Incidence of Scholarly Publication by Selected Content Experts Presenting at National Society Foot and Ankle Meetings From 2016 to 2020.

Continuing medical education (CME) is an important element to maintain licensing requirements, enhance professional competence, and disseminate up to date, evidence-based, treatment recommendations. A key resource of CME are the 2 annual society meetings hosted by the American College of Foot and Ankle Surgeons (ACFAS) and American Orthopedic Foot and Ankle Society (AOFAS). It is assumed that the selected speakers at these meetings are content experts, providing validated expertise on treatment recommendations, rather than anecdotal experience or opinion. Across all medical specialists, peer-reviewed publication(s) on a particular subject matter have long bestowed the ultimate validity of "expertise." The purpose of this study was to assess the incidence of scholarly publication for invited speakers at the ACFAS and AOFAS annual meetings from 2016 to 2020, in relation to the topic they were selected to present. A review of invited lectures given at the ACFAS and AOFAS annual meetings from 2016 to 2020 was conducted, and lecturer demographics were categorized into predetermined content areas for assessment. Selected speakers were individually cross-referenced with content-specific peer-reviewed published literature, and overall h-index using Scopus. Topic and society specific comparisons were then made. Overall, 1028 lectures were identified during the temporal period. Only 300 (29.18%) presentations were given by a speaker with least one or more publication on the society specific lecture-topic presented. The greatest proportion of lecturers with content-specific publications was Charcot reconstruction (67.57%) followed by ankle fusion/replacement (55%). The average presenter h-index was greatest among total ankle replacement/ankle fusion (12.16 ± 6.90) and Charcot reconstruction (11.27 ± 7.10) content. The results of the present study illustrate a disparity of expertise among different content areas. While both meetings provide well-published lecturers, this study reveals areas for improvement.

Takedown of Painful Ankle Arthrodesis to Total Ankle Arthroplasty: A Case Series of 77 Patients.

Treatment of painful or malaligned ankle arthrodesis can present as a challenging issue. Several published studies have demonstrated that takedown of a painful ankle arthrodesis to total ankle arthroplasty can assist in restoring some sagittal plane motion and improving functional scores. The goal of this study was to contribute to the limited body of literature with the largest cohort and longest follow-up to date. A retrospective analysis was performed on patient and surgical characteristics of those who underwent a conversion of a painful ankle arthrodesis to a total ankle arthroplasty by 1 of 3 experienced total ankle arthroplasty surgeons from February 2003 to December 2016 with ≥2 years of follow up. Seventy-seven subjects were included for evaluation, with an implant retention rate of 88% (68 of 77) and mean follow-up of 8.3 years (range 2.6 to 15.8). Of the 11 (14%) failures (defined as retrieval or exchange of metallic components), 8 (10%) were revised to a total ankle replacement, 2 (2%) underwent revision arthrodesis, and 1 (1%) elected for below-the-knee amputation. The mean time since the primary arthrodesis was 8.6 years (range 1 to 44), and the longer time interval between primary arthrodesis to takedown total ankle arthroplasty did not correlate with poorer outcome scores or increased risk of failure. The mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot, Buechel-Pappas, and visual analog pain scale scores improved from preoperative values, with less satisfaction noted in those who needed revision surgery. The conversion of a painful ankle arthrodesis to a total ankle implant is a viable option to obtain range of motion and improved patient satisfaction scores similar to primary total ankle replacement.

Early Protected Weightbearing After Open Reduction Internal Fixation of Ankle Fractures With Trans-syndesmotic Screws.

