Outcomes of Isolated Open Gastrocnemius Recession for the Treatment of Chronic Insertional Achilles Tendinopathy: A Retrospective Cohort Study.

BACKGROUND: Insertional Achilles tendinopathy (IAT) is a common condition causing pain and dysfunction. Patients with diabetes, hyperlipidemia, hypothyroidism, and obesity are at increased risk of developing IAT. These comorbidities also carry an increased risk of wound healing complications following surgery. Therefore, there is a need for alternative management strategies for this high-risk patient population. This study investigated the potential role of isolated GR in patients with chronic IAT. METHODS: This study is a single-institution retrospective review of adult patients who underwent isolated GR to address chronic IAT with a minimum 1-year follow-up. Demographics, complications, radiographic findings, and preoperative and postoperative patient-reported outcome scores (PROs) were collected. The primary outcome was improvement in PROMIS scores from preoperative to postoperative. Secondary outcomes were complication and reoperation rates. RESULTS: Sixteen patients underwent open GR with a mean follow-up of 2.7 years. Postoperative PROMIS domain scores improved significantly from preoperative scores for physical function, pain interference, pain intensity, and global physical function. Two patients (13%) underwent reoperation (open calcaneal exostectomy and tendon debridement) at a mean time of 7 months from gastrocnemius recession. One patient developed a postoperative hematoma that resolved with conservative management. CONCLUSION: This single-institution series reports on a small cohort of patients with chronic IAT treated with open GR. We found significant improvement in patient-reported outcomes. Rates of complication and reoperation were low. This study supports the potential use of isolated gastrocnemius recession in IAT patients who, because of age or medical comorbidities, may benefit from a less invasive surgery and faster rehabilitation. LEVEL OF EVIDENCE: Level III, retrospective case control study.

Association Between Fulfillment of Preoperative Expectations and Diagnosis in Foot and Ankle Surgery.

BACKGROUND: There has been growing interest in patient-reported outcomes in foot and ankle surgery, and the fulfillment of patient expectations is a potentially powerful tool that compares preoperative expectations and perceived postoperative improvement. Prior work has validated the use of expectation fulfillment in foot and ankle surgery. However, given the wide spectrum of pathologies and treatments in foot and ankle, no study has examined the association between expectation fulfillment and specific diagnosis. METHODS: This is a retrospective cohort study consisting of 266 patients who completed the Foot & Ankle Expectations Survey and the Foot and Ankle Outcome Survey (FAOS) preoperatively and 2 years postoperatively. A fulfillment proportion (FP) was calculated using the pre- and postoperative Foot & Ankle Expectations Survey scores. An estimated mean fulfillment proportion for each diagnosis was calculated using a multivariable linear regression model, and pairwise comparisons were used to compare the FP between diagnoses. RESULTS: All diagnoses had an FP less than 1, indicating partially fulfilled expectations. Ankle arthritis had the highest FP (0.95, 95% CI 0.81-1.08), whereas neuromas and mid/hindfoot diagnoses had the lowest FPs (0.46, 95% CI 0.23-0.68; 0.62, 95% CI 0.45-0.80). Higher preoperative expectations were correlated with lower fulfillment proportions. CONCLUSION: FP varied with diagnosis and preoperative expectations. An understanding of current expectation fulfillment among different diagnoses in foot and ankle surgery helps highlight areas for improvement in the management of expectations for presumed diagnoses. LEVEL OF EVIDENCE: Level III, retrospective review of prospective cohort study.

Early Radiographic Outcomes of Minimally Invasive Chevron Bunionectomy Compared to the Modified Lapidus Procedure.

