Safety of Same-Day Discharge Following Total Ankle Arthroplasty: A Retrospective Cohort Analysis.

Background: Joint replacement procedures have traditionally been performed in an inpatient setting to minimize complication rates. There is growing evidence that total ankle arthroplasty (TAA) can safely be performed as an outpatient procedure, with the potential benefits of decreased health care expenses and improved patient satisfaction. Prior studies have not reliably made a distinction between outpatient TAA defined as length of stay <1 day and same-day discharge. The purpose of our study was to compare a large volume of same-day discharge and inpatient TAA for safety and efficacy. Methods: Patients undergoing TAA at our US-based institution are part of an institutional review board-approved registry. We queried the registry for TAA performed by the single highest-volume surgeon at our institution between May 2020 and March 2022. Same-day discharge TAA was defined as discharge on the day of the procedure. Patient demographics, baseline clinical variables, concomitant procedures, postoperative complications, and patient-reported outcomes were collected. Postoperative outcomes were compared after 1:1 nearest-neighbor matching by age, sex, Charlson Comorbidity Index (CCI), and American Society of Anesthesiologists (ASA) score. Multivariable models were created for comparison with the matched cohort outcome comparison analysis. Results: Our same-day discharge group was younger (median 58 vs 67 years; P < .001), with proportionally fewer females (36.4% vs 51.4%; P = .044) and lower Charlson Comorbidity Indices (median 1 vs 3; P < .001) than the inpatient group. At a median follow-up of 1 year, after matching by age, sex, CCI, and ASA score, there was no difference in complications (P = .788), reoperations (P = .999), revisions (P = .118), or Patient-Reported Outcomes Measurement Information System (PROMIS) scores between the 2 groups. Multivariable analyses performed demonstrated no evidence of association between undergoing same-day discharge TAA vs inpatient TAA and reoperation, revision, complication, or 1-year PROMIS scores (P > .05). Conclusion: In our system of health care, with appropriate patient selection, same-day discharge following TAA can be a safe alternative to inpatient TAA. Level of Evidence: Level III, retrospective cohort study.

Defining the patient acceptable symptom state using PROMIS following reconstruction of the progressive collapsing foot deformity.

BACKGROUND: The patient acceptable symptom state (PASS) represents the threshold beyond which patients are satisfied with their outcome. This study aimed to define PASS thresholds for progressive collapsing foot deformity (PCFD) reconstruction using Patient-Reported Outcomes Measurement Information System (PROMIS) scores and anchor question responses. METHODS: This retrospective study consisted of 109 patients who underwent flexible PCFD reconstruction, had preoperative and 2-year postoperative PROMIS scores, and 2-year postoperative anchor question responses. ROC curve analyses were performed to quantify PASS thresholds. RESULTS: PASS thresholds for the PROMIS Physical Function (PF) and Pain Interference (PI) domains were found to be lower and higher, respectively, than population norms. Furthermore, patients with higher preoperative PROMIS PF scores or lower preoperative PROMIS PI scores had a significantly higher likelihood of achieving the PASS thresholds. CONCLUSION: In addition to guiding future outcomes research, these results may help surgeons optimize treatment for PCFD and better manage patient expectations. LEVEL OF EVIDENCE: III, retrospective cohort study.

Discrepancies Between Intraoperative and Postoperative Ankle Motion Measured for Anterior-Approach Total Ankle Arthroplasty.

