A flexion osteotomy for correction of a distal tibial recurvatum deformity: a retrospective case series.

AIMS: There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure. PATIENTS AND METHODS: A total of 39 patients (12 women, 27 men; mean age 47 years (28 to 72)) with a distal tibial recurvatum deformity were treated with a flexion osteotomy, between 2010 and 2015. Nine patients (23%) subsequently required conversion to either a total ankle arthroplasty (seven) or an arthrodesis (two) after a mean of 21 months (9 to 36). A total of 30 patients (77%), with a mean follow-up of 30 months (24 to 76), remained for further evaluation. Functional outcome, sagittal ankle joint OA using a modified Kellgren and Lawrence Score, tibial lateral surface (TLS) angle, and talar offset ratio (TOR) were evaluated on pre- and postoperative weight-bearing radiographs. RESULTS: Postoperatively, the mean score for pain, using a visual analogue scale, decreased significantly from 4.3 to 2.5 points and the mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly from 59 to 75 points (both p < 0.001). The mean TLS angle increased significantly by 6.6°; the mean TOR decreased significantly by 0.24 (p < 0.001). Radiological evaluation showed an improvement or no progression of sagittal ankle joint OA in 32 ankles (82%), while seven ankles (18%) showed further progression. CONCLUSION: A flexion osteotomy effectively improved the congruency of the ankle joint. In 30 patients (77%), the joint could be saved, whereas in nine patients (23%), the treatment delayed a joint-sacrificing procedure. Cite this article: Bone Joint J 2019;101-B:682-690.

Arthroscopically assisted fixation of Hawkins type II talar neck fractures: a case series.

Aims: Arthroscopically controlled fracture reduction in combination with percutaneous screw fixation may be an alternative approach to open surgery to treat talar neck fractures. The purpose of this study was thus to present preliminary results on arthroscopically reduced talar neck fractures. Patients and Methods: A total of seven consecutive patients (four women and three men, mean age 39 years (19 to 61)) underwent attempted surgical treatment of a closed Hawkins type II talar neck fracture using arthroscopically assisted reduction and percutaneous screw fixation. Functional and radiological outcome were assessed using plain radiographs, as well as weight-bearing and non-weight-bearing CT scans as tolerated. Patient satisfaction and pain sensation were also recorded. Results: Primary reduction was obtained arthroscopically in all but one patient, for whom an interposed fracture fragment had to be removed through a small arthrotomy to permit anatomical reduction. The quality of arthroscopic reduction and restoration of the talar geometry was excellent in the remaining six patients. There were no signs of talar avascular necrosis or subtalar degeneration in any of the patients. In the whole series, the functional outcome was excellent in five patients but restricted ankle movement was observed in two patients. All patients had a reduction in subtalar movement. At final follow-up, all patients were satisfied and all but one patient were pain free. Conclusion: Arthroscopically assisted reduction and fixation of talar neck fractures was found to be a feasible treatment option and allowed early functional rehabilitation. Cite this article: Bone Joint J 2018;100-B:461-7.

[Triple arthrodesis for correction of cavovarus deformity]. / Die Triplearthrodese als Baustein für die Korrektur der Pes-cavovarus-Deformität.

OBJECTIVE: The aim is to correct the underlying cavovarus deformity and to achieve a pain-free and stable hindfoot. INDICATIONS: Rigid neurologic, posttraumatic, congenital, and idiopathic cavovarus deformities. CONTRAINDICATIONS: General surgical or anesthesiological risks, infections, critical soft tissue conditions, neurovascular impairment of the lower extremity, noncompliance, patients with severely reduced bone quality, insulin-dependent diabetes mellitus, smoking. SURGICAL TECHNIQUE: The talonavicular and subtalar joints are exposed using a single medial approach. Joint cartilage is carefully debrided. Hindfoot reposition with complete correction of cavovarus deformity in all three planes. Joints are stabilized using cannulated screws, followed by wound closure. POSTOPERATIVE MANAGEMENT: A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 using a stabilizing walking boot or cast for 6 weeks with 15 kg partial weight bearing. Clinical and radiographic follow-up 6 weeks postoperatively to assess osseous consolidation at the arthrodesis site. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is gradually initiated. RESULTS: Between January 2012 and July 2014, triple arthrodesis was performed in 11 patients with a mean age of 62 ± 14 years due to cavovarus deformity. The mean follow-up was 34 ± 8 months (range 24-48 months). In all patients, the cavovarus deformity was substantially corrected. Significant pain relief from 7.1 ± 2.2 (range 5-10) to 1.8 ± 1.5 (range 0-4) on the visual analogue scale was observed.