Traditional postoperative care after open reduction internal fixation (ORIF) of unstable ankle fractures with syndesmotic instability includes non-weightbearing for 6 to 8 weeks. However, prolonged non-weightbearing may be detrimental. The goal of this case series was to assess the outcomes of early protected weightbearing after operative treatment of acute ankle fractures with syndesmotic instability requiring screw stabilization. Fifty-eight consecutive patients, treated from January 2006 to January 2013, met the inclusion criteria with a minimum follow up of 1 year. Electronic medical records and radiographs were reviewed for patient and surgical characteristics, postoperative complications, and maintenance of reduction. Patients initiated walking at an average of 10 days (range 1 to 15) postoperatively. Surgical treatment consisted of operative reduction with standard fixation devices and 1 or 2 trans-syndesmotic screws that purchased 4 cortices. All 58 patients maintained correction after surgery when allowed to weightbear early in the postoperative recovery. Five complications (8.6%) occurred in the 58 patients, which included 3 superficial infections (5.2%) and 2 cases (3.4%) of neuritis. The maintenance of reduction and low complication rate in this study support the option of early protected weightbearing after ankle fracture ORIF with trans-syndesmotic fixation.

Takedown of Ankle Arthrodesis With Insufficient Fibula: Surgical Technique and Intermediate-Term Follow-Up.

Conversion of ankle arthrodesis to total ankle arthroplasty has recently gained popularity. However, technical challenges are present when treating patients without a sufficient fibular buttress. We describe a technique for restoration of an adequate fibular buttress using an iliac crest bone graft or malleolar relocation. The results of 10 patients with an average follow-up period of 56 (range 24 to 123) months are presented. Of the 10 patients, 3 underwent tricortical iliac bone augmentation of the fibula, 4 underwent repositioning of the remnant fibula, and in 3, the in situ fibula was used. The average interval from fusion to takedown was 15.1 (range 5 to 35) years, and the average age at takedown was 52.8 (range 33 to 75) years. The average improvement in the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale and Buechel-Pappas scale scores was 35.8 (range 30 to 46) and 34 (range 25 to 42), respectively. Three patients underwent a total of 7 subsequent operations related to the ankle implant. Only 1 of the patients had any residual frontal plane deformity. None of the patients exhibited any component subsidence; however, 2 patients experienced asymptomatic lateral talar component overgrowth. The improvement in the clinical scores in this group of patients suggests that takedown of an ankle arthrodesis with an insufficient fibula is a viable option to improve function. Various techniques to restore the lateral buttress can be used even with complete absence of the distal fibula.

Total Ankle Replacement with Severe Valgus Deformity: Technique and Surgical Strategy.

Correction of severe valgus deformity of the foot and ankle with ankle replacement is challenging. We describe the controversies and specific issues of surgical management and provide a detailed surgical strategy for management of this common deformity. A reliable technique for deltoid reconstruction is also described and illustrated in detail.

Early Protected Weightbearing After Ankle Fractures in Patients With Diabetes Mellitus.

The traditional protocol for treatment after ankle fracture in the diabetic patient involves a period of prolonged non-weightbearing to reduce the incidence of complications. The goal of the present study was to identify the risk factors and complications associated with early protected weightbearing after closed ankle fractures in patients with diabetes. The data from 73 diabetic patients with operatively and nonoperatively treated ankle fractures were retrospectively reviewed. All patients were allowed to begin protected weightbearing in a cast or removable boot at 2 weeks after the index injury or surgery. The mean follow-up period was 51 (range of 26 to 480) weeks. Complications occurred in 25% of the operative cases and 8% of the nonoperative cases. In both categories, the complication rate was less than that from existing reports using prolonged non-weightbearing. Wound dehiscence was the most common complication in the operatively treated patients (18.8%). A statistically significant difference was found in the complications rates for the patients aged >60 years (p = .0403). No statistically significant differences were identified according to hemoglobin A1c, the presence of peripheral neuropathy, smoking status, fracture type, or the presence of end-stage renal disease. The results of the present study suggest that early protected weightbearing after closed ankle fractures in diabetic patients is fairly safe, with an acceptable complication rate. However, the patients selected for early weightbearing had low comorbidity profiles, which might have accounted, in part, for the low complication rate.

Combined Total Ankle Arthroplasty With Posterior Tibial Tendon Transfer for End-Stage Cavovarus Deformity.