BACKGROUND: Although intraoperative ankle motion serves as a foundational reference for anticipated motion after surgery and guides the addition of procedures to enhance ankle motion in total ankle arthroplasty (TAA), the relationship between intraoperative and postoperative ankle motion remains unclear. This study aimed to investigate the discrepancy between intraoperative and postoperative ankle range of motion (ROM) following TAAs using the anterior-approach, fixed-bearing systems. METHODS: This study retrospectively reviewed 67 patients (67 ankles) who underwent primary TAA at a single institution. Three different types of anterior-approach, fixed-bearing TAA systems were included. Intraoperative fluoroscopy was used to document the maximal dorsiflexion and plantar flexion at the end of the case. Standardized weightbearing maximum dorsiflexion and plantar flexion sagittal radiographs were obtained pre- and postoperatively, following a previously described method. The motion between 3 different time points (preoperative, intraoperative, and postoperative [mean 11.4 months]) was compared using pairwise t tests, and their differences were quantified. RESULTS: The mean total tibiotalar ROM was 38.1 degrees (SD 7.8) intraoperatively, and the postoperative total tibiotalar ROM was 24.2 degrees (SD 9.7) (P < .001), indicating that a mean of 65.3% (SD 26.7) of the intraoperative motion was maintained postoperatively. Intraoperative dorsiflexion (mean 11.6 [SD 4.5] degrees) showed no evidence of difference from postoperative dorsiflexion (mean 11.4 [SD 5.8] degrees, P > .99), indicating that a median of 95.6% (interquartile range: 66.2-112) of the intraoperative maximum dorsiflexion was maintained postoperatively. However, there was a significant difference between intraoperative plantarflexion (mean 26.4 [SD 6.3]) and postoperative plantarflexion (12.8 [SD 6.9] degrees, P < .001), indicating a mean 50.6% (SD 29.6) of intraoperative motion maintained in the postoperative assessment. There was an improvement of 2.5 degrees in the total tibiotalar ROM following TAA with statistical significance (P < .043). CONCLUSION: This study revealed a significant difference between intraoperative ankle ROM and ankle ROM approximately 1 year after anterior-approach, fixed-bearing TAA, mainly due to plantarflexion motion restriction. Minimal difference in dorsiflexion suggests the importance of achieving the desired postoperative dorsiflexion motion during the surgery using the best possible adjunct procedures. LEVEL OF EVIDENCE: Level IV, case series.

Implant Choice May Reduce the Risk of Early Mechanical Failure in Total Ankle Replacement.

BACKGROUND: Total ankle replacements (TARs) have rapidly advanced in terms of volume, technique, design, and indications. However, TARs are still at risk for early mechanical failure and revision. Prior studies have investigated potential risk factors for failure, but have been limited to smaller series or older implants. This study sought to identify risk factors for early mechanical failure in modern TAR. METHODS: This is a retrospective study of a single-institution registry. Five surgeons contributed cases involving patients who underwent a primary TAR with any implant. Implants were grouped on the basis of the type of fixation. The primary outcome was early mechanical failure (revision with component removal for a non-infectious etiology, that is, subsidence, aseptic loosening, and/or malalignment). Logistic regression determined the effects of age, weight, hindfoot arthrodesis, implant type, and radiographic deformity on failure. RESULTS: The 731 included patients had a mean follow-up of 2.7 years. Ten percent (71 patients) had hindfoot arthrodesis. There were 33 mechanical failures (4.5%) at a mean of 1.7 years after the index surgical procedure. Our model demonstrated that hindfoot arthrodesis was associated with 2.7 times greater odds of failure (p = 0.045), every 10 kg of body weight increased the odds of tibial-sided failure by 1.29 times (p = 0.039), and implants with more extensive tibial fixation (stems or keels) lowered the odds of tibial failure by 95% (p = 0.031). CONCLUSIONS: In patients with uncontrollable risk factors (hindfoot arthrodesis) or risk factors that may or may not be modifiable by the patient (weight), implants with more robust tibial fixation may be able to reduce the risk of early mechanical failure. Further research is warranted to support efforts to decrease early failure in TAR. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Approach Matter in Robotic-Assisted Total Hip Arthroplasty? A Comparison of Early Reoperations Between Direct Anterior and Postero-Lateral Approach.