Background: Minimally invasive (MIS) bunion surgery has become increasingly popular. Although early reports on outcomes have been encouraging, no study to date has compared outcomes from the MIS chevron and Akin procedures to the modified Lapidus procedure. Our primary aim was to compare early radiographic outcomes of the MIS chevron and Akin osteotomies to those of the modified Lapidus procedure in patients with comparable deformities, and secondarily to compare clinical outcomes. Methods: Patients were retrospectively reviewed for inclusion from a prospectively collected foot and ankle registry. Patients were eligible if they underwent either the MIS bunionectomy or modified Lapidus procedure and had preoperative and minimum 5-month postoperative weightbearing radiographs. Forty-one patients who underwent MIS bunionectomy were matched to 41 patients who underwent Lapidus bunionectomy based on radiographic parameters. Demographics, radiographic parameters, complications, reoperations, and PROMIS scores were compared between groups. Results: Both groups achieved similar radiographic correction. There was no significant difference in pre- or postoperative PROMIS scores between groups. Procedure duration was significantly faster in the MIS group (P < .001). Bunion recurrence (hallux valgus angle ≥20 degrees) occurred in 1 MIS patient and 2 Lapidus patients, with all patients asymptomatic. The most common reason for reoperation was removal of hardware (4 patients in the MIS group, 2 patients in the Lapidus group). Conclusion: This is the first study to our knowledge to compare early radiographic outcomes between MIS bunionectomy and the modified Lapidus procedure in patients matched for bunion severity. We found that patients with similar preoperative deformities experience similar radiographic correction following MIS chevron and Akin osteotomies vs modified Lapidus bunionectomy. Further research is needed to investigate satisfaction differences between the procedures, longer-term outcomes, and which deformities are best suited to each procedure. Level of Evidence: Level III, Retrospective case control study.

Association of Depression and Anxiety With Expectations and Satisfaction in Foot and Ankle Surgery.

INTRODUCTION: Mental health diagnoses involving depression or anxiety are common and can have a dramatic effect on patients with musculoskeletal pathologies. In orthopaedics, depression/anxiety (D/A) is associated with worse postoperative patient-reported outcomes. However, few studies have assessed the effect of D/A on expectations and satisfaction in foot and ankle patients. METHODS: Adult patients undergoing elective foot and ankle surgery were prospectively enrolled. Preoperatively, patients completed the eight-item Patient Health Questionnaire Depression Scale, Generalized Anxiety Disorder Screener-7, Foot and Ankle Outcome Score (FAOS), and Expectations Survey. At 2 years postoperatively, surveys including satisfaction, improvement, and fulfillment of expectations were administered. Fulfillment of expectations (fulfillment proportion) and FAOS scores were compared between patients with D/A and non-D/A patients. RESULTS: Of 340 patients initially surveyed, 271 (80%) completed 2-year postoperative expectations surveys. One in five patients had D/A symptoms. Preoperatively, D/A patients had greater expectations of surgery (P = 0.015). After adjusting for measured confounders, the average 2-year postoperative fulfillment proportion was not significantly lower among D/A compared with non-D/A (0.86 versus 0.78, P = 0.2284). Although FAOS scores improved postoperatively for both groups, D/A patients had significantly lower preoperative and postoperative FAOS scores for domains of symptoms, activity, and quality of life (P < 0.05 for all). D/A patients reported less improvement (P = 0.036) and less satisfaction (P = 0.005) and were less likely willing to recommend surgery to others (P = 0.011). DISCUSSION: Patients with D/A symptoms had higher preoperative expectations of surgery. Although D/A patients had statistically similar rates of fulfillment of expectations compared with non-D/A patients, they had markedly lower FAOS scores for domains of symptoms, activity, and quality of life. D/A patients also perceived less improvement and were more often dissatisfied with their outcomes. These findings should not dissuade providers from treating these patients surgically but rather emphasize the importance of careful patient selection and preoperative expectation management. LEVEL OF EVIDENCE: Level III; retrospective review of prospective cohort study.

Avascular Necrosis of the Talus After Subchondroplasty.

BACKGROUND: Subchondroplasty (SCP) is a relatively new procedure, developed in 2007 for the treatment of bone marrow lesions (BMLs), that has shown promising results in the knee through several different case series. The foot and ankle literature, however, is sparse, with only a few documented case reports or case series. At our institution, we have identified several patients with complications after this specific procedure. As a result, we report our case series of patients who developed talar avascular necrosis (AVN) after undergoing SCP. METHODS: A retrospective review was performed of patients who underwent SCP for a talar BML at our facility or who were referred to our facility after undergoing SCP at an outside institution. Patients were included if they developed radiographic evidence of talar AVN after the procedure. Patient demographics, comorbidities, concomitant intraoperative procedures, complications, and subsequent interventions were reviewed. RESULTS: Seven patients were identified as having radiographic evidence of talar AVN after SCP. Average time interval was 23 months postoperative from index procedure to radiographic confirmation of AVN. Two of the index procedures were performed at our institution, whereas 5 of the index procedures were performed at outside institutions and referred for further management. Three patients had documented risk factors for AVN before the SCP procedure. All 7 patients were symptomatic from the AVN. CONCLUSION: We identified 7 patients who went on to develop talar AVN after having undergone SCP. LEVEL OF EVIDENCE: Level IV, case series.