Posterior tibial tendon transfer has been described to reduce and balance the cavovarus deformity in those patients who receive a total ankle replacement for end-stage arthritis. In this article, we discuss the indications and provide a detailed description of the technique for this powerful procedure. Case examples that demonstrate the utility of the procedure are provided.

The Neglected Achilles Tendon Rupture Repaired With Allograft: A Review of 14 Cases.

Various surgical techniques have been reported for the repair of neglected Achilles tendon ruptures, including V-Y advancements, synthetic augmentations, and collagen implants. The use of an Achilles tendon allograft allows bridging of large defects without donor site morbidity, with a relative ease of technique and adequate graft availability. The present retrospective report focused on the outcomes of a series of 14 patients with neglected ruptures treated with an Achilles tendon allograft. Patients were included in the present series if they had ≥12 months of postoperative follow-up data available and the allograft had been used without any adjunctive procedures. Of the 14 patients, 6 were female (43%) and 8 were male (57%), with a mean follow-up period of 16.1 ± 3 (range 12 to 27) months. The mean interval from the initial injury to surgery was 6.9 ± 5 (range 1 to 28) months. The mean intraoperative defect size was 7.0 ± 3 (range 4 to 15) cm. A calcaneal block was used in 2 patients (14%). All patients were able to perform a single heel rise at a mean of 27 ± 11 (range 12 to 37) weeks postoperatively. Weightbearing in normal shoe gear was achieved at a mean of 13.5 ± 3 (range 12 to 17) weeks. Complications included 1 delayed union (7%) of the calcaneal bone block. Repair of the neglected Achilles tendon rupture with an allograft appears to be an acceptable approach, with good overall outcomes and low risk. These results suggest that this method of repair compares favorably with established alternatives.

Talolisthesis in end stage ankle arthrosis.

BACKGROUND: Sagittal displacement in patients with end stage ankle arthritis has been described as the tibiotalar ratio (TTR). Yet the incidence, distribution and predictive factors of talolisthesis are unknown. METHODS: The radiographs of 470 cases of ankle arthritis were compared with a control group of 49 normal ankles. The TTR was measured for both groups. Additional co-variables included the anterior and lateral distal tibial angles, and talar tilt. RESULTS: The mean TTR in the arthritis cohort was 34.8+9.12 compared to the normal group of 34.1+2.62. Twenty-eight percent of the ankles had anterior displacement and twenty-eight percent had posterior talolisthesis, while forty-four percent had normal tibiotalar alignment. Multivariate linear regression revealed significant predictors of anterior distal tibial angle (p<0.0001) and talar tilt (p=0.0007) for abnormal TTR. CONCLUSION: Sagittal displacement is common in end stage ankle arthritis and is affected by ligamentous laxity and joint morphology.

Primary subtalar joint arthrodesis for comminuted fractures of the calcaneus.

Severely comminuted intra-articular calcaneal fractures often culminate in subtalar arthrosis and stiffness even after operative reduction. In some instances, subtalar arthrodesis is necessary to reduce the symptoms. Primary subtalar arthrodesis for these fractures has gained acceptance in recent years. However, few definite predictors of functional outcome after primary fusion have been found. A series of 17 patients with highly comminuted fractures were studied to determine which radiographic parameters were predictive of functional outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was obtained at an average of 34 (range 12 to 157) months after arthrodesis. Radiographic measurements included the talocalcaneal, calcaneal inclination, talo-first metatarsal, and Böhler's angles, and the height of the tibial plafond, width of the calcaneus, and the presence of a medial step-off on the injured and uninjured foot. The mean Ankle-Hindfoot scale score was 78 (range 56 to 92), and the mean visual analog score was 1.9 (0 to 4). Statistically significant associations were noted between greater postoperative function and increasing age (p = .028), the quality of restoration of Böhler's angle (p = .038), and the talocalcaneal angle (p = .049). No patient had nonunion. The results of the present study suggest that the outcomes after primary arthrodesis of the subtalar joint are favorable, in particular, when the radiographic relationships of the hindfoot have been restored.