BACKGROUND: There is no consensus on whether direct anterior approach (DAA) or postero-lateral approach (PLA) total hip arthroplasty (THA) confers a lower risk of postoperative complications. Robotic assistance in THA results in a more consistently accurate component position compared to manual THA. The objective of this study was to compare rates of dislocation, reoperation, revision, and patient-reported outcome measures between patients undergoing DAA and PLA robotic-assisted primary THA. METHODS: We identified 2,040 consecutive robotic-assisted primary THAs performed for primary osteoarthritis, using DAA (n = 497) or PLA (n = 1,542) between 2017 and 2020. The mean follow-up was 18 months. Kaplan-Meier analysis estimated survivorship free of dislocation, reoperation, and revision. Achievement of patient acceptable symptom state and minimum clinically important difference were used to compare changes in the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) and Visual Analog Scale. RESULTS: Dislocation was rare in this series (14 in 2,040, 0.7%), including 1 of 497 (0.2%) in the DAA cohort and 13 of 1,542 (0.8%) in the PLA cohort (P = .210). There was no difference in 2-year reoperation-free survivorship (97.8 versus 98.6%, P = .59) or revision-free survivorship (98.8 versus 99.0%, P = .87) at any time point. After controlling for age, sex, and body mass index, there was no difference in dislocation, reoperation, or revision. At 6-week follow-up, after controlling for age, sex, and body mass index, patients in the DAA cohort had higher odds of achieving HOOS JR minimum clinically important difference (odds ratio = 2.01, P = .012) and HOOS JR patient acceptable symptom state (odds ratio = 1.72, P = .028). There were no differences in patient-reported outcome measures by 3 months. CONCLUSIONS: For robotic-assisted primary THA, DAA may confer enhanced early (<6 weeks) functional recovery compared to the PLA, but there was no significant difference in postoperative dislocation, reoperation, or revision rates.

Does the Presence of Asymptomatic Flatfoot Deformity Impact the Clinical and Radiographic Outcomes of the Minimally Invasive Chevron and Akin Bunionectomy?

BACKGROUND: Flatfoot deformity is believed to play a role in hallux valgus development and recurrence. While symptomatic flatfoot deformity can be treated with separate procedures at the time of hallux valgus correction, the question remains whether the patient undergoing correction of a symptomatic hallux valgus deformity should have their asymptomatic flatfoot concurrently addressed. We aimed to investigate whether the presence of asymptomatic flatfoot influences patient-reported and radiographic outcomes of the minimally invasive chevron and Akin bunionectomy. METHODS: A total of 104 patients were included in this study. Forty-two asymptomatic patients met the radiographic criteria for flatfoot while 62 had a normal arch. Patient-reported outcomes were evaluated and compared between the two groups using validated PROMIS measures preoperatively and at a minimum one-year postoperatively. Radiographic outcomes including hallux valgus angle (HVA), intermetatarsal angle (IMA), Meary's angle, calcaneal pitch (CP), and talonavicular coverage angle (TNCA) were measured and compared preoperatively and minimum six-months postoperatively. RESULTS: Both groups demonstrated similar preoperative and postoperative PROMIS scores with significant improvements in physical function, pain interference, pain intensity, and global physical health. Preoperatively, HVA was similar between both groups, however the flatfoot group showed a greater IMA, Meary's angle, TNCA, and lower CP. Postoperatively, HVA and IMA were similar between groups, although patients in the flatfoot group retained a significantly greater Meary's angle, TNCA, and lower CP. Both groups showed significant improvements in HVA, IMA, and TNCA. CONCLUSION: Our study indicates that the minimally invasive chevron and Akin bunionectomy leads to improved clinical and radiographic hallux valgus outcomes without adversely impacting radiographic flatfoot parameters. Therefore, the MIS bunionectomy may be an effective option for hallux valgus correction in patients with mild, asymptomatic flatfoot. LEVEL OF EVIDENCE: Level III, retrospective cohort.

Influence of Joint Line Level on Clinical Outcomes and Range of Motion in Total Ankle Arthroplasty.

