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.

Ankle Arthritis Networking: Getting the right treatment to the right patient first time.

End stage ankle joint arthritis is a debilitating condition. Surgical treatment, most commonly ankle arthrodesis or fusion, can be highly effective. The authors outline the nature and prevalence of ankle arthritis and show that the frequency of each type of procedure varies geographically. They present data supporting the hypothesis that units performing ankle replacement more frequently tend to have better outcomes, both clinically and financially. Adoption of country-wide Ankle Arthritis Networks is proposed, ensuring that every patient seeing a foot and ankle orthopaedic surgeon has potential access to all treatment options whether their surgeon chooses to perform replacement or not. The case is made that establishment of Ankle Arthritis Networks will avoid the need for units to perform a low number of replacements per year, homogenise treatment availability across the country and enables the right patient to receive the right treatment first time. LEVEL OF EVIDENCE: IV.

Systemic medical complications following total ankle arthroplasty: A review of the evidence.

BACKGROUND: Total Ankle Arthroplasty (TAA) is increasingly undertaken for the treatment of end-stage ankle arthritis. For each TAA procedure informed consent is required. The consent process should include discussion of the relevant complications, both systemic and regional. There is a lack of data regarding the systemic complications of TAA. This might cause problems in obtaining valid informed consent. METHODS: We reviewed and summarised the literature regarding the systemic complications and mortality rate of TAA. RESULTS: The average rate of systemic medical complications after TAA was 3% (range: 0-7%). The average mortality rate following TAA was 0.3% (range: 0-0.72%). The following were risk factors for systemic medical complications: obesity, diabetes, systemic co-morbidities, preoperative blood transfusion, revision procedures, and long anaesthetic duration. CONCLUSIONS: When obtaining informed consent for TAA a systemic complication rate of 3% and a mortality rate of 0.3% ought to be included and documented.

Cost-Utility Analysis of Total Ankle Replacement Compared with Ankle Arthrodesis for Patients Aged 50-85 Years with End-Stage Ankle Osteoarthritis: The TARVA Study.

BACKGROUND: Patients with end-stage ankle osteoarthritis suffer from reduced mobility and quality of life and the main surgical treatments are total ankle replacement (TAR) and ankle fusion (AF). OBJECTIVES: Our aim was to calculate the mean incremental cost per quality-adjusted life-year (QALY) of TAR compared with AF in patients with end-stage ankle osteoarthritis, over 52 weeks and over the patients' lifetime. METHOD: We conducted a cost-utility analysis of 282 participants from 17 UK centres recruited to a randomised controlled trial (TARVA). QALYs were calculated using index values from EQ-5D-5L. Resource use information was collected from case report forms and self-completed questionnaires. Primary analysis was within-trial analysis from the National Health Service (NHS) and Personal Social Services (PSS) perspective, while secondary analyses were within-trial analysis from wider perspective and long-term economic modelling. Adjustments were made for baseline resource use and index values. RESULTS: Total cost at 52 weeks was higher in the TAR group compared with the AF group, from the NHS and PSS perspective (mean adjusted difference £2539, 95% confidence interval [CI] £1142, £3897). The difference became very small from the wider perspective (£155, 95% CI -  £1947, £2331). There was no significant difference between TAR and AF in terms of QALYs (mean adjusted difference 0.02, 95% CI -  0.015, 0.05) at 52 weeks post-operation. The incremental cost-effectiveness ratio (ICER) was £131,999 per QALY gained 52 weeks post-operation. Long-term economic modelling resulted in an ICER of £4200 per QALY gained, and there is a 69% probability of TAR being cost effective at a cost-effectiveness threshold of £20,000 per QALY gained. CONCLUSION: TAR does not appear to be cost effective over AF 52 weeks post-operation. A decision model suggests that TAR can be cost effective over the patients' lifetime but there is a need for longer-term prospectively collected data. Clinical trial registration ISRCTN60672307 and ClinicalTrials.gov NCT02128555.

Development and validation of the unifying elective orthopaedic score (UnEOS). A pilot study.

BACKGROUND: Patient reported outcome measures (PROMs) are increasingly valued in orthopaedics. There are already many site specific or pathology specific scores. These scores are usually validated for specific pathologies and can be complicated and time consuming to use. The aim of the present pilot study is to develop a new orthopaedic score for elective operations, which measures patient satisfaction simply and quickly, and is not limited to a single site or pathology. MATERIALS & METHODS: The UnEOS questionnaire has 16 questions. Eleven questions relate to the three main dimensions (Symptoms, Function, Mental Status) and can be used both preoperatively and postoperatively. Five questions are added to the questionnaire at the postoperative mode, which form the satisfaction dimension. For this pilot study we enrolled all patients listed for surgery from our foot and ankle clinics. Each patient was asked to complete the UnEOS and FADI questionnaires. RESULTS: A total of 181 questionnaires were collected from patients (aged 56.4 ±â€¯14.8, range 20-85) with a variety of foot and ankle pathologies. Scores were obtained both pre- and post-operatively. The scale reliability was checked with the Cronbach's Alpha score, which was 0.87 for the UnEOS scale. Each subscale had good reliability with 0.73, 0.77 and 0.76 respectively (Symptoms, Function, Mental Status). The validity of the scale was checked using the Spearman's Rho correlation, which was strong between the UnEOS and the FADI score (0.79) and each subscale (0.7, 0.75 and 0.69 respectively). CONCLUSION: The UnEOS score is a valid and easy to use PROM which is not limited by site or pathology. Further validation with other orthopaedic pathologies will lead to a Unified Elective Orthopaedic score.

