A single-centre experience of 29 total ankle replacement in haemophiliac patients: Therapeutic management, factor consumption and cost.

INTRODUCTION: In patients with haemophilia, repeated bleeding in large joints leads to chronic haemophilic arthropathy, a rare disease that can be managed surgically with ankle arthrodesis or with total ankle replacement (TAR). TAR has been reported to provide good surgical results in the medium/long-term and allow preservation of joint mobility but the medical therapeutic management of the patients has not been described. AIM: To describe the medical therapeutic management of TAR. METHODS: All patients with haemophilia A/B, with haemophilic ankle arthropathy, and who underwent TAR between April 2006 and October 2019 were retrospectively included. Factor consumption, perioperative and early complications, volume of blood lost, and orthopaedic data were collected. RESULTS: A total of 25 patients underwent 29 TAR (mean age was 44.7 years [range: 26-65]). In the 17 patients with HA without history of anti-FVIII inhibitor, the mean ± SD consumption the day of surgery was 116 ± 16 UI/kg when clotting factors were administered by continuous infusion, 106 ± 13 UI/kg when SHL factors were administered by bolus infusion, and 75 ± 22 UI/kg when EHL factors were administered by bolus infusion. During hospitalisation, the mean factor cost was €38,073 (83.7% of the total cost of surgery). Mean blood loss was significantly lower in patients treated with tranexamic acid (164 mL, range: 40-300) than in those not (300 mL, range: 70-800; p = .01). Six patients had haematoma. The 10-year survival free of any prosthesis removal/arthrodesis was estimated to be 92.2% (95% CI [83; 100]). CONCLUSION: The medical therapeutic management of TAR is complex, carried out by a multidisciplinary team but effective in avoiding the occurrence of complications.

Current Trends in Total Ankle Replacement.

Ankle arthritis can result in significant pain and restriction in range of motion. Total ankle replacement (TAR) is a motion-preserving surgical option used as an alternative to total ankle arthrodesis to treat end-stage ankle arthritis. There are several generations of TAR techniques based on component design, implant material, and surgical technique. With more recent TAR implants, an attempt is made to minimize bone resection and mirror the native anatomy. There are more than 20 implant devices currently available. Implant survivorship varies among prosthesis types and generations, with improved outcomes reported with use of the more recent third- and fourth-generation ankle implants. Pre- and postoperative assessments of TAR are primarily performed by using weight-bearing radiography, with weight-bearing CT emerging as an additional imaging tool. Preoperative assessments include those of the tibiotalar angle, offset, and adjacent areas of arthritis requiring additional surgical procedures. US, nuclear medicine studies, and MRI can be used to troubleshoot complications. Effective radiologic assessment requires an understanding of the component design and corresponding normal perioperative imaging features of ankle implants, as well as recognition of common and device-specific complications. General complications seen at radiography include aseptic loosening, osteolysis, hardware subsidence, periprosthetic fracture, infection, gutter impingement, heterotopic ossification, and syndesmotic nonunion. The authors review several recent generations of TAR implants commonly used in the United States, normal pre- and postoperative imaging assessment, and imaging complications of TAR. Indications for advanced imaging of TAR are also reviewed. ©RSNA, 2023 Supplemental material is available for this article. Test Your Knowledge questions for this article are available through the Online Learning Center.

The Effect of Frontal Deformity at the Ankle Joint on Total Ankle Arthroplasty Revision Rate.