BACKGROUND: Ankle arthritis leads to an elevated joint line compared to the nonarthritic ankle, as measured by the "joint line height ratio" (JLHR). Previous work has shown that the JLHR may remain elevated after total ankle arthroplasty (TAA). However, the clinical impact of this has yet to be determined. This study assessed the correlation between postoperative JLHR, post-TAA range of motion (ROM), and 1-year Patient-Reported Outcome Measurement Information System (PROMIS) scores. METHODS: A retrospective review of 150 patients who underwent primary TAA was performed. Preoperative and postoperative JLHR, as well as postoperative dorsiflexion, plantarflexion, and total ROM, was calculated on weightbearing radiographs at a minimum of 1-year follow-up. Correlation between JLHR, post-TAA ROM, and 1-year PROMIS scores was investigated using Pearson correlation and multiple linear regression models. Interobserver reliability for the JLHR was also calculated. RESULTS: Interobserver reliability for the JLHR was excellent (r = 0.98). Mean (SD) JLHR changed from 1.66 (0.45) to 1.55 (0.26) after TAA (P < .001), indicating that the joint line was lowered after TAA. An elevated joint line was correlated with decreased post-TAA dorsiflexion (r = -0.26, P < .001), total ROM (r = -0.18, P = .025), and worse 1-year PROMIS physical function (r = -0.22, P = .046), pain intensity (r = 0.22, P = .042), and pain interference (r = 0.29, P = .007). There was no correlation between the JLHR and post-TAA plantarflexion (r = -0.025, P = .76). Regression analysis identified a 0.5-degree reduction in post-TAA dorsiflexion with each 0.1-unit increase in JLHR (Coeff. = -5.13, P = .005). CONCLUSION: In this patient cohort, we found that an elevated joint line modestly correlated with decreased postoperative dorsiflexion, total ROM, and worse 1-year PROMIS scores. These data suggest that effort likely should be made toward restoring the native joint line at the time of TAA. In addition, future studies investigating the clinical outcomes after TAA may consider including a measure of joint line height, such as the JLHR, because we found it was associated with patient-reported outcomes. LEVEL OF EVIDENCE: Level III, retrospective review of prospectively collected data.

A Patient-Reported Outcome-Based Comparison of Cheilectomy With and Without Proximal Phalangeal Dorsiflexion Osteotomy for Hallux Rigidus.

INTRODUCTION: This study provides the first comparison of patient-reported outcomes between isolated cheilectomy (C) and cheilectomy with Moberg (CM) osteotomy for hallux rigidus. METHODS: A single-center, retrospective registry search identified all patients with preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores who underwent cheilectomy, with and without concomitant proximal phalangeal dorsiflexion osteotomy, for hallux rigidus between January 2016 and December 2020. Because there were far fewer isolated cheilectomies (62), all C patients were compared with a commensurate number of consecutive CM cases (67) using preoperative, 1-year, and 2-year PROMIS scores for physical function, pain interference, pain intensity, global physical health, global mental health, and depression, as well as complication and revision data from a chart review. A multivariable linear regression analysis was performed to compare adjusted postoperative PROMIS scores between the 2 cohorts. RESULTS: There were no differences between groups among the demographic and preoperative variables compared. The CM cohort reported worse pain interference scores preoperatively (P < .001) and at 1 year postoperatively (P = .01). However, the C cohort reported worse pain intensity scores preoperatively (P < .001) and at 1 year postoperatively (P < .001). Adjusted postoperative PROMIS score comparison demonstrated that the CM cohort had better 1-year postoperative pain intensity scores (P < .05). However, there were no differences between cohorts for additional PROMIS scores or complications data. CONCLUSION: The addition of a Moberg osteotomy does not appear to significantly change short- to medium-term outcomes of cheilectomy for hallux rigidus treatment. LEVELS OF EVIDENCE: Level III: Retrospective comparative study.

Early Periprosthetic Femur Fractures After Primary Cementless Total Hip Arthroplasty: High Risk of Periprosthetic Joint Infection and Subsequent Reoperation.

BACKGROUND: Periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late. METHODS: We retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as "early" if they occurred within 90 days of THA (n = 117) or "late" if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation. RESULTS: Early PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union). CONCLUSIONS: There are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF.

Cervical Ligament Insufficiency in Progressive Collapsing Foot Deformity: It May Be More Important Than We Know.