[Aseptic loosening of total ankle replacement and conversion to ankle arthrodesis]. / Aseptische Lockerung einer OSG­Endoprothese und Konversion zur OSG­Arthrodese.

OBJECTIVE: To remove loosened prosthesis components, to perform augmentation, to address osseous defects, to perform neutrally aligned ankle arthrodesis, and to achieve postoperative pain relief. INDICATIONS: Symptomatic, aseptic loosening of total ankle replacement (TAR) with/without substantial bone defect of the tibial and/or talar bone stock. CONTRAINDICATIONS: General surgical or anesthesiological risks, periprosthetic infection, local or systemic infection, nonmanageable soft tissue problems. SURGICAL TECHNIQUE: Removal of both prosthesis components using the previous incision (mostly using anterior ankle approach). Careful debridement of bone stock at the tibial and talar side. Osseous augmentation of defects using autologous or homologous cancellous bone, if needed, using structural allografts. POSTOPERATIVE MANAGEMENT: A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot or cast for 6-8 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated gradually after progressive osseous healing has been confirmed. RESULTS: Between January 2007 and December 2012, ankle arthrodesis was performed in 9 patients with failed TAR (6 men and 3 women, mean age 56.4 ± 7.0 years, range 47.8-66.0 years). The mean time between the initial TAR and revision surgery was 4.5 ± 2.4 years (range 1.2-7.9 years). In one patient irrigation and debridement was performed due to superficial wound infection. Another patient had a delayed osseous healing 11 months after the revision surgery.

Custom-made total ankle arthroplasty for the salvage of major talar bone loss.

AIMS: A failed total ankle arthroplasty (TAA) is often associated with much bone loss. As an alternative to arthrodesis, the surgeon may consider a custom-made talar component to compensate for the bone loss. Our aim in this study was to assess the functional and radiological outcome after the use of such a component at mid- to long-term follow-up. PATIENTS AND METHODS: A total of 12 patients (five women and seven men, mean age 53 years; 36 to77) with a failed TAA and a large talar defect underwent a revision procedure using a custom-made talar component. The design of the custom-made components was based on CT scans and standard radiographs, when compared with the contralateral ankle. After the anterior talocalcaneal joint was fused, the talar component was introduced and fixed to the body of the calcaneum. RESULTS: At a mean follow-up of 6.9 years (1 to 13), 11 ankles were stable with no radiological evidence of loosening. Only one was lost to follow-up. The mean arc of movement was 21° (10° to 35°). A total of nine patients (75%) were satisfied or very satisfied with the outcome, two (17%) were satisfied but with reservations and one (8%) was not satisfied. All but one patient had an improvement in the American Orthopaedic Foot and Ankle Society hindfoot score (p = 0.01). Just one patient developed deep infection, leading to arthrodesis. CONCLUSION: A custom-made talar component yielded satisfactory results with regard to function, stability and satisfaction. This should encourage the use of such components as an alternative to arthrodesis of the ankle in patients with a failed TAA. Cite this article: Bone Joint J 2017;99-B:231-6.

Treatment of extended osteochondral lesions of the talus with a free vascularised bone graft from the medial condyle of the femur.

Large osteochondral lesions (OCLs) of the shoulder of the talus cannot always be treated by traditional osteochondral autograft techniques because of their size, articular geometry and loss of an articular buttress. We hypothesised that they could be treated by transplantation of a vascularised corticoperiosteal graft from the ipsilateral medial femoral condyle. Between 2004 and 2011, we carried out a prospective study of a consecutive series of 14 patients (five women, nine men; mean age 34.8 years, 20 to 54) who were treated for an OCL with a vascularised bone graft. Clinical outcome was assessed using a visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. Radiological follow-up used plain radiographs and CT scans to assess graft incorporation and joint deterioration. At a mean follow-up of 4.1 years (2 to 7), the mean VAS for pain had decreased from 5.8 (5 to 8) to 1.8 (0 to 4) (p = 0.001) and the mean AOFAS hindfoot score had increased from 65 (41 to 70) to 81 (54 to 92) (p = 0.003). Radiologically, the talar contour had been successfully reconstructed with stable incorporation of the vascularised corticoperiosteal graft in all patients. Joint degeneration was only seen in one ankle. Treatment of a large OCL of the shoulder of the talus with a vascularised corticoperiosteal graft taken from the medial condyle of the femur was found to be a safe, reliable method of restoring the contour of the talus in the early to mid-term.