The presence of severe coronal plane deformity in the ankle joint is widely recognized as challenging to correct by total ankle joint arthroplasty alone, necessitating additional rearfoot fusion. The primary aim of this retrospective study was to investigate the potential associations between the presence or severity of coronal tibiotalar deformities and adverse outcomes after isolated total ankle arthroplasty, such as revisions and complications. The secondary aim was to analyze the potential associations between comorbidities, demographics, and implant types, and adverse outcomes. Our study's distinctive feature was its exclusive concentration on patients with deformities centralized in the ankle joint. Chart review was performed on 496 ankles in 456 patients who had a total ankle arthroplasty by 5 surgeons from 1/1/2010 to 12/31/2019. After exclusion and inclusion criteria were applied, total of 214 ankles in 210 patients were included for data analysis. At a mean follow-up period of 3 ± 2.0 years, our cohort had 15 (7.0%) revisions and 15 (7.0%) complications. Multivariable logistic regression model showed that the presence or severity of the coronal deformity was not significantly associated with incidences of revisions or complications. Female patients had significantly lower revision rate. Otherwise, the differences in age, race, body mass index, tobacco use, presence of diabetes, chronic kidney disease, atrial fibrillation, length of surgery, or type of implant were not significantly associated with incidences of revisions or complications. Further study could be performed to analyze the extent and duration that the coronal deformity correction is maintained after total ankle arthroplasty as well as the effect of each soft tissue procedure performed with the total ankle arthroplasty.

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.

Ankle arthrodesis or total ankle arthroplasty surgery for end stage ankle arthritis, which is best? A review of the best available evidence.

BACKGROUND: End Stage Ankle Arthritis (ESAA) causes pain and dysfunction. It is treated effectively with Total Ankle Arthroplasty (TAA) or Ankle Arthrodesis (AA). Currently there is no consensus on which surgical procedure is superior. This paper will provide a systematic review of all published high-quality studies directly comparing TAA and AA for the surgical treatment of ESAA to determine superiority. METHODS: A comprehensive literature review of the highest quality studies published that directly compare clinical outcomes of TAA and AA for surgical treatment of ESAA was conducted. Each study was assigned a Level of Evidence (LOE) rating (I-III) and then summarized to assign a grade of recommendation (A-C, I). Superiority was determined for the clinical outcomes of pain, activity, Health Related Quality of Life (HRQL), readmission to hospital, revision surgery and general complications. RESULTS: There is fair evidence (GOR B) that supports both TAA and AA for the surgical treatment of ESAA. However, TAA trended to be superior for pain relief (GOR B), activity (GOR B), health related quality of life (GOR B) and readmission rate (GOR B) while AA trended to be superior for revision rates (GOR B). Conflicting evidence was presented for general complications (GOR C) CONCLUSION: Due to the lack of level I papers and the findings from the papers reviewed not being consistent, no definitive conclusion on which procedure is better can be made. However, there is enough evidence to provide a basis for which procedure is more effective in each of the outcomes reviewed. This should be considered when deciding on which procedure is best suited for a patient on a case-by-case basis. To allow for a stronger recommendation, further studies-ideally, high-quality level I randomized control trials directly comparing Ankle Arthrodesis and Total Ankle Arthroplasty are needed. LEVEL OF EVIDENCE: Level III, systematic review.

Revision of total ankle arthroplasty: Survival and medium-term functional results.

BACKGROUND: The objective of this study was to analyze the results and survivorship of total ankle arthroplasty (TAA) revision surgery with standard (Salto Talaris®) or revision (Salto Talaris XT®) implants. METHODS: Between January 2005 and December 2017, all patients undergoing TAA revision at our hospital were included. Indications for revision, type of surgery performed, improvement in function assessed with the AOFAS score, occurrence of complications and implant survival at last follow-up were analyzed. RESULTS: In the end, 25 TAA patients who had undergone revision (11 unipolar, 14 bipolar) were included. The mean follow-up time was 5.1 ± 1.9 years. At the last follow-up, function was improved compared to the preoperative AOFAS score (51.3 ± 17.5 vs. 83.5 ± 10.1; p < .001), but not plantar flexion (17.5 ± 5.7 vs. 15.4 ± 7.1; p = 0.28) or dorsal flexion (7 ± 5.6 vs. 8.3 ± 4.9; p = 0.3). Complications occurred in six patients (24 %) that led to reoperation: three infections, one lateral impingement, one implant malposition, and one hindfoot alignment disorder. At the last follow-up, implant survival was 96 %, but the probability of survival without reoperation was 78.7 ± 8.5 % at 4 years. CONCLUSION: TAA revision by arthroplasty is feasible, produces good functional results in the medium term, but has a high risk of complications. The challenge of revision TAA is managing the loss of bone stock and anchoring the new implants.