Timeline for maximal subjective outcome improvement following total ankle arthroplasty.

BACKGROUND: Maximal medical improvement (MMI) establishes the timepoint when patients no longer experience clinically significant improvements following surgery. The purpose of this investigation is to establish when patients achieve MMI following total ankle arthroplasty (TAA) through the use of patient reported outcome measures (PROMs). METHODS: A systematic review to identify studies on TAA which reported consecutive PROMs for two years postoperatively was performed. Pooled analysis was done at 6 months, 12 months, and 24 months. Clinically significant improvement was defined as improvement between time intervals exceeding the minimal clinically important difference. RESULTS: Twelve studies and 1514 patients met inclusion criteria. Clinically significant improvement was seen up to 6 months postoperatively in both the American Orthopaedic Foot and Ankle Society Ankle Hindfoot Score and Visual Analog Scale scoring systems. The Short Musculoskeletal Function Assessment Dysfunction and Bother subsections showed maximal clinically significant improvement by 1 year postoperatively. CONCLUSION: Following TAA, MMI is seen by one year postoperatively. Physicians may allocate the majority of resources within the first year when most of the improvement is perceived. This data may help inform preoperative counseling as it establishes a timeline for MMI. LEVEL OF EVIDENCE: IV.

Radiographic and Clinical Outcomes of Hallux Valgus and Metatarsus Adductus Treated With a Modified Lapidus Procedure.

BACKGROUND: Previous studies have found an increased rate of deformity recurrence in hallux valgus (HV) patients with concomitant metatarsus adductus (MA) undergoing metatarsal osteotomies. The purpose of this paper was to determine if there were radiographic or clinical outcome differences between HV patients with and without MA undergoing a modified Lapidus procedure. METHODS: One hundred forty-seven feet that underwent a modified Lapidus procedure for HV were divided into 2 groups based on their preoperative modified Sgarlato's angle: (1) the MA group had an angle ≥20 degrees and (2) the HV-only group had an angle <20 degrees. HV angle (HVA) and intermetatarsal angle (IMA) were measured on preoperative and ≥5-month postoperative weightbearing radiographs. Patient-Reported Outcome Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores were obtained preoperatively and postoperatively. RESULTS: Patients in the MA group had a significantly higher mean postoperative HVA (10.8 vs 7.5 degrees; P = .038). There was a trend toward higher PROMIS PI scores in the MA group at 1 year postoperatively (51.9 vs 47.6; P = .088). Patients in the MA group were more likely to have a revision surgery (7.3% vs 0%; P = .021), and there was a trend toward those patients having a higher recurrence rate (17.1% vs 6.6%; P = .064). CONCLUSION: Despite potentially worse postoperative outcomes in patients with HV and MA who undergo a modified Lapidus procedure, the recurrence rates reported here are lower than those reported in the literature for patients with MA undergoing metatarsal osteotomies, indicating that a modified Lapidus procedure may be an acceptable choice in these patients. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Association Between Baseline PROMIS Scores, Patient-Provider Communication Factors, and Musculoskeletal Health Literacy on Patient and Surgeon Expectations in Foot and Ankle Surgery.