[Lateral column lengthening osteotomy of calcaneus]. / Laterale Verlängerungsosteotomie des Kalkaneus.

OBJECTIVE: Lengthening of the lateral column for adduction of forefoot and restoration of the medial arch. Stabilization of the ankle joint complex. INDICATIONS: Supple flatfoot deformity (posterior tibial tendon dysfunction stage II). Instability of the medial ankle joint complex (superficial deltoid and spring ligament). Posttraumatic valgus and pronation deformity of the foot. CONTRAINDICATIONS: Rigid flatfoot deformity (posterior tibial tendon dysfunction stage III and IV). Talocalcaneal and naviculocalcaneal coalition. Osteoarthritis of calcaneocuboid joint. SURGICAL TECHNIQUE: Exposition of calcaneus at sinus tarsi. Osteotomy through sinus tarsi and widening until desired correction of the foot is achieved. Insertion of bone graft. Screw fixation. POSTOPERATIVE MANAGEMENT: Immobilization in a cast for 6 weeks. Weight-bearing as tolerated from the beginning. RESULTS: In the majority of cases, part of hindfoot reconstruction. Reliable and stable correction. Safe procedure with few complications.

Osteoligamentous injuries of the medial ankle joint.

Injuries of the ankle joint have a high incidence in daily life and sports, thus, playing an important socioeconomic role. Therefore, proper diagnosis and adequate treatment are mandatory. While most of the ligament injuries around the ankle joint are treated conservatively, great controversy exists on how to treat deltoid ligament injuries in ankle fractures. Missed injuries and inadequate treatment of the medial ankle lead to inferior outcome with instability, progressive deformity, and ankle joint osteoarthritis.

Mid- to long-term outcome of 96 corrective hindfoot fusions in 84 patients with rigid flatfoot deformity.

Talonavicular and subtalar joint fusion through a medial incision (modified triple arthrodesis) has become an increasingly popular technique for treating symptomatic flatfoot deformity caused by posterior tibial tendon dysfunction. The purpose of this study was to look at its clinical and radiological mid- to long-term outcomes, including the rates of recurrent flatfoot deformity, nonunion and avascular necrosis of the dome of the talus. A total of 84 patients (96 feet) with a symptomatic rigid flatfoot deformity caused by posterior tibial tendon dysfunction were treated using a modified triple arthrodesis. The mean age of the patients was 66 years (35 to 85) and the mean follow-up was 4.7 years (1 to 8.3). Both clinical and radiological outcomes were analysed retrospectively. In 86 of the 95 feet (90.5%) for which radiographs were available, there was no loss of correction at final follow-up. In all, 14 feet (14.7%) needed secondary surgery, six for nonunion, two for avascular necrosis, five for progression of the flatfoot deformity and tibiotalar arthritis and one because of symptomatic overcorrection. The mean American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score) at final follow-up was 67 (between 16 and 100) and the mean visual analogue score for pain 2.4 points (between 0 and 10). In conclusion, modified triple arthrodesis provides reliable correction of deformity and a good clinical outcome at mid- to long-term follow-up, with nonunion as the most frequent complication. Avascular necrosis of the talus is a rare but serious complication of this technique.

The treatment and outcome of peri-prosthetic infection of the ankle: a single cohort-centre experience of 34 cases.

The treatment of peri-prosthetic joint infection (PJI) of the ankle is not standardised. It is not clear whether an algorithm developed for hip and knee PJI can be used in the management of PJI of the ankle. We evaluated the outcome, at two or more years post-operatively, in 34 patients with PJI of the ankle, identified from a cohort of 511 patients who had undergone total ankle replacement. Their median age was 62.1 years (53.3 to 68.2), and 20 patients were women. Infection was exogenous in 28 (82.4%) and haematogenous in six (17.6%); 19 (55.9%) were acute infections and 15 (44.1%) chronic. Staphylococci were the cause of 24 infections (70.6%). Surgery with retention of one or both components was undertaken in 21 patients (61.8%), both components were replaced in ten (29.4%), and arthrodesis was undertaken in three (8.8%). An infection-free outcome with satisfactory function of the ankle was obtained in 23 patients (67.6%). The best rate of cure followed the exchange of both components (9/10, 90%). In the 21 patients in whom one or both components were retained, four had a relapse of the same infecting organism and three had an infection with another organism. Hence the rate of cure was 66.7% (14 of 21). In these 21 patients, we compared the treatment given to an algorithm developed for the treatment of PJI of the knee and hip. In 17 (80.9%) patients, treatment was not according to the algorithm. Most (11 of 17) had only one criterion against retention of one or both components. In all, ten of 11 patients with severe soft-tissue compromise as a single criterion had a relapse-free survival. We propose that the treatment concept for PJI of the ankle requires adaptation of the grading of quality of the soft tissues.