Does anxiety influence outcome measurements in ankle replacement patients?

BACKGROUND: Total ankle arthroplasty (TAA) is increasingly used to treat end-stage ankle arthritis to restore ankle functional outcomes and alleviate pain. This treatment outcome may be influenced by pre-morbid patient anxiety. METHODS: Twenty-five Infinity TAA implants were prospectively followed post-operatively with a mean follow-up time of 34.18 months. Demographic, clinical, and functional outcomes were assessed. Analysis was performed on the effect of anxiety, reported by the HADS, on patient-perceived postoperative pain, functioning, and quality of life. RESULTS: Postoperative the PROMs and Range of Motion (ROM) improved significantly. Linear regression analysis and Pearson correlation showed a significant negative effect of anxiety on the postoperative patient-reported outcome measurements (EQ-5D-5L, VAS, and MOxFQ) at the end of follow-up. CONCLUSION: Good functional, clinical, and radiographic results were observed in this prospective cohort study. Anxiety had a negative influence on the outcome of the patient-reported outcome measurements (EQ-5D-5L and MOxFQ) postoperatively. LEVEL OF EVIDENCE: Level III, prospective cohort study.

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.

How Does a Novel In Situ Fixed-bearing Implant Design Perform in Revision Ankle Arthroplasty in the Short Term? A Survival, Clinical, and Radiologic Analysis.

BACKGROUND: Given the growing number of primary total ankle replacements (TAR), an increase in the number of patients undergoing subsequent revisions might be expected. Achieving a stable and balanced ankle while preserving the remaining bone stock as much as possible is crucial for success in revision TAR. Most reported techniques rely on bulky implants with extended fixation features. Since 2018, we have used a novel, three-component ankle prosthesis for revision that is converted in situ to a fixed-bearing, two-component ankle prosthesis once the components have found their position according to an individual's anatomy. The results of this novel concept (fixation, revision, pain, or function) have not, to our knowledge, been reported. QUESTIONS/PURPOSES: What are the short-term results with this new revision TAR design, in terms of (1) repeat revision surgery, (2) patient-reported outcomes on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, (3) pain according to the VAS, and (4) radiographic signs of fixation? METHODS: Between February 2018 and February 2020, we performed 230 TAR surgeries (in 206 patients) for any indication in our clinic. The novel semiconstrained, uncemented Hintermann Series H2 © implant was used in 96% (220 of 230) of procedures (201 patients). Fifty-four percent (119 of 220) of these were converted from an existing TAR to H2, which was the focus of the present study. However, only 45% (54 of 119) of these conversions to H2 were eligible for analysis. These patients had a mean age of 63 ± 12 years, and 43% (23 of 54) were women. The median (range) follow-up time was 3.2 years (2.0 to 4.3). The H2 design allows in situ conversion to a fixed-bearing system, with minimal bone resection. It achieves translational and rotational stability while preserving function and supporting the periarticular soft tissues. We defined repeat revision as exchange of one or both metal components, ankle fusion, or amputation and assessed it using a cumulative incidence survivorship estimator. Factors potentially associated with revision were assessed using Cox regression analyses. Clinical and radiologic outcomes were assessed preoperatively and at the most recent follow-up interval. Clinical outcomes included pain on the VAS (average pain during normal daily activity during the past seven days) and AOFAS score. Radiologic outcomes were the tibial articular surface angle, tibiotalar surface angle, talar tilt angle in the coronal plane, and AP offset ratio in the sagittal plane, as well as radiolucent lines and radiographic signs of loosening, defined as change in position greater than 2° of the flat base of the tibia component in relation to the long axis of the tibia, subsidence of the talar component into the talus greater than 5 mm, or change in position greater than 5° relative to a line drawn from the top of the talonavicular joint to the tuberosity of the calcaneus, as seen on plain weightbearing radiographs. RESULTS: The cumulative incidence of repeat revision after 1 and 2 years was 5.6% (95% CI 0% to 11%) and 7.4% (95% CI 0% to 14%), respectively. With the numbers available, no clinical factors we analyzed were associated with the risk of repeat revision. The median values of all assessed clinical outcomes improved; however, not all patients improved by clinically important margins. The median (range) AOFAS ankle-hindfoot score increased (from 50 [16 to 94] to 78 [19 to 100], difference of medians 28; p < 0.01), and the median pain on the VAS decreased (from 5 [0 to 9] to 2 [0 to 9], difference of medians 3; p < 0.01) from before surgery to follow-up at a minimum of 2 years. Radiographically, lucency was seen in 12% (6 of 49 patients) and loosening was seen in 8% (4 of 49). One of these patients showed symptomatic loosening and was among the four patients overall who underwent revision. We could not assess risk factors for repeat revision because of the low number of events (four). CONCLUSION: The investigated new in situ fixed-bearing ankle design achieved overall better short-term results than those reported in previous research. Destabilization of the ankle joint complex, soft tissue insufficiency, and possible changes of the joint configuration need an optimal solution in revision arthroplasty. The studied implant might be the answer to this complex issue and help surgeons in the perioperative decision-making process. However, a relatively high percentage of patients did not achieve a clinically important difference. Observational studies are needed to understand long-term implant behavior and possibly to identify ankles benefiting the most from revision. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial.