BACKGROUND: Various factors may affect differences between patient and surgeon expectations. This study aimed to assess associations between patient-reported physical and mental status, patient-surgeon communication, and musculoskeletal health literacy with differences in patient and surgeon expectations of foot and ankle surgery. METHODS: Two hundred two patients scheduled to undergo foot or ankle surgery at an academic hospital were enrolled. Preoperatively, patients and surgeons completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey. Patients also completed Patient-Reported Outcomes Measurement Information System (PROMIS) scores in Physical Function, Pain Interference, Pain Intensity, Depression, and Global Health. Patient-surgeon communication and musculoskeletal health literacy were assessed via the modified Patients' Perceived Involvement in Care Scale (PICS) and Literacy in Musculoskeletal Problems (LiMP) questionnaire, respectively. RESULTS: Greater differences in patient and surgeon overall expectations scores were associated with worse scores in Physical Function (P = .003), Pain Interference (P = .001), Pain Intensity (P = .009), Global Physical Health (P < .001), and Depression (P = .009). A greater difference in the number of expectations between patients and surgeons was associated with all of the above (P ≤ .003) and with worse Global Mental Health (P = .003). Patient perceptions of higher surgeons' partnership building were associated with a greater number of patient than surgeon expectations (P = .017). There were no associations found between musculoskeletal health literacy and differences in expectations. CONCLUSION: Worse baseline patient physical and mental status and higher patient perceptions of provider partnership building were associated with higher patient than surgeon expectations. It may be beneficial for surgeons to set more realistic expectations with patients who have greater disability and in those whom they have stronger partnerships with. Further studies are warranted to understand how modifications in patient and surgeon interactions and patient health literacy affect agreement in expectations of foot and ankle surgery. LEVEL OF EVIDENCE: Level II, prospective comparative series.

Prevalence of Hallux Rigidus in Patients With End-Stage Ankle Arthritis.

Arthritis of the foot is a significant cause of pain and disability. The prevalence of foot arthritis in adults aged ≥50 has been reported to be 17%. Of those, 25% are estimated to be radiographic arthritis of the first metatarsophalangeal joint. The purposes of this study were to (1) identify the prevalence of radiographic hallux rigidus (HR) in a population of patients with end-stage ankle arthritis relative to that reported in the general population and (2) identify associations between the presence of HR and demographic and clinical factors. A total of 870 feet in 809 subjects with end-stage ankle arthritis who underwent primary total ankle arthroplasty between November 2006 and November 2017 were included. Feet were stratified by patient age: <40, 40 to 59, 60 to 79, and ≥80 years. Etiology of ankle arthritis was classified as inflammatory, post-traumatic, primary, and other. The prevalence of HR in the study group was 72.9%. The prevalence of HR was slightly higher in patients with inflammatory arthritis (odds ratio 1.31, 95% confidence interval 0.73 to 2.32) and primary arthritis (odds ratio 1.18, 95% confidence interval 0.86 to 1.63). The prevalence of HR increased with age (p = .01). In conclusion, the prevalence of radiographic HR in a population with end-stage ankle arthritis was significantly higher relative to patients without documented comorbidities in the foot and ankle. Increasing age was associated with a higher prevalence of the disease.

Comparison of Patients' and Surgeons' Expectations in Foot and Ankle Surgery.

BACKGROUND: Aligning patient and surgeon expectations may improve patient satisfaction and outcomes. This study aimed to assess differences in expectations of foot and ankle surgery between patients and their surgeons. METHODS: Two hundred two patients scheduled to undergo foot or ankle surgery by one of 7 fellowship-trained foot and ankle surgeons were enrolled. Preoperatively, patients and surgeons completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey independently. Differences between patient and surgeon overall expectations scores, number of expectations, and number of expectations with complete improvement expected were assessed. A difference of ≥10 points was considered a clinically important difference in expectations score. Associations between patient demographic and clinical characteristics, major/minor surgery, and individual surgeon with differences in expectations were also assessed. RESULTS: Overall, 66.3% of patients had higher expectations, 21.3% had concordant expectations, and 12.4% had lower expectations compared with their surgeons. On average, patients had higher expectations scores than their surgeons (70 ± 20 vs 52 ± 20 points, P < .001). Patients expected complete improvement in a greater number of expectations than surgeons (mean 11 ± 7 vs 1 ± 3, P < .001). Patients had higher expectations than surgeons for 18 of 23 items (78%). Items that had the greatest number of patients with higher expectations than surgeons were "improve confidence in foot/ankle," "prevent foot/ankle from getting worse," and "improve pain at rest." Higher body mass index (BMI) (P = .027) and individual surgeon (P < .001) were associated with greater differences between patient-surgeon expectations. Major/minor surgery was not associated with differences in expectations (P ≥ .142). CONCLUSION: More than two-thirds of patients had significantly higher expectations than their surgeons. Higher BMI was associated with higher patient than surgeon expectations. These results emphasize the importance for foot and ankle surgeons to adequately educate patients preoperatively. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Contribution of First-Tarsometatarsal Joint Fusion to Deformity Correction in the Treatment of Adult-Acquired Flatfoot Deformity.