[Thromboembolic complications following ankle prosthesis implantation]. / Thrombembolische Komplikationen nach Sprunggelenkprothesenimplantation.

BACKGROUND: Total ankle replacement is becoming an increasingly used treatment for patients with degenerative arthritis of the ankle; however, there is limited literature available addressing the incidence of thromboembolic complications after total ankle replacement. Therefore, we performed a systematic literature review addressing thrombosis prophylaxis and incidence of thromboembolic complications after total ankle replacement. Furthermore, we evaluated the incidence of thromboembolic complications in our clinic. METHODS: A systemic literature review was performed using established medical literature data bases. The following information was retrieved from the literature: thrombosis prophylaxis and duration and deep vein thrombosis/pulmonary embolism as postoperative complication. The incidence of thromboembolic complications was evaluated in our patient cohort including 964 total ankle replacement procedures. RESULTS: A total of 21 clinical studies were included in the systematic literature review. The range of incidence of thromboembolic complications was between 0.0 % and 4.8 %. In our patient cohort the incidence of symptomatic deep vein thrombosis was 3.4 %. There were no cases of pulmonary embolism. All patients received low molecular weight heparin prophylaxis. CONCLUSION: The incidence of thromboembolic complications in our patient cohort was comparable to that of symptomatic deep vein thrombosis in patients undergoing total knee or hip replacement or ankle fusion. We suggest the prophylactic use of low molecular weight heparin for patients after total ankle replacement.

Corrective supramalleolar osteotomy for malunited pronation-external rotation fractures of the ankle.

We undertook a prospective study to analyse the outcome of 48 malunited pronation-external rotation fractures of the ankle in 48 patients (25 females and 23 males) with a mean age of 45 years (21 to 69), treated by realignment osteotomies. The interval between the injury and reconstruction was a mean of 20.2 months (3 to 98). In all patients, valgus malalignment of the distal tibia and malunion of the fibula were corrected. In some patients, additional osteotomies were performed. Patients were reviewed regularly, and the mean follow-up was 7.1 years (2 to 15). Good or excellent results were obtained in 42 patients (87.5%) with the benefit being maintained over time. Congruent ankles without a tilted talus (Takakura stage 0 and 1) were obtained in all but five cases. One patient required total ankle replacement.

[Medial pain syndrome in patients with total ankle replacement]. / Mediales Schmerzsyndrom nach Sprunggelenkprothesenimplantation.

Total ankle replacement is an increasingly recommended treatment for patients with end-stage ankle osteoarthritis. The increasing experience with this procedure explains its acceptance as a therapeutic option in complex cases as part of reconstruction surgery. However, the complication rate including failure of the prosthesis should not be underestimated. Previous studies have shown that most patients developed ankle osteoarthritis secondary to previous trauma. Patients with posttraumatic osteoarthritis often have varus or valgus misalignment of the hindfoot. In cases with incorrectly addressed hindfoot misalignment and/or incorrectly positioned prosthesis components, pain may remain postoperatively because of biomechanical dysbalance and asymmetrical load. The pain is mostly localized on the medial side the so-called medial pain syndrome.The following classification of the medial pain syndrome has been established in our practice: type I medial impingement/contracture of medial ligaments, type II valgus deformity, type III varus deformity, type IV combined varus-valgus deformity.

[Revision arthroplasty of the ankle joint]. / Revisionsarthroplastik des oberen Sprunggelenks.