BACKGROUND: End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF). OBJECTIVE: To determine which treatment is superior in terms of clinical scores and adverse events. DESIGN: A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307). SETTING: 17 National Health Service trusts across the United Kingdom. PATIENTS: Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure. INTERVENTION: Patients were randomly assigned to TAR or AF surgical treatment. MEASUREMENTS: The primary outcome was change in Manchester-Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible. RESULTS: Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was -5.6 (95% CI, -12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (-11.1 [CI, -19.3 to -2.9]). LIMITATION: Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques. CONCLUSION: Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%. PRIMARY FUNDING SOURCE: National Institute for Health and Care Research Heath Technology Assessment Programme.

What is the best way for an inexperienced surgeon to learn total ankle arthroplasty?

BACKGROUND: Previous reports on the learning curve of total ankle arthroplasty (TAA) revealed that inexperienced surgeons should be more careful about operative indications and procedures during the learning curve period. Patients who underwent surgery with inexperienced surgeons may be associated with inferior clinical outcomes, such as frequent complications. This study aimed to evaluate the effect of the participation of experienced surgeons as assistants on the results of TAA performed by inexperienced surgeons. METHODS: Surgeons whose experience in performing TAA included less than 15 ankles were defined as inexperienced surgeons; on the other hand, those whose experience included more than 20 ankles were defined experienced surgeons in this study. Thirteen ankles operated by inexperienced surgeons, with an experienced surgeon who participated as an assistant, were assigned to the inexperienced group. Fifteen ankles operated on by an experienced surgeon were assigned to the experienced group. TNK Ankle (Kyocera, Kyoto, Japan) was used for all experiments. The coronal and sagittal alignments and the size of the tibial component relative to the tibial shaft were measured. Preoperative and postoperative Japanese Society for Surgery of the Foot (JSSF) and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were used for clinical assessment. RESULTS: There were two malleolar fractures during the operation in both groups, and there were no cases of revision surgery. There were no significant differences in the coronal and sagittal tibial component alignment and size between the groups. The JSSF and SAFE-Q improved. There were no significant differences between groups, except for the preoperative JSSF score. CONCLUSIONS: During the learning curve period, careful surgical indications and surgeries are desired. However, we found that when experienced surgeons participated as assistants, favorable results could be expected even when inexperienced surgeons performed the surgery. LEVEL OF EVIDENCE: Ⅲ.