BACKGROUND: Subluxation at the subtalar joint is one of the major radiographic features that characterize progressive collapsing foot deformity (PCFD). Although it is recognized that the cervical ligament plays an important function in maintaining the subtalar joint's stability, its role and involvement in PCFD is largely unknown. The purpose of this study was to assess the prevalence of cervical ligament insufficiency in patients with PCFD and to establish if the degree of its pathology changes with increasing axial plane deformity. METHODS: This study retrospectively reviewed magnetic resonance imaging (MRI) of 78 PCFD patients and age- and gender-matched controls. The structures evaluated were the cervical, spring, and talocalcaneal interosseous ligaments. Structural derangement was graded on a 5-part scale (0-4), with grade 0 being normal and grade 4 indicating a tear of greater than 50% of the cross-sectional area. Plain radiographic parameters (talonavicular coverage angle [TNC], lateral talo-first metatarsal [Meary] angle, calcaneal pitch, and hindfoot moment arm) as well as axial plane orientation of the talus (TM-Tal) and calcaneus (TM-Calc) relative to the transmalleolar axis and talocalcaneal subluxation (Diff Calc-Tal) were correlated with the cervical ligament MRI grading system. RESULTS: The overall distribution of the degree of cervical ligament involvement was significantly different between the PCFD and control groups (P < .001). MRI evidence of a tear in the cervical ligament was identified in 47 of 78 (60.3%) feet in the PCFD group, which was significantly higher than the control group (10.9%) and comparable to that of superomedial spring (43.6%) and talocalcaneal interosseous (44.9%) ligaments. Univariate ordinal logistic regression modeling demonstrated a predictive ability of TM-Calc (odds ratio [OR] 1.17, 95% CI 1.06-1.30, P = .004), Diff Calc-Tal (OR 1.15, 95% CI 1.06-1.26, P = .002), TNC (OR 1.08, 95% CI 1.03-1.13, P = .003), and Meary angle (OR 1.05, 95% CI 1.02-1.10, P = .006) in determining higher cervical ligament grade on MRI. CONCLUSION: This study found that cervical ligament insufficiency is more often than not associated with PCFD, and that an increasing axial plane deformity appears to be associated with a greater degree of insufficiency. LEVEL OF EVIDENCE: Level III, case-control study.

Predictors for activity following total and unicompartmental knee arthroplasty.

BACKGROUND: Functional demands of patients undergoing knee arthroplasty are increasing. However, it remains unclear which patient-specific factors have an impact on postoperative activity and whether there is a difference between total and unicompartmental knee arthroplasties (TKA/UKA). MATERIALS AND METHODS: This retrospective study analyzed 1907 knees with TKA (n = 1746) or UKA (n = 161), implanted for primary osteoarthritis. Pain and activity (lower extremity activity scale, LEAS) were assessed 2 years after surgery. High activity was defined as LEAS ≥ 14. Cohorts were compared using Kruskal-Wallis or Pearson-Chi-square test. A generalized least squares model was used to predict LEAS scores between cohorts adjusted for age, sex, BMI, Charlson Comorbidity Index, ASA score, and preoperative LEAS. RESULT: There was no difference in pain 2 years after surgery between UKA and TKA (p = 0.952). Preoperative LEAS was similar for UKA and TKA (p = 0.994), and both groups showed significant (p < 0.001 respectively) and similar improvements after surgery (p = 0.068). LEAS 2 years after surgery was 11.1 (SD 3.2) for TKA and 11.9 (SD 3.5) for the UKA group (p = 0.004). After adjusting for preoperative LEAS, age, sex, BMI, CCI and ASA, the difference was not significant (p = 0.225). Male sex, lower BMI, higher preoperative LEAS, and younger age were associated with higher postoperative LEAS (p < 0.001, respectively). CONCLUSION: Patients can achieve a high level of activity following both TKA and UKA. While the postoperative activity level did not depend on the type of the procedure, younger age, male sex, lower BMI, and a higher preoperative activity level were associated with a higher postoperative activity level.

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.

Does high activity after total and unicompartmental knee arthroplasty increase the risk for aseptic revision?