In the last 20 years total ankle replacement has become a viable alternative to arthrodesis for end-stage osteoarthritis of the ankle. Numerous ankle prosthesis designs have appeared on the market in the past and attracted by the encouraging intermediate results reported in the literature, many surgeons have started to perform this procedure. With increased availability on the market the indications for total ankle replacement have also increased in recent years. In particular, total ankle replacement may now be considered even in younger patients. Therefore, despite progress in total ankle arthroplasty the number of failures may increase. Up to now, arthrodesis was considered to be the gold standard for salvage of failed ankle prostheses. Because of extensive bone loss on the talar side, in most instances tibiocalcaneal fusion is the only reliable solution. An alternative to such extended hindfoot fusions would be revision arthroplasty. To date, however, there are no reported results of revision arthroplasty for salvage of a failed ankle replacement.Based on our experience prosthetic components with a flat undersurface are most likely to be able to find solid support on remaining bone stock. The first 83 cases (79 patients, 46 males, 33 females, average age 58.9 years, range 30.6-80.7 years) with a average follow-up of 5.4 years (range 2-11 years) showed excellent to good results in 69 cases (83%), a satisfactory result in 12 cases (15%) and a fair result in 2 cases (2%) and 47 patients (56%) were pain free. Primary loosening was noted in three cases and of these two cases were successfully revised by another total ankle replacement and in one case with arthrodesis. Another case with hematogenous infection was also revised by arthrodesis. At the last follow-up control two components were considered to be loose and the overall loosening rate was thus 6%.This series has proven that revision arthroplasty can be a promising option for patients with failed total ankle prosthesis. The most challenging issue is the solid anchoring of available components on residual bone. More experience is needed, however, to better define the possibilities and limitations of revision arthroplasty.

[Total ankle replacement for varus deformity]. / Sprunggelenkprothese bei Varusarthrose.

Coronal plane deformity has been found to be one of the main risk factors for poor clinical results, higher complication rates and failure of total ankle replacements. Initially, many authors considered a malalignment of more than 10° to be a contraindication for total ankle replacement, however, several publications later underlined the usefulness of the distinction of different etiologies of hindfoot malalignment. This subsequently led to suggestions for additional procedures in order to avoid early implant failure.The aim of the present article is to illustrate the different causes of varus malaligned arthritic ankles and to present procedures to balance these ankles at the time of replacement.

The role of the fibula in varus and valgus deformity of the tibia: a biomechanical study.

It has been suggested that a supramalleolar osteotomy can return the load distribution in the ankle joint to normal. However, due to the lack of biomechanical data, this supposition remains empirical. The purpose of this biomechanical study was to determine the effect of simulated supramalleolar varus and valgus alignment on the tibiotalar joint pressure, in order to investigate its relationship to the development of osteoarthritis. We also wished to establish the rationale behind corrective osteotomy of the distal tibia. We studied 17 cadaveric lower legs and quantified the changes in pressure and force transfer across the tibiotalar joint for various degrees of varus and valgus deformity in the supramalleolar area. We assumed that a supramalleolar osteotomy which created a varus deformity of the ankle would result in medial overload of the tibiotalar joint. Similarly, we thought that creating a supramalleolar valgus deformity would cause a shift in contact towards the lateral side of the tibiotalar joint. The opposite was observed. The restricting role of the fibula was revealed by carrying out an osteotomy directly above the syndesmosis. In end-stage ankle osteoarthritis with either a valgus or varus deformity, the role of the fibula should be appreciated and its effect addressed where appropriate.

Risk factors for symptomatic deep-vein thrombosis in patients after total ankle replacement who received routine chemical thromboprophylaxis.

The aim of this study was to identify the incidence of post-operative symptomatic deep-vein thrombosis (DVT), as well as the risk factors for and location of DVT, in 665 patients (701 ankles) who underwent primary total ankle replacement. All patients received low-molecular-weight heparin prophylaxis. A total of 26 patients (3.9%, 26 ankles) had a symptomatic DVT, diagnosed by experienced radiologists using colour Doppler ultrasound. Most thrombi (22 patients, 84.6%) were localised distally in the operated limb. Using a logistic multiple regression model we identified obesity, a previous venous thromboembolic event and the absence of full post-operative weight-bearing as independent risk factors for developing a symptomatic DVT. The incidence of symptomatic DVT after total ankle replacement and use of low-molecular-weight heparin is comparable with that in patients undergoing total knee or hip replacement.

[Modified Lambrinudi arthrodesis with additional posterior tibial tendon transfer in adult drop foot]. / Modifizierte Arthrodese nach Lambrinudi mit zusätzlichem Transfer der Tibialis-posterior-Sehne zur Behandlung des adulten Fallfußes.