A comparative study of modern total ankle replacement and ankle arthrodesis for ankle osteoarthritis at different follow-up times: a systematic review and meta-analysis.

PURPOSE: Total ankle replacement (TAR) or ankle arthrodesis (AA) is the main surgical treatment for end-stage ankle osteoarthritis. However, the therapeutic effect of the two surgical procedures at different follow-up times remains controversial. The purpose of this meta-analysis is to compare the short-term, medium-term, and long-term safety and efficiency of the two modern surgical treatments. METHODS: We conducted a comprehensive search in PubMed, EMBASE, Cochrane library databases, Web of Science, and Scopus. The main results were the patient's reported outcome measure (PROM) score, satisfaction, complications, reoperation, and surgery success rate. Different follow-up times and implant designs were used to evaluate the source of heterogeneity. We used a fixed effects model for meta-analysis and I2 statistic for evaluating heterogeneity. RESULTS: Thirty-seven comparative studies were included. In the short term, TAR significantly improved clinical scores (AOFAS score: WMD = 7.07, 95% Cl: 0.41-13.74, I2 = 0.0%; SF-36 PCS score: WMD = 2.40, 95% Cl: 2.22-2.58, I2 = 0.0%; SF-36 MCS score: WMD = 0.40, 95% Cl: 0.22-0.57, I2 = 0.0%; VAS for pain: WMD = - 0.50, 95% Cl: - 0.56-0.44, I2 = 44.3%) and had the lower incidence of revision (RR = 0.43, 95% CI: 0.23-0.81, I2 = 0.0%) and complications (RR = 0.67, 95% Cl: 0.50-0.90, I2 = 0.0%). In the medium term, there were still higher improvements in both the clinical scores (SF-36 PCS score: WMD = 1.57, 95% Cl: 1.36-1.78, I2 = 20.9%; SF-36 MCS score: WMD = 0.81, 95% Cl: 0.63-0.99, I2 = 48.8%) and the patient satisfaction (RR = 1.24, 95% Cl: 1.08-1.41, I2 = 12.1%) in the TAR group, but its total complications rate (RR = 1.84, 95% Cl: 1.26-2.68, I2 = 14.9%) and revision rate (RR = 1.58, 95% CI: 1.17-2.14, I2 = 84.6%) were significantly higher than that of the AA group. In the long term, there was no significant difference in clinical score and satisfaction, and a higher incidence of revision (RR = 2.32, 95% Cl: 1.70-3.16, I2 = 0.0%) and complications (RR = 3.18, 95% Cl: 1.69-5.99, I2 = 0.0%) was observed in TAR than in AA. The result of the third-generation design subgroup was consistent with that of the above pooled results. CONCLUSION: TAR had advantages over AA in the short term due to better performance in terms of PROMs, complications, and reoperation rates, but its complications become a disadvantage in the medium term. In the long term, AA seems to be favored because of lower complications and revision rates, although there is no difference in clinical scores.

Comparison of patient demographics, utilization trends, and costs of total ankle arthroplasty and ankle fusion in the United States from 2010 to 2019.

INTRODUCTION: Contemporary studies evaluating utilization and trends of total ankle arthroplasty (TAA) and ankle fusion (AF) for tibiotalar osteoarthritis are sparse. Therefore, the purpose of this study was to utilize a nationwide administrative claims database from 2010 to 2019 to compare: (1) baseline demographics; (2) utilization, (3) in-hospital length of stay (LOS), and (4) costs of care. METHODS: Using the PearlDiver database, a retrospective query from January 1st, 2010 to December 31st, 2019 was performed for all patients who underwent TAA and AF for tibiotalar osteoarthritis. Baseline demographics, comorbidities, and geographic utilization were compared using Pearson Chi-square analyses. Linear regression was used to compare differences in procedure utilization and in-hospital LOS during the study interval. Reimbursements between the two cohorts during the study interval were compared. A p value less than 0.05 was statistically significant. RESULTS: In total, 14,248 patients underwent primary TAA (n = 5544) or AF (n = 8704). Patients undergoing AF were generally younger (< 60) with greater comorbidity burden driven by hypertension, diabetes mellitus, obesity, and tobacco use compared to TAA patients (p < 0.0001). Over the study interval, TAA utilization remained constant (912 vs 909 procedures; p = 0.807), whereas AF utilization decreased by 42.5% (1737 vs 998 procedures; p = 0.0001). Mean in-hospital LOS for patients undergoing TAA decreased (2.5 days vs. 2.0 days, p = 0.0004), while AF LOS increased (2.6 days vs. 3.5 days, p = 0.0003). Reimbursements for both procedures significantly declined over the study interval (TAA: $4559-$2156, AF: $4729-$1721; p < 0.013). CONCLUSION: TAA utilization remained constant, while AF utilization declined by 42.5% from 2010 to 2019. There was divergence in the LOS for TAA versus AF patients. Both procedures significantly declined by over 50% in reimbursements over the study interval.