Articular congruency of the Salto Talaris total ankle prosthesis.

BACKGROUND: The Salto-Talaris polyethylene articulating surface was designed to allow, but limit accessory motion. This investigation examines surface characteristics between the polyethylene bearing and anatomic talar component in various positions of function. METHODS: A Salto Talaris talar prosthesis and matching polyethylene bearing were scanned to create digital solid body models and manipulated to assess surface contact during simulated gait. With computer micromanipulation of the component positions, the surface intersections were recorded for 15 different alignments. RESULTS: The Salto Talaris has limited contact congruity with four points of contact in dorsiflexion, neutral, and plantarflexion. Lateral and medial translations showed only 2-point contact. The radii of curvatures between the talar component and polyethylene surfaces do not match. There was no sulcus contact yet component separation distance was small, suggesting increased loads. CONCLUSION: Surface incongruency was measured based on computer model analysis which raises a concern of increased contact pressures.

Gutter impingement after total ankle arthroplasty.

BACKGROUND: Symptomatic gutter impingement after ankle arthroplasty has been reported with various designs. However, the incidence and origin of impingement have not been fully elucidated. Furthermore, the outcome of patients following gutter debridement has not been reported. METHODS: A review of 489 total ankle replacements was performed to calculate the incidence of symptomatic gutter impingement in 4 different devices and between the presenting causes of arthritis. The incidence of gutter impingement was determined for patients with and without preemptive gutter resection at the time of implantation. The functional outcome of 30 of the 34 patients who had subsequent gutter debridement was determined with 3 different outcome instruments. RESULTS: Symptomatic gutter disease occurred in 34 of 489 cases (7%) followed for a minimum of 1 year (range, 1-12 years). There was a 2% incidence of gutter disease in the 194 ankles that had prophylactic gutter resection at the time of implantation and a 7% incidence in the 295 ankles that did not have gutter resection at the time of implantation. When the ankle treated with an Agility (DePuy Orthopaedics, Inc, Warsaw, IN) device was excluded, there was a 2% and an 18% incidence of gutter disease in the 2 groups, respectively (P < .05). There was no difference in the incidence of gutter disease between the various implants and origins of ankle arthritis. Postoperative outcomes were favorable in the 27 patients who did not have another procedure after the initial gutter debridement. Seven patients (21%) required reoperation. CONCLUSION: Prophylactic gutter resection should be considered at the time of implantation to reduce the incidence of postoperative symptoms. Although most patients had favorable outcomes following gutter debridement, there was a high reoperation rate. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Relationship of alignment and tibial cortical coverage to hypertrophic bone formation in Salto Talaris® total ankle arthroplasty.

A retrospective analysis of 107 Salto Talaris(®) total ankle replacements was performed to determine the effect of alignment and tibial cortical coverage on the formation of heterotopic bone. The radiographic parameters were studied for at least 18 months to detect any changes over time. The angle of insertion of the implant was most often in varus and with a positive anterior slope. A slight increase was seen in the slope over time (p < .0001) but was not clinically relevant. The mean percentage of cortical coverage of the tibial component was 89%, and only 7 patients had complete coverage of both the anterior and the posterior cortices. The percentage of patients who had hypertrophic bone growth increased over time (p < .0001). As the slope of the implant increased, there was a negative correlation with the degree of tibial coverage (p = .007). There was also an increase in the extent of hypertrophic bone as the tibial coverage decreased. None of the patients had symptoms that required an additional surgical procedure. The results of the present study indicate a high incidence of hypertrophic bone proliferation when the dimensions of the tibial component do not match the anteroposterior depth of the tibia at the plane of resection. Despite the high occurrence rate, the clinical relevance of hypertrophic bone is obscure.

Surgical Considerations for Revision Flatfoot Reconstruction: Overcorrection/Undercorrection.