Synovial osteochrondomatosis of the talonavicular joint: a case report.

Synovial osteochondromatosis is a condition of unknown etiology affecting articular synovium, characterised by the formation of osteochondral nodules. Occurrences in the foot and ankle are rare. To our knowledge, this condition has never previously been described in the talonavicular joint. In the following article, we present two cases and review the literature regarding this condition.

Arthroscopic ankle debridement: 5-year survival analysis.

Little information exists regarding the long term prognosis following ankle arthroscopy, particularly in avoiding further major surgery. The purpose of this study is to evaluate the prognosis of arthroscopic ankle treatment. We also investigated the relationship between the arthroscopic treatment and time for a further major ankle surgery. In this consecutive case series study using a prospectively collected database, 80 consecutive patients (80 ankles) having ankle arthroscopy with the finding of osteoarthritis or impingement were identified and their outcome at five years was ascertained. Fifty five (69%) patients had soft tissue impingement, and 25 (31%) patients had osteoarthritic degenerative changes. Seven (9%) patients had further major surgery and 6 (8%) had repeat arthroscopy. The surgery was required for 7 arthritic ankles among which, however, survival analysis showed no significant difference between those under 50 and those over 50 years. Twenty-eight percent of osteoarthritic patients progressed to major ankle surgery, within 5 years of arthroscopic treatment. None of the patients with impingement symptoms required further major surgery. In conclusion, arthroscopically treated impingement ankles were found to have an excellent prognosis, while osteoarthritic ankles had a less favoured prognosis, with a high proportion requiring further major surgery. Age did not appear to affect the prognosis in the osteoarthritic group.

Patients' preferred mode of travel to the orthopaedic theatre.

AIM: To determine the preferred mode of travel to the operating theatre for elective orthopaedic patients. METHODS: Data was collected prospectively over a 2-wk period at an elective Orthopaedic Treatment Centre. Patients were asked to complete a patient satisfaction questionnaire following their surgery on their experience and subsequent preferred mode of transport to theatre. The data was then recorded in a tabulated format and analysed with percentages. Fisher's exact test was used to determine if there was any statistical association between patients' preference to walk and various groups; in-patient or day case procedures, and whether patients were < 60 years or > 60 years of age. RESULTS: Seventy patients (40 females and 30 males) fully completed the questionnaire. In total there were 33 d-cases and 37 in-patients. The spectrum of orthopaedic sub-specialties included was knee (41%), hip (17%), foot and ankle (24%), spine (13%) and upper limb (4%). Patient satisfaction for overall experience of travelling to theatre was either excellent (77%) or good (23%). Following their experience of travelling to theatre, 87% (95%CI: 79%-95%) of the total cohort would have preferred to walk to the operating theatre. There was a statistically significant association (P = 0.003) between patients' preference to walk and whether they were day-case or in-patients. Similarly, there was a statistically significance association (P = 0.028) between patients' preference to walk and whether they were < 60 years or > 60 years of age. CONCLUSION: This study confirms the majority of Orthopaedic elective patients would prefer to walk to theatre, when given the choice and if practically possible.

Pigmented villonodular synovitis of the ankle occurring in a patient on anticoagulation therapy.

A case report is presented of a 45-year-old woman with an 18-month history of pain and swelling in her right ankle. There was no history of trauma. Routine investigations failed to elicit a diagnosis. The patient had been on warfarin anticoagulation therapy for 12 years. The onset of symptoms coincided with a period of poor control of her anticoagulation therapy and her international normalized ratio was recorded at 5 or above on three occasions. A diagnosis of pigmented villonodular synovitis (PVNS) was made on arthroscopic examination of her ankle; this was confirmed histologically. The etiology of PVNS remains controversial. Hemarthrosis has been suggested as an etiological factor. Although there are reports of PVNS in patients with hemophilia, there are no reports of PVNS occurring in patients on anticoagulation therapy. This case report supports a possible role for hemarthrosis in the etiology of PVNS.

The 'ABC' of examining foot radiographs.

INTRODUCTION: We report a simple systematic method of assessing foot radiographs that improves diagnostic accuracy and can reduce the incidence of inappropriate management of serious forefoot and midfoot injuries, particularly the Lisfranc-type injury. STUDY GROUP AND METHODS: Five recently appointed senior house officers (SHOs), with no casualty or Orthopaedic experience prior to their appointment, were shown a set of 10 foot radiographs and told the history and examination findings recorded in the casualty notes of each patient within 6 weeks of taking up their posts. They were informed that the radiographs might or might not demonstrate an abnormality. They were asked to make a diagnosis and decide on a management plan. The test was repeated after they were taught the 'ABC' method of evaluating foot radiographs. RESULTS: Diagnostic accuracy improved after SHOs were taught a systematic method of assessing foot radiographs. The proportion of correct diagnoses increased from 0.64 to 0.78 and the probability of recognising Lisfranc injuries increased from 0 to 0.6. CONCLUSIONS: The use of this simple method of assessing foot radiographs can reduce the incidence of inappropriate management of serious foot injuries by casualty SHOs, in particular the Lisfranc type injury.