BACKGROUND: Severe adult-acquired flatfoot deformity (AAFD) is often associated with painful medial column collapse at the naviculocuneiform (NC) joint. However, many surgeons surgically correct the deformity without directly addressing this joint. The purpose of this study was to examine the role of first-tarsometatarsal (TMT) fusion combined with subtalar fusion in correcting deformity at the NC joint. METHODS: We retrospectively analyzed 40 patients (41 feet) who underwent first-TMT and subtalar (ST) fusion as part of a flatfoot reconstructive procedure. We assessed 6 radiographic parameters both preoperatively and at a minimum of 6 months postoperatively, including talonavicular (TN) coverage angle, lateral talo-first metatarsal angle, lateral talocalcaneal angle, calcaneal pitch, hindfoot moment arm, and a newly defined navicular-cuneiform incongruency angle (NCIA). Patient-Reported Outcomes Measurement Information System (PROMIS) clinical outcomes were assessed preoperatively and at a minimum 1-year follow-up. RESULTS: The NCIA demonstrated excellent interobserver reliability, with no significant change between pre- and postoperative measurements. All other radiographic parameters, except calcaneal pitch, demonstrated statistically significant improvement postoperatively (P < .01). Overall, patients had statistically significant improvement in all PROMIS domains (P < .01), except for depression. Worsening NC deformity was not associated with worse patient-reported outcomes. CONCLUSIONS: Our data suggest that when addressing painful collapse of the medial arch in patients with AAFD, fusion of the first-TMT joint in combination with other procedures leads to acceptable radiographic and clinical outcomes. There was no change in deformity at the NC joint in our patient cohort at short-term follow-up, and patients achieved significant improvement in multiple PROMIS domains. Although TMT fusion had no effect on NC deformity, residual or worsening NC deformity did not significantly affect clinical outcomes. In addition, the NCIA was found to be a reliable radiographic parameter to assess NC deformity in the presence of talonavicular and/or first-TMT fusion. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Effect of the Modified Lapidus Procedure for Hallux Valgus on Foot Width.

BACKGROUND: Despite the importance of shoe wear to patients with hallux valgus (HV), few studies have investigated changes in foot width following surgery in this population. The purpose of our study was to determine if the modified Lapidus procedure would effectively decrease foot width in patients with HV. METHODS: Thirty-one feet (19 left, 12 right) in 30 patients (29 females, 1 male) who underwent a modified Lapidus procedure in combination with a modified McBride and Akin osteotomy for treatment of HV were included in the study. All patients had preoperative and at least 5-month postoperative imaging, consisting of both weightbearing radiographs and computed tomography (WBCT) scans, which were used to measure bony and soft tissue foot widths pre- and postoperatively by 2 independent observers. RESULTS: Intraclass correlation coefficients (ICCs) demonstrated high interobserver reliability (all ICCs >0.90). Bony foot width decreased significantly, by a mean of 8.9 mm (9.1%) on radiographs and 7.9 mm (8.4%) on WBCT scans (P < .001). The soft tissue foot width also decreased significantly, by a mean of 6.9 mm (6.3%) on radiographs and 6.7 mm (6.4%) on WBCT scans (P < .001). Changes in the hallux valgus angle and intermetatarsal angle correlated with changes in bony foot width on WBCTs (both r > 0.4, P < .02). CONCLUSIONS: The modified Lapidus procedure in combination with a modified McBride and Akin osteotomy resulted in statistically significant changes in both bony and soft tissue foot width. Patients should be counseled that foot width decreases, on average, by 0.5 to 1 cm. LEVEL OF EVIDENCE: Level III, comparative series.

Fulfillment of Expectations After Orthopedic Foot and Ankle Surgery.