Reconstructive surgery of the symptomatic pes planus deformity is a very common procedure with relatively good outcomes. Many factors such as patient selection, patient expectations, and surgical execution can influence the results. In addition to achieving osseous union, the overall postoperative alignment is critical in determining functional outcome. Specifically, under- and over-correction respectively present their own unique problems and symptomatology. The purpose of this review is to discuss the adverse outcomes after mal-reduction of flatfoot reconstruction and emphasize the strategies to correct the subsequent deformity.

Cement spacer as definitive management for postoperative ankle infection.

BACKGROUND: Postoperative infection can be a devastating complication of ankle replacement and arthrodesis surgery. Management consists of eradication of the infection and either, revision of the initial surgery or some form of salvage procedure. There are instances however when the patient is asymptomatic, medically unfit, or the local tissue is too tenuous to warrant performing additional surgery. We conducted a retrospective review of the outcome of the use of an antibiotic impregnated cement spacer as the definitive procedure in this kind of patient. METHODS: There were nine patients with post operative deep ankle infection following surgery who did not undergo subsequent revision surgery. The initial surgeries were either total ankle replacement (TAR) (n = 6) or ankle arthrodesis (n = 3). The indications for the retention of the cement spacer were patients who were asymptomatic following insertion of the cement spacer, did not desire further surgery, or were medically unfit for further surgery. The patients all underwent removal of hardware or implants, debridement, and insertion of an antibiotic impregnated cement spacer. Six weeks of intravenous antibiotics were administered according to culture sensitivity results. Patients were followed up closely for complications (wound dehiscence, spacer migration, bone loss), resolution of infection, functionality, and satisfaction. RESULTS: The average time of cement spacer retention was 20.1 months, ranging from 6 to 62 months. The most common infecting organisms were Staph. Aureus (n = 3) and Staph. Epidermidis (n = 3). One patient had wound complications, possibly due to the proximity of the cement spacer to the anterior skin surface. One patient had a repeat infection at 52 months. The most common co-morbidities were rheumatoid arthritis (n = 3) and diabetes (n = 2). At final followup, seven patients still had a retained cement spacer and two had subsequent below knee amputations (BKA) performed as a result of delayed complications. Review of the X-rays revealed two patients with loosening and migration of the cement spacer. No patients had signs of excessive bone loss. All patients with a retained antibiotic cement spacer were mobile and able to perform basic activities of daily living with minimal discomfort. CONCLUSION: The long-term use of antibiotic impregnated cement spacers following postoperative ankle infection is a reasonable option in the low demand patient with surgical or medical co-morbidities.

Early protected weightbearing after open reduction internal fixation of ankle fractures.

The present retrospective study assessed the complications and loss of reduction in 126 patients aged 16 years or older who bore weight in a short leg cast within 15 days after surgical repair of acute unilateral closed ankle fractures from January 1997 to December 2003. Fracture reduction was assessed on immediate postoperative and weightbearing digital radiographs at least 6 weeks after surgery. The medical records were reviewed for postoperative complications. Complete radiographs were available for 81 patients. The mean follow-up period was 171 (range 42 to 1275) days. The mean patient age was 50 years. Patients began walking an average of 8 days after surgery. From the medical record review, no cases of malunion or nonunion occurred. A total of 14 complications developed in 12 (9.5%) of 126 patients, including a delay in wound healing in 6, nerve paresthesia in 5, and hardware migration in 1. The patients aged 60 years or older had a slightly greater overall complication rate (6 of 38, p = .18). Patients who walked on postoperative day 1 had slightly more wound problems (2 of 19, p = .36). Of the 81 ankle fracture radiographs, 80 (98.8%) showed no displacement in fracture reduction on the final follow-up examination. One patient had a 2-mm loss of fracture reduction and was allowed to walk on postoperative day 1 (p = .09). These results support early protected weightbearing after operative treatment of closed isolated lateral malleolar and bimalleolar ankle fractures without syndesmotic involvement in patients of all ages.