Failure rates and patient-reported outcomes of revision of total ankle arthroplasty.

INTRODUCTION: Despite the increasing number of revision total ankle arthroplasty (TAA), the literature on indications, surgical options, and outcomes is limited. This study reports on failure rates and patient-reported outcomes (PROM) for a cohort of 122 patients who underwent revision of TAA. MATERIALS AND METHODS: A retrospective review of revision TAA between 2006 and 2020 was performed at one institution. Patient's demographics and different surgical procedures were analyzed with particular attention to comparing polyethylene exchange with revision of both metallic components and to additional interventions for axis correction. Failure rates and the European Foot and Ankle Society (EFAS) score were collected. The average follow-up period was 70.37 ± 46.76 months. RESULTS: 122 patients were treated with an exchange procedure. The surgery included 69 polyethylene exchanges, 12 revisions of one metallic component, and 41 revisions of both metallic components. The overall failure rate was 14.75%. The EFAS score, completed by 94 of the 122 patients, was used to evaluate clinical outcomes. Median EFAS score was 12.51 ± 5.53, and median EFAS sports score was 2.97 ± 3.04. Revision rates after polyethylene exchange were significantly higher than after exchanging both metallic components (p value = 0.03), while the EFAS score showed slightly better results in patients treated with polyethylene exchange. Adding procedures to induce axis correction led to significantly lower revision rates (p value = 0.03), and the EFAS score was also improved but without statistical significance. CONCLUSIONS: The high failure rate of polyethylene exchange indicates that the intervention does not address the actual cause of failed TAA in many cases. Additional axis correction should be considered more frequently. If the underlying issues of prosthesis failure can be identified and sufficiently addressed, the results of revision surgery are likely to improve.

An Analysis of 50 Consecutive Total Ankle Replacements Undergoing Preoperative Computerized Tomography Scan-Based, Engineer-Provided Planning From a Single Noninventor, Nonconsultant Surgeon.

Preoperative computerized tomography (CT) scan-based, engineer-provided alignment plans and patient-specific pinning blocks for total ankle replacement (TAR) are available for use in the United States. However, nonbiased studies that justify the additional expense associated with this technology through support of the marketed benefits of less procedural complexity, less intraoperative radiation and reduced surgical time, are lacking. Therefore, to verify the manufacturer's proposed benefits, we sought to investigate our experience with this preoperative CT scan-based, engineer-provided plan and patient-specific pinning blocks during primary TAR. In review of our 50 TAR patients, we found that "perfect" radiographic alignment was not consistently achieved and the accuracy of component prediction was modest. Furthermore, the preoperative plans and patient-specific pinning blocks did not simplify the complexity of our operations since the operative time, intraoperative image intensification time and radiation dose per case all exceeded published historical TAR controls. Interestingly, we identified a significant difference in placement accuracy between the arced and flat-top talar component types that were implanted with the arced being more frequently malaligned. We did not find associations between preoperative deformity severity and accuracy of postoperative alignment. These findings suggest that it is imperative to have surgeons continue to rely on their own surgical planning and experience to achieve optimum radiographic alignment rather than depending on engineer-based recommendations or "surface matched" pinning blocks. Ultimately, we were unable to support the purported benefits of this CT scan-based, engineer-provided alignment plan and patient-specific pinning blocks for this manufacturer's primary TAR systems.

