Comparing the Interobserver Reliability of 4 Methods Used to Measure Knee Laxity on Coronal Plane Stress Radiograph.

Background: Varus and valgus knee stress radiographs provide valuable information in the pre- and postoperative evaluation of joint laxity in patients with multiligament knee injuries (MLKIs). Purpose: To review the literature for described techniques of quantifying laxity on coronal stress radiographs of the knee and identify the most reliable method. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A thorough literature search using the MEDLINE and Embase databases identified 4 studies with distinct methods for objectively measuring laxity on varus and valgus stress radiographs: Heesterbeek et al (2008), Jacobsen (1976), LaPrade et al (2004), and Sawant et al (2004). To compare these methods, 200 coronal plane stress radiographs from 50 patients with MLKIs were retrospectively reviewed from an MLKI database at a single institution. The amount of varus and valgus laxity on each radiograph was measured independently by 4 reviewers using each method. Intraclass correlation coefficients (ICCs) with 95% CIs were calculated to assess the interobserver reliability of each method overall and the varus and valgus measurements individually. Results: For all 4 methods, the overall interobserver reliability was considered at least moderate. The method by Heesterbeek et al proved to have the highest interrater reliability in all domains-overall (ICC, 0.87 [95% CI, 0.85-0.90]), valgus (ICC, 0.83 [95% CI, 0.78-0.88]), and varus (ICC, 0.87 [95% CI, 0.83-0.90])-demonstrating good to excellent reliability both overall and in varus measurements and showing good reliability in valgus measurements. The method by Sawant et al demonstrated good reliability in valgus measurements. All other measures demonstrated moderate reliability. Conclusion: Available methods for measuring knee joint laxity on varus and valgus knee stress radiographs in patients with MLKIs demonstrated moderate to good interobserver reliability. The method described by Heesterbeek et al proved to have the highest reliability overall as well as in measurements on varus and valgus views individually.

Metal hypersensitivity in foot & ankle orthopaedic surgery: A systematic review.

Introduction: Metal hypersensitivity affects 10-15% of individuals. Orthopaedic implants contain various metals and, therefore, metal hypersensitivity may impact patient outcomes. Purpose: We report a systematic review of the literature on metal hypersensitivity in patients undergoing foot and ankle (F&A) surgery. Our goal is to provide an overview presenting symptoms, diagnostic methods, treatment, and clinical outcomes. Methods: A comprehensive literature search of Ovid MEDLINE and EMBASE was performed from its inception (01-Jan 1966) to 23-Nov 2021. MeSH search terms on F&A were used including orthopaedic surgeries, metal types, and hypersensitivity. All full-text, English, experimental and observational studies reporting on metal hypersensitivity in the context of foot and/or ankle surgeries using metallic orthopaedic devices were included. Article screening, critical appraisal, and data extraction was performed by two reviewers. Disagreements were resolved by a third reviewer. Results: Fifteen studies were identified, reporting on 45 patients (18 male and 27 female). Median age was 58 years and mean follow-up was 20.8 months. 42 static and three arthroplasty implants were included. In total, 19 patients (42.2%) were diagnosed with metal hypersensitivity to a constituent of their implant, including two (4.4%) patients diagnosed without metal hypersensitivity testing. Twenty-six patients (57.8%) tested negative to their metal implant components. Of the 19 patients allergic to a constituent of their implant, 14 underwent hardware removal and improved. Four patients were asymptomatic and the last was symptomatic, but not revised. Of these, 23 patients retained their hardware (eight with skin reactions) and two symptomatic patients underwent hardware removal. Conclusion: Metal hypersensitivity in the context of F&A surgery is not widely reported. It should be a differential diagnosis in patients who present with hypersensitivity-type symptoms once infection and mechanical failure are ruled out. This data informs a comprehensive algorithm for identifying and treating metal hypersensitivity in F&A patients. Level of evidence: Level IV.

Two-Year Outcomes After Total Ankle Replacement With a Novel Fixed-Bearing Implant.