BACKGROUND: To date, no study has assessed fulfillment of patients' expectations after foot and ankle surgery. This study aimed to validate a method of assessing expectation fulfillment in foot/ankle patients postoperatively. METHODS: Preoperatively, patients completed the expectations survey, consisting of 23 questions for domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfillment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. The FP ranges from 0 (no expectations fulfilled), to between 0 and 1 (expectations partially fulfilled), to 1 (expectations met), to greater than 1 (expectations surpassed). Receiver operating characteristic (ROC) curves and areas under the curve (AUCs) with 95% confidence intervals (CIs) were used to compare the expectations survey to other outcome surveys, including Foot and Ankle Outcome Score, improvement, overall fulfillment, Delighted-Terrible scale, and satisfaction. RESULTS: Of the 271 patients (mean age 55.4 years, mean BMI 27.5, 65% female), 34% had expectations surpassed (FP >1), 4% had expectations met, 58% had expectations partially fulfilled (FP between 0 and 1), and 5% had no expectations met. The mean FP was 0.84 ± 0.41 (range 0-3.13), indicating partially fulfilled expectations. FP correlated significantly with all outcome measures (P ≤ .007). FP was associated most closely with satisfaction (r = 0.66 [95% CI 0.57-0.75]; AUC = 0.92 [95% CI 0.88-0.96]; P < .001) and improvement (r = 0.73 [95% CI 0.64-0.81]; AUC = 0.94 [95% CI 0.91-0.96]; P < .001). Based on the associations with satisfaction and improvement outcomes, a clinically important proportion of expectations fulfilled is 0.68, with sensitivity 0.85-0.90 and specificity 0.84-0.86. CONCLUSION: The proportion of expectations fulfilled is a novel patient-centered outcome that correlated with validated outcome measures. The expectations survey may be used by surgeons to counsel patients preoperatively and also to assess patients' results postoperatively. LEVEL OF EVIDENCE: Level II, prospective comparative series.

Vascularized Pedicle Graft for Talar Osteonecrosis.

Vascularized bone grafting for talar avascular osteonecrosis is indicated for patients with modified Ficat and Arlet stage I to III disease with minimal subchondral collapse. Outcomes may be more durable than core decompression alone, especially in patients with more advanced disease. Our preferred method, described in this article, involves core decompression followed by use of a vascularized cuboid pedicle graft placed in the defect. Outcomes reported in a small case series have been encouraging, with more than 80% of patients requiring no further surgery.

Risk Factors for Failure of Total Ankle Arthroplasty With a Minimum Five Years of Follow-up.

BACKGROUND:: As the popularity of total ankle arthroplasty (TAA) increases and indications expand, surgeons require a better understanding of which patient factors are associated with implant failure. In this study, we aimed to use a large total ankle database to identify independent risk factors for implant failure at mid- to long-term follow-up. METHODS:: A prospectively collected database was used to identify all patients who underwent primary TAA with a minimum 5 years' follow-up. The primary outcome was revision, defined as removal of one or both metal components; failures due to infection were excluded. Patient and clinical factors analyzed included age, sex, body mass index (BMI), smoking status, presence of diabetes, indication for TAA, implant, tourniquet time, and presence of ipsilateral hindfoot fusion. Preoperative coronal deformity and sagittal talar translation were assessed, as were postoperative coronal and sagittal tibial component alignment. Univariable and multivariable analyses were performed to identify predictors of implant failure. After excluding 5 ankles that failed because of deep infection, 533 ankles with a mean 7 (range, 5-11) years of follow-up met the inclusion criteria. Four implants were used: INBONE I, INBONE II, STAR, and Salto-Talaris. RESULTS:: Thirty-four ankles (6.4%) were revised or removed a mean 4 (range, 1-9) years postoperatively. The only independent predictors of failure were the INBONE I prosthesis and ipsilateral hindfoot fusion ( P = .006 and P = .023, respectively). CONCLUSIONS:: This is among the largest studies to analyze the relationship between TAA failure rates and multiple different patient, operative, and radiographic factors. Of note, age, BMI, and amount of deformity were not associated with higher failure rates. Only patients with ipsilateral hindfoot fusion or who received the INBONE I prosthesis were at significantly higher risk of implant failure. LEVEL OF EVIDENCE:: Level III, retrospective cohort study.

Lower Bone Density on Preoperative Computed Tomography Predicts Periprosthetic Fracture Risk in Total Ankle Arthroplasty.