OBJECTIVE: Treatment of adult instable drop foot by modified Lambrinudi arthrodesis (removal of a wedge between the talus and calcaneus), followed by a posterior tibial tendon transfer to the medial cuneiform in order to provide active dorsiflexion. INDICATIONS: Severe drop foot (of various etiologies) in combination with hindfoot instability. Sufficient function of the posterior tibial muscle. CONTRAINDICATIONS: Neurologic dysfunction of the posterior tibial muscle, infection of foot/hindfoot, Charcot arthropathy, and insufficient patient compliance. RELATIVE CONTRAINDICATIONS: Previous surgery of posterior tibial tendon, critical soft tissues/skin conditions, insufficient neurovascular conditions. SURGICAL TECHNIQUE: Lateral skin incision. Debridement of sinus tarsi and removal of the bifurcate ligament to expose the subtalar, calcaneocuboidal, and talonavicular joints. Resection of a bone wedge from the calcaneus and talus (25-30°) to correct the drop foot deformity. Cartilage removal from the calcaneocuboid joint. Debridement of both the talar head and the navicular to allow adequate fitting. After reduction (neutral dorsiflexion and 10° foot abduction), preliminary fixation with Kirschner wires. Final fixation with canulated screws (talonavicular, calcaneocuboidal, and subtalar joints). Medial skin incision at the navicular tuberositas to deattach the posterior tibial tendon with a bony fragment. The tendon stump is harvested 10 cm proximal to the tibiotalar joint. Small skin incision at the anterolateral aspect of the distal lower leg. The posterior tibial tendon is transferred through the interosseous membrane and reattached to the medial cuneiform with a screw. POSTOPERATIVE MANAGEMENT: Immobilization with a removable short leg cast for 2-4 days. Ambulation with full weightbearing in a cast for 8 weeks. Radiographic assessment 8 weeks postoperatively. After bony healing, mobilization in normal shoes is allowed. Intensive physiotherapy to train the dorsiflexion. RESULTS: The average correction of drop foot deformity was 18.7°. Active dorsiflexion increased significantly from 30° preoperatively to 10° postoperatively.

Simultaneous bilateral versus unilateral total ankle replacement: a patient-based comparison of pain relief, quality of life and functional outcome.

The aim of this study was to compare the outcome of bilateral sequential total ankle replacement (TAR) with that of unilateral TAR. We reviewed 23 patients who had undergone sequential bilateral TAR under a single anaesthetic and 46 matched patients with a unilateral TAR. There were no significant pre-operative differences between the two groups in terms of age, gender, body mass index, American Society of Anaesthesiologists classification and aetiology of the osteoarthritis of the ankle. Clinical and radiological follow-up was carried out at four months, one and two years. After four months, patients with simultaneous bilateral TAR reported a significantly higher mean pain score than those with a unilateral TAR. The mean American Orthopaedic Foot and Ankle Society hindfoot score and short-form 36 physical component summary score were better in the unilateral group. However, this difference disappeared at the one-and two-year follow-ups. Bilateral sequential TAR under one anaesthetic can be offered to patients with bilateral severe ankle osteoarthritis. However, they should be informed of the long recovery period.

Total ankle replacement in association with hindfoot fusion: Outcome and complications.

We report the clinical and radiological outcome of total ankle replacement performed in conjunction with hindfoot fusion or in isolation. Between May 2003 and June 2008, 60 ankles were treated with total ankle replacement with either subtalar or triple fusion, and the results were compared with a control group of 288 ankles treated with total ankle replacement alone. After the mean follow-up of 39.5 months (12 to 73), the ankles with hindfoot fusion showed significant improvement in the mean visual analogue score for pain (p < 0.001), the mean American Orthopaedic Foot and Ankle Society score (p < 0.001), and the mean of a modified version of this score (p < 0.001). The mean visual analogue pain score (p = 0.304) and mean modified American Orthopaedic Foot and Ankle Society score (p = 0.119) were not significantly different between the hindfoot fusion and the control groups. However, the hindfoot fusion group had a significantly lower mean range of movement (p = 0.009) and a higher rate of posterior focal osteolysis (p = 0.04). Both groups showed various complications (p = 0.131) and failure occurring at a similar rate (p = 0.685). Subtalar or triple fusion is feasible and has minimal adverse effects on ankles treated with total ankle replacement up to midterm follow-up. The clinical outcome of total ankle replacement when combined with hindfoot fusion is comparable to that of ankle replacement alone. Thus, hindfoot fusion should be performed in conjunction with total ankle replacement when indicated.