Autologous split peroneus longus lateral ankle stabilization.

Lateral ankle instability is a common clinical entity, and a variety of surgical procedures are available for stabilization after conservative management fails. Herein the authors reviewed outcomes after performing autologous split peroneus longus lateral ankle stabilization, using a previously described surgical technique to anatomically recreate the anterior talofibular and calcaneofibular ligaments. Twenty-five consecutive patients from 2 surgeons' practices underwent reconstruction between March 2007 and January 2011 with a minimum follow-up of 12 (range 12 to 51) months (mean 29.5 months). Follow-up interviews demonstrated 92.0% good or excellent outcomes with only 8.0% rating the outcome as fair and none as poor; 92.0% had no recurrent sprains or difficulty going up or down hills; 88.0% related no difficulty with uneven ground. The authors conclude that the autologous split peroneus longus lateral ankle stabilization results in a stable ankle with a low rate of complications and high patient satisfaction.

Complications after open reduction and internal fixation of ankle fractures in the elderly.

BACKGROUND: Open reduction with internal fixation for unstable ankle fractures is relatively predictable with excellent outcomes. However, the management of ankle fractures in the elderly remains less predictable secondary to the various co-morbidities associated with advanced age. METHODS: A retrospective chart review of 216 patients over the age of 60 that sustained an ankle fracture, was performed to determine the incidence of complications after ORIF of ankle fractures in an elderly population in the perioperative course. Secondly, the incidence of complications in patients that had locking plate fixation compared to those that had non-locking plate fixation was determined. Lastly, the effect of early weight bearing on the incidence of complications was analyzed. RESULTS: There was not a statistically significant difference in the complication rates between the group with co-morbidities (19.01%) and those without (11.96%). The postoperative complication with the highest incidence was wound dehiscence (9.7%), and only diabetes significantly predicted wound dehiscence. The fixation construct and weight-bearing protocol failed to significantly predict any of the indexed complications. CONCLUSIONS: Overall, the results suggest that surgical treatment of unstable ankle fractures in the elderly is fairly predictable with an acceptable complication rate. The complication rates are higher with increased age and diabetes, but they failed to reach statistical significance. Conventional plating appears to provide adequate stability without increased risk of hardware failure. In addition patients that were allowed to walk within the first 2 weeks postoperatively did not experience a higher rate of hardware failure.

Peroneal Stabilization Via Tightening of the Peroneal Tendon Sheath.

Peroneal subluxation is a rare but debilitating pathology that can be the result of a superior peroneal retinaculum tear or intrasheath laxity. On clinical examination of both cases, the pathology is observed when the ankle is circumducted in eversion and dorsiflexion. With a superior peroneal retinaculum tear, the tendons dislocate from the peroneal groove, whereas with intrasheath laxity the tendons remain in the groove. In the present case series, peroneal stabilization was performed for both superior peroneal retinaculum tear and intrasheath laxity. With our technique, the fibro-osseous connections of the peroneal tendon sheath are detached from the distal one third of the fibula. Drill holes are made through the fibula for suture to be passed through and the peroneal tendon sheath is reattached to the fibula through horizontal mattress sutures via pants over vest technique to restore tension to the sheath. A total of 5 patients underwent peroneal stabilization, 100% (5/5) of which had preoperative pain with palpation along the peroneal tendons and a palpable click with range of motion of the ankle joint. Postoperatively, 100% (5/5) of the patients were fully weight-bearing, compared to 60% (3/5) preoperatively. No patients had residual subluxation of the peroneal tendons postoperatively or a need for revisional surgery. Residual peroneal tendonitis was present in 20% (1/5) of patients and sural neuritis occurred in 20% (1/5) of patients. The peroneal tendons are physiologically tightened within the peroneal tendon sheath to mitigate the pathologic subluxation, without sacrificing tendons for transfer or using allograft material.Clinical Level of Evidence: Therapeutic, Case Series, Level 4.