BACKGROUND:: The effect of bone mineral density (BMD) on outcomes from total ankle arthroplasty (TAA) has not been studied. BMD can be estimated by measuring Hounsfield units (HU) on standard computed tomography (CT), which is frequently performed prior to TAA. We aimed to identify whether tibial and talar HU measured from preoperative CT scans were associated with periprosthetic fracture or revision risk in patients undergoing TAA. METHODS:: A prospectively collected database was used to retrospectively screen all patients undergoing primary TAA. Only patients with a preoperative CT within 1 year of surgery were included. Primary outcomes were periprosthetic fracture and prosthetic revision. HU were measured on axial CT cuts in the distal tibia and talus. Additional patient factors analyzed included age, sex, weight, body mass index (BMI), tobacco use, presence of rheumatoid arthritis, and preoperative deformity. A total of 198 ankles were included, with a mean 2.4 years of follow-up. RESULTS:: There were 7 intraoperative and 9 postoperative periprosthetic fractures (3.5% and 4.5%, respectively). Seven patients (3.5%) underwent prosthetic removal or revision. Lower tibial and talar HU, lower weight, and lower BMI were associated with periprosthetic fractures ( P < .05). After controlling for age, sex, and weight, only tibial HU was significantly associated with periprosthetic fracture ( P = .018). All intraoperative fractures occurred in patients with tibial HU less than 200. None of the patient factors analyzed were associated with revision. CONCLUSIONS:: Lower tibial HU on preoperative CT was strongly associated with periprosthetic fracture risk with TAA. In patients with tibial HU less than 200, surgeons may consider prophylactic internal fixation of the medial malleolus. LEVEL OF EVIDENCE:: Level III, retrospective cohort study.

Outcomes of Total Ankle Arthroplasty in Moderate and Severe Valgus Deformity.

Introduction. Failure to correct coronal deformity at the time of total ankle arthroplasty (TAA) can lead to early implant failure. We aimed to determine clinical, radiographic, and patient-reported outcomes of patients with moderate to severe valgus deformity who underwent TAA for end-stage ankle arthritis. Methods. Patients with a valgus deformity of at least 10° who underwent TAA were retrospectively reviewed. The coronal tibiotalar angle was assessed on radiographs preoperatively, at 1 year, and at final follow-up. The visual analog scale (VAS) for pain, Short Form-36 (SF-36), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle scale, and Short Musculoskeletal Function Assessment (SMFA) scores were assessed preoperatively and at final follow-up. Results. Mean preoperative valgus deformity was 15.5 ± 5.0°, and was corrected to a mean of 1.2 ± 2.6° of valgus postoperatively. VAS, SF-36, AOFAS, and SMFA scores improved significantly (P < .001 for all). There was no significant change in tibiotalar angle between 1 year and final follow-up in either group. Reoperation and revision rates did not differ between groups. Conclusion. Correction of coronal alignment was achieved and maintained in patients with both moderate and severe preoperative valgus malalignment. Outcome scores significantly improved for all patients. Levels of Evidence: Therapeutic, Level IV.

Increased Early Revision Rate With the INFINITY Total Ankle Prosthesis.

BACKGROUND:: A number of new 2-component total ankle arthroplasty systems that emphasize minimal bone resection have been introduced for which few clinical outcomes reports are available. Our aim was to identify the rate of early revision among patients receiving the 2-component INFINITY prosthesis. METHODS:: Patients from 2 prospectively collected databases at the authors' institution were screened for inclusion in the present study. All patients who underwent a primary total ankle arthroplasty (TAA) with the INFINITY prosthesis and who were at least 1 year postoperative were included. A total of 159 ankles with a mean 20 months of follow up (range, 12-37) met these criteria. All surgeries were performed by 1 of 2 orthopedic foot and ankle surgeons with extensive experience in TAA. The primary outcome was the need for revision surgery, defined as removal of 1 or both metal components. Peri-implant lucency at most recent follow-up was a secondary outcome. Weightbearing radiographs at most recent follow-up were graded for lucency independently by 2 reviewers. RESULTS:: Sixteen ankles (10%) underwent revision at a mean 13 months postoperatively. The most common reasons for revision were symptomatic tibial component loosening and deep infection (6 patients each, 3.8%). Of the 108 ankles with retained components and at least 1 year of radiographic follow-up, 8 (7.4%) had global lucency around the tibial component suggestive of loosening at most recent follow-up. CONCLUSIONS:: Our initial review of patients undergoing TAA with this new 2-component prosthesis demonstrates an elevated early revision rate due to tibial component loosening compared to other implant systems. LEVEL OF EVIDENCE:: Level IV, case series.