BACKGROUND: The Integra Cadence total ankle replacement (TAR) is a fourth-generation anatomic, fixed-bearing implant requiring minimal tibial and talar resection, which has been in clinical use since June 2016. The primary purpose of this study is to assess its short-term clinical and radiographic outcomes after TAR using this prosthesis. METHODS: This is a prospective case series of consecutive patients that underwent TAR using this novel fourth-generation prosthesis between June 2016 and November 2017. The primary outcome of interest was the Ankle Osteoarthritis Scale (AOS). Secondary outcomes included Short Form Health Survey-36 (SF-36) scores, radiographic alignment, complications, reoperations, and revisions. RESULTS: In total, 69 patients were included in our study. Fifty-one patients (73.9%) required a total of 91 ancillary procedures. Postoperatively, AOS pain scores decreased significantly by an average of 17.8±30.1 points from 45.9±18.2 to 28.4±27.3 (P < .001). AOS disability scores also decreased significantly following surgery by an average of 22.0±30.5 points from 53.9±18.5 to 32.5±27.9 (P < .001). The SF-36 physical component summary score improved 10.4±9.8 points from 33.1±9.1 to 42.6±9.1 (P < .001). Radiographic analysis demonstrated significant improvement to neutral coronal plane alignment, which was achieved in 97% of patients (P < .01) with no cyst formation at 2 years. There was 1 reported complication, 9 reoperations, and no metal or polyethylene component revisions. Overall, the 2-year implant survivorship was 100% in our cohort. Eighteen patients (26.1%) demonstrated fibrous ingrowth of the tibial component. However, outcome scores for these patients did not demonstrate any negative effects. CONCLUSION: In our hands, this TAR system demonstrated excellent early clinical and radiographic outcomes. Patients reported improved physical health status, pain, and disability in the postoperative period. Total ankle instrumentation allowed for accurate and reproducible implantation with correction of coronal and sagittal plane deformities. Early results for the clinical use of this TAR system are promising, but further long-term prospective outcome studies are necessary. LEVEL OF EVIDENCE: Level IV, case series.

Living With Both a Total Ankle Replacement and an Ankle Fusion: A Qualitative Study From the Patients' Perspective.

BACKGROUND: Total ankle replacement (TAR) and ankle fusion are effective treatments for end-stage ankle arthritis. Comparative studies elucidate differences in treatment outcomes; however, the literature lacks evidence demonstrating what outcomes are important to patients. The purpose of this study was to investigate patients' experiences of living with both a TAR and ankle fusion. METHODS: This research study used qualitative description. Individuals were selected from a cohort of patients with TAR and/or ankle fusion (n = 1254). Eligible patients were English speaking with a TAR and contralateral ankle fusion, and a minimum of 1 year since their most recent ankle reconstruction. Surgeries were performed by a single experienced surgeon, and semistructured interviews were conducted by a single researcher in a private hospital setting or by telephone. Ankle Osteoarthritis Scale (AOS) scores, radiographs, and ancillary surgical procedures were collected to characterize patients. Themes were derived through qualitative data analysis. RESULTS: Ten adults (8 men, 2 women), ages 59 to 90 years, were included. Average AOS pain and disability scores were similar for both surgeries for most patients. Participants discussed perceptions of each reconstructed ankle. Ankle fusions were considered stable and strong, but also stiff and compromising balance. TARs were considered flexible and more like a "normal ankle," though patients expressed concerns about their TAR "turning" on uneven ground. Individuals applied this knowledge to facilitate movement, particularly during a first step and transitioning between positions. They described the need for careful foot placement and attention to the environment to avoid potential challenges. CONCLUSION: This study provides insight into the experiences of individuals living with a TAR and ankle fusion. In this unusual but limited group of patients, we found that each ankle reconstruction was generally perceived to have different characteristics, advantages, and disadvantages. Most participants articulated a preference for their TAR. These findings can help clinicians better counsel patients on expectations after TAR and ankle fusion, and improve patient-reported outcome measures by better capturing meaningful outcomes for patients. LEVEL OF EVIDENCE: Level IV, case series.

"I Don't Have to Think About Watching the Ground": A Qualitative Study Exploring the Concept of Vigilance as an Important Outcome for Ankle Reconstruction.

OBJECTIVE: To understand patients' experiences of ankle reconstruction for treatment of end-stage ankle osteoarthritis. METHODS: Individuals were recruited from a cohort of individuals who had undergone total ankle replacement or ankle fusion. English-speaking individuals who had surgery at least 1 year prior were invited to participate. Semistructured, face-to-face interviews relying on a phenomenological approach were conducted in a private hospital clinic room. RESULTS: A total of 25 adults (12 women, 13 men), ages 25-82 years, were interviewed for 1-2 hours. Participants commonly described a state of having to keep careful watch for potential environmental challenges. Vigilance was related to ongoing symptoms (i.e., pain, stiffness) and concerns regarding balance, stability, and potential damage to the fused ankle or implant. Vigilance was described along a continuum, with higher levels associated with stress and mental exhaustion. Vigilance affected participants' perception of their surgical outcome, with high vigilance levels linked to negative perceptions of outcome. The degree to which individuals perceived the need for vigilance was influenced by environmental factors like uneven ground or crowds. Contrary to descriptions of vigilance in the coping literature, vigilance related to ankle reconstruction constituted a situational, rather than dispositional, response. CONCLUSION: Vigilance and its associated burden are not captured by current instruments. The mental load and worry associated with vigilance was important to patients, distinct from related pain or functional status. Thus, reducing high levels of vigilance appears to be an appropriate target for patient-centered treatment outcomes. A thorough battery of outcome measures for ankle reconstruction should consider this domain.