Association of Preoperative Depression Score With Outcomes of Transfibular Total Ankle Arthroplasty.

Favorable short-term results of transfibular total ankle arthroplasty have been reported in several studies; however, the factors affecting these results have not been elucidated. This study aimed to determine whether preoperative depression affects the outcome of transfibular total ankle arthroplasty and whether depression changes with surgery. Scores from the Japanese Society of Surgery of the Foot Ankle/Hindfoot scale (JSSF scale), Self-Administered Foot Evaluation Questionnaire (SAFE-Q), Hospital Anxiety and Depression Scale (HADS), and Timed Up & Go test (TUG) were collected preoperatively, at 6 months, and at 1 year postoperatively from 20 patients. Eighteen patients were diagnosed with osteoarthritis and 2 patients with rheumatoid arthritis. The mean age of the patients was 75 years. Patients were divided into 2 groups: those with preoperative HADS depression scores above the median (higher depression score group) and below the median (lower depression score group), and intergroup comparisons were made. No significant differences were observed in the JSSF and TUG scores between the groups, both preoperatively and postoperatively. Meanwhile, the SAFE-Q pain subscale score was significantly lower in the higher depression score group than in the lower depression score group (median, 59 vs 90) 1 year postoperatively. There were no differences in the other SAFE-Q subscale scores between the groups. The results suggested that depressive tendencies did not affect postoperative functional results using objective assessment measures but had a negative impact on pain in subjective assessment measures.

Tibial Component Subsidence in a Total Ankle System Comparing Standard Technique Versus a Hybrid Technique.

Total ankle arthroplasty (TAA) is a viable treatment option for end-stage ankle arthritis. However, implant survivorship remains an important consideration. Concerns regarding early component loosening with the low-profile tibial tray utilized by fourth-generation TAA systems have been raised in the literature. We have previously described our preliminary outcomes of a hybrid technique combining a stemmed intramedullary tibial component with a chamfer-cut talar component for TAA. A retrospective study comparing short-term outcomes of the tibial component between a standard fourth-generation TAA system versus our hybrid technique was performed. 46 patients with a minimum of 1-year follow up were included in the analyses. There were 25 subjects in the standard implant cohort utilizing a low-profile tibial tray, and 21 subjects in the hybrid group utilizing a stemmed intramedullary tibial component. No statistically significant difference between the demographics of each group was found. The rate of tibial component subsidence was 8% (n = 2) in the standard implant group, and 0% (n = 0) in the hybrid group, though this did not meet statistical significance (p = .49). Mean time to subsidence was 6 months, and revision rate due to tibial component subsidence was 2.1% (n = 1). Periprosthetic lucency was present on most recent follow-up radiographs in 32% and 9.5% of ankles in the standard and hybrid groups, respectively (p = .08). Despite prior concerns for tibial component subsidence with the standard fourth-generation system, we demonstrated low rates in both implant groups. Additional studies are needed to further explore factors that may predispose patients to early tibial component subsidence and resulting implant failure.

Computed Tomography Derived Patient-specific Instrumentation Total Ankle Arthroplasty Survivorship Outcomes.

