden in the appropriately chosen surgical candidate for ankle arthrodesis and ankle arthroplasty.

Inflammatory cytokines and matrix metalloproteinases in the synovial fluid after intra-articular elbow fracture.

BACKGROUND AND HYPOTHESIS: Post-traumatic elbow contracture remains a common and challenging complication with often unsatisfactory outcomes. Although the etiology is unknown, elevated or abnormal post-fracture synovial fluid cytokine levels may result in the migration of fibroblasts to the capsule and contribute to capsular pathology. Thus, the purpose of this study was to characterize the cytokine composition in the synovial fluid fracture hematoma of patients with intra-articular elbow fractures. METHODS: The elbow synovial fluid fracture hematoma of 11 patients with intra-articular elbow fractures was analyzed for CTXII (C-terminal telopeptides of type II collagen [a cartilage breakdown product]) as well as 15 cytokines and matrix metalloproteinases (MMPs) including interferon γ, interleukin (IL) 1ß, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, tumor necrosis factor α, MMP-1, MMP-2, MMP-3, MMP-9, and MMP-10. The uninjured, contralateral elbow served as a matched control. Mean concentrations of each factor were compared between the fluid from fractured elbows and the fluid from control elbows. RESULTS: The levels of 14 of 15 measured cytokines and MMPs-interferon γ, IL-1ß, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, tumor necrosis factor α, MMP-1, MMP-3, MMP-9, and MMP-10-were significantly higher in the fractured elbows. In addition, post hoc power analysis revealed that 10 of 14 significant differences were detected with greater than 90% power. The mean concentration of CTXII was not significantly different between groups. CONCLUSIONS: These results demonstrate a proinflammatory environment after fracture that may be the catalyst to the development of post-traumatic elbow joint contracture. The cytokines with elevated levels were similar, although not identical, to the cytokines with elevated levels in studies of other weight-bearing joints, indicating the elbow responds uniquely to trauma.

Total Ankle Total Talus Replacement Using a 3D Printed Talus Component: A Case Report.

The 3D custom total talus replacement is a novel treatment for avascular necrosis of the talus. However, patients who require a total talus replacement often have concomitant degenerative changes to the tibiotalar, subtalar, or talonavicular joints. The combined 3D custom total ankle-total talus replacement (TATTR) is used for patients with an unreconstructable talus and adjacent tibial plafond involvement. The goal of performing a TATTR is to provide pain relief, retain motion at the tibiotalar joint, maintain or improve the patient's functional status, and minimize limb shortening. TATTR is made possible by 3D printing. The advent of 3D printing has allowed for the accurate recreation of the native talar anatomy with a talar dome that can be matched to a total ankle replacement polyethylene bearing. In this article, we will discuss a case of talar avascular necrosis treated with a combined TATTR and review the current literature for TATTR.

Comparison of 3D Printed Spherical Implants versus Femoral Head Allografts for Tibiotalocalcaneal Arthrodesis.

Successful tibiotalocalcaneal (TTC) arthrodesis can be difficult to achieve in patients with bulk bone defects even with the use of femoral head allograft. Retrograde intramedullary nail placement through custom 3-dimensional (3D) spherical implants is an innovative option for these patients. The purpose of this study was to compare fusion rates, graft resorption, and complication rates between patients undergoing TTC fusion with 3D sphere implants versus femoral head allografts. Patients who underwent TTC arthrodesis with an intramedullary nail along with a 3D spherical implant (n = 8) or femoral head allograft (n = 7) were included in this study. The rate of successful fusion of the tibia, calcaneus, and talar neck to the 3D sphere or femoral head allograft was compared between the groups. The rate of total fused articulations was significantly higher in the 3D sphere group (92%) than the femoral head allograft group (62%; p = .018). The number of patients achieving successful fusion of all 3 articulations was higher in the 3D sphere group (75%) than the femoral head allograft group (42.9%, p = .22). The rate of graft resorption was significantly higher in the femoral head allograft group (57.1%) than the 3D sphere group (0%, p = .016). There were no significant differences between the groups in terms of complications. These data demonstrate that the use of a custom 3D printed sphere implant is safe in patients with severe bone loss undergoing TTC arthrodesis with a retrograde intramedullary nail and may result in improved rates of successful arthrodesis.