Computed tomography (CT) derived patient-specific total ankle arthroplasty (TAA) systems have been utilized for improved accuracy and reproducible implant alignment. The purpose of the present study was to report the overall implant survivorship as well as radiographic analysis of patients who underwent primary TAA utilizing CT-derived patient-specific instrumentation. A retrospective review of medical charts and radiographs were performed on patients who had undergone primary TAA at a single institution in the Midwest region from March 2013 to October 2020. Radiographic analysis included preoperative, initial postoperative, and final follow-up coronal and sagittal tibiotalar alignment as well as periprosthetic radiolucency. A total of 96 patients with a mean follow-up of 3 years (range, 0.3-7.3 years) were included. Implant survivorship was found to be 92% at median follow-up of 3 years. A total of 8 cases (8.3%) required revision/reoperation, with 6 (6.3%) of these reoperations directly related for failure of one of the metallic implant components. There was significant improvement in both coronal and sagittal tibiotalar alignment from preoperative to initial postoperative follow-up (p < .001). At latest postoperative follow-up, there were 88% of TAAs that remained in a neutral alignment following surgery. A total of 10 cases were found to have radiolucency at latest follow-up. In conclusion, the use of CT derived patient-specific TAA showed high implant survivorship with significant improvement of sagittal and coronal tibiotalar alignment. With better implant alignment and position, it potentially reduces the risk of early implant failure or implant loosening in long-term follow-up.

Results of Transfibular Total Ankle Arthroplasty. A Series of 50 Implants.

Total ankle arthroplasty has become popular in the last few years. The lateral transfibular approach is an alternative to the traditional anterior approach. The purpose of this study was to evaluate our 50 first and consecutive clinical and radiological outcomes of transfibular total ankle replacements (Trabecular Metal Total AnkleR Zimmer Biomet, Warsaw, IN) with a follow-up of at least 3 years. This retrospective study included 50 patients. The main indication was post-traumatic osteoarthritis (n = 41). The mean age was 59 (range = 39-81). All patients were followed for at least 36 months postoperatively. Patients were assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score and Visual analog scale (VAS) preoperatively and postoperatively. Range of motion and radiological measures were assessed as well. Postoperatively, patients demonstrated statistically significant improvement in the AOFAS score from 32 (range = 14-46) to 80 (range = 60-100) (p < .01) and VAS from 7.8 (range = 6.1-9.7) to 1.3 (range = 0-6) (p < .01). The average total range of motion increased significantly from 19.8° to 29.2° of plantarflexion and 6.8° to 13.5° of dorsiflexion. Alignment measured by alpha, beta, and gamma angles was satisfactorily achieved. No patient demonstrated any radiographic evidence of tibial or talar lucency at the final follow-up. Five patients (10%) experienced delayed wound healing. One patient (2%) developed a postoperative prosthetic infection. One patient (2%) developed fibular pseudoarthrosis and 2 patients (4%) suffered impingement. Two patients (4%) needed surgery for symptomatic fibular hardware. This study found excellent clinical and radiological results of transfibular total ankle replacement. This is a safe and effective option that allows the correction of sagittal and coronal malalignment.

Midterm Outcomes of the INBONETM II Total Ankle Arthroplasty.

As the number of total ankle arthroplasties (TAA) performed continues to increase, understanding midterm outcomes can guide both implant selection and preoperative patient counseling. The purpose of this study was to investigate midterm results including the survival rate and reasons for revision for the INBONETM II TAA. Patients undergoing a primary TAA with the study implant and minimum of 4.6 years postoperative follow-up were reviewed from a prospectively collected database. The primary outcome was implant survival. Secondary outcomes included coronal plane radiographic alignment, evaluation for cysts and osteolysis, and failure mode when applicable. Patients were eligible for inclusion in this study if they had a minimum of 4.6-year follow-up TAA with the study implant. Eighty-five TAAs in 83 patients were eligible for inclusion; 75 TAA in 73 patients were included in the study. The mean duration of follow up was 6.2 ± 0.9 years (range 4.7-8.1 years). Thirty-six percent of the TAAs had a preoperative coronal plane deformity of at least 10°, and 12% of the TAAs had at least 20°. There were 6 (8%) implant failures that occurred at a mean 2.0 ± 1.4 years postoperatively. Eighty-one percent of the TAAs had no reoperation events in the follow-up period. Midterm outcomes at a minimum of 4.6 years postoperatively in patients undergoing a TAA using this implant demonstrates acceptable implant survival, an approximately 20% reoperation rate, and maintenance of coronal plane alignment.