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).

Are There Differences in Gait Mechanics in Patients With A Fixed Versus Mobile Bearing Total Ankle Arthroplasty? A Randomized Trial.

BACKGROUND: Total ankle arthroplasty (TAA) is an alternative to arthrodesis, but no randomized trial has examined whether a fixed bearing or mobile bearing implant provides improved gait mechanics. QUESTIONS/PURPOSES: We wished to determine if fixed- or mobile-bearing TAA results in a larger improvement in pain scores and gait mechanics from before surgery to 1 year after surgery, and to quantify differences in outcomes using statistical analysis and report the standardized effect sizes for such comparisons. METHODS: Patients with end-stage ankle arthritis who were scheduled for TAA between November 2011 and June 2013 (n = 40; 16 men, 24 women; average age, 63 years; age range, 35-81 years) were prospectively recruited for this study from a single foot and ankle orthopaedic clinic. During this period, 185 patients underwent TAA, with 144 being eligible to participate in this study. Patients were eligible to participate if they were able to meet all study inclusion criteria, which were: no previous diagnosis of rheumatoid arthritis, a contralateral TAA, bilateral ankle arthritis, previous revision TAA, an ankle fusion revision, or able to walk without the use of an assistive device, weight less than 250 pounds (114 kg), a sagittal or coronal plane deformity less than 15°, no presence of avascular necrosis of the distal tibia, no current neuropathy, age older than 35 years, no history of a talar neck fracture, or an avascular talus. Of the 144 eligible patients, 40 consented to participate in our randomized trial. These 40 patients were randomly assigned to either the fixed (n = 20) or mobile bearing implant group (n = 20). Walking speed, bilateral peak dorsiflexion angle, peak plantar flexion angle, sagittal plane ankle ROM, peak ankle inversion angle, peak plantar flexion moment, peak plantar flexion power during stance, peak weight acceptance, and propulsive vertical ground reaction force were analyzed during seven self-selected speed level walking trials for 33 participants using an eight-camera motion analysis system and four force plates. Seven patients were not included in the analysis owing to cancelled surgery (one from each group) and five were lost to followup (four with fixed bearing and one with mobile bearing implants). A series of effect-size calculations and two-sample t-tests comparing postoperative and preoperative increases in outcome variables between implant types were used to determine the differences in the magnitude of improvement between the two patient cohorts from before surgery to 1 year after surgery. The sample size in this study enabled us to detect a standardized shift of 1.01 SDs between group means with 80% power and a type I error rate of 5% for all outcome variables in the study. RESULTS: This randomized trial did not reveal any differences in outcomes between the two implant types under study at the sample size collected. In addition to these results, effect size analysis suggests that changes in outcome differ between implant types by less than 1 SD. Detection of the largest change score or observed effect (propulsive vertical ground reaction force [Fixed: 0.1 ± 0.1; 0.0-1.0; Mobile: 0.0 ± 0.1; 0.0-0.0; p = 0.0.051]) in this study would require a future trial to enroll 66 patients. However, the smallest change score or observed effect (walking speed [Fixed: 0.2 ± 0.3; 0.1-0.4; Mobile: 0.2 ± 0.3; 0.0-0.3; p = 0.742]) requires a sample size of 2336 to detect a significant difference with 80% power at the observed effect sizes. CONCLUSIONS: To our knowledge, this is the first randomized study to report the observed effect size comparing improvements in outcome measures between fixed and mobile bearing implant types. This study was statistically powered to detect large effects and descriptively analyze observed effect sizes. Based on our results there were no statistically or clinically meaningful differences between the fixed and mobile bearing implants when examining gait mechanics and pain 1 year after TAA. LEVEL OF EVIDENCE: Level II, therapeutic study.