INTRODUCTION: It has been suggested that high activity might negatively impact implant survival following total and unicompartmental knee arthroplasty (TKA/UKA) and many surgeons advise their patients to only participate in moderate level sport activities. To date, it remains unclear whether such restraints are necessary to assure longevity of the implants. MATERIALS AND METHODS: We conducted a retrospective study on 1906 knees (1745 TKA, 161 UKA) in 1636 patients aged 45-75 years who underwent primary arthroplasty for primary osteoarthritis. Lower extremity activity scale (LEAS) at a two year follow-up was assessed to define the activity level. Cases were grouped in low (LEAS ≤ 6), moderate (LEAS 7-13) and high activity (LEAS ≥ 14). Cohorts were compared with Kruskal-Wallis- or Pearson-Chi2-Test. Univariate logistic regression was conducted to test for association between activity level at two years and later revisions. Odds ratio was reported and converted to predicted probability. A Kaplan-Meier curve was plotted to predict implant survival. RESULTS: The predicted implant survival for UKA was 100.0% at two years and 98.1% at five years. The predicted implant survival for TKA was 99.8% at two years, 98.1% at five years. The difference was not significant (p = 0.410). 2.5% of the UKA underwent revision, one knee in the low and three knees in the moderate activity group, differences between the moderate and high activity group were not significant (p = 0.292). The revision rate in the high activity TKA group was lower than in the low and moderate activity groups (p = 0.008). A higher LEAS two years after surgery was associated with a lower risk for future revision (p = 0.001). A one-point increase in LEAS two years after surgery lowered the odds for undergoing revision surgery by 19%. CONCLUSIONS: The study suggests that participating in sports activity following both UKA and TKA is safe and not a risk factor for revision surgery at a mid-term follow-up. Patients should not be prevented from an active lifestyle following knee replacement.

No Difference in the Rate of Periprosthetic Joint Infection in Patients Undergoing the Posterolateral Compared to the Direct Anterior Approach.

BACKGROUND: There remains inconsistent data about the association of surgical approach and periprosthetic joint infection (PJI). We sought to evaluate the risk of reoperation for superficial infection and PJI after primary total hip arthroplasty (THA) in a multivariate model. METHODS: We reviewed 16,500 primary THAs, collecting data on surgical approach and all reoperations within 1 year for superficial infection (n = 36) or PJI (n = 70). Considering superficial infection and PJI separately, we used Kaplan-Meier survivorship to assess survival free from reoperation and a Cox Proportional Hazards multivariate models to assess risk factors for reoperation. RESULTS: Between direct anterior approach (DAA) (N = 3,351) and PLA (N = 13,149) cohorts, rates of superficial infection (0.4 versus 0.2%) and PJI (0.3 versus 0.5%) were low and survivorship free from reoperation for superficial infection (99.6 versus 99.8%) and PJI (99.4 versus 99.7%) were excellent at both 1 and 2 years. The risk of developing superficial infection increased with high body mass index (BMI) (hazard ratio [HR] = 1.1 per unit increase, P = .003), DAA (HR = 2.7, P = .01), and smoking status (HR = 2.9, P = .03). The risk of developing PJI increased with the high BMI (HR = 1.04, P = .03), but not surgical approach (HR = 0.68, P = .3). CONCLUSION: In this study of 16,500 primary THAs, DAA was independently associated with an elevated risk of superficial infection reoperation compared to the PLA, but there was no association between surgical approach and PJI. An elevated patient BMI was the strongest risk factor for superficial infection and PJI in our cohort. LEVEL OF EVIDENCE: III, retrospective cohort study.

Significantly Worse Fixation of Cemented Patellar Components on Multiacquisition Variable-Resonance Image Combination Magnetic Resonance Imaging Compared to Femoral and Tibial Components: A Cause for Concern?

BACKGROUND: The etiology of anterior knee pain after total knee arthroplasty (TKA) remains unclear. Few studies have examined patellar fixation quality. The purpose of the present study was to evaluate the patellar cement-bone interface after TKA on magnetic resonance imaging (MRI) and to correlate the patella fixation grade with the incidence of anterior knee pain. METHODS: We retrospectively reviewed 279 knees undergoing metal artifact reduction MRI for either anterior or generalized knee pain at least 6 months after cemented, posterior-stabilized TKA with patellar resurfacing with one implant manufacturer. MRI cement-bone interfaces and percent-integration of the patella, femur, and tibia were assessed by a fellowship-trained senior musculoskeletal radiologist. The grade and character of the patella interface were compared to the femur and tibia. Regression analyses were used to determine the association between patella integration with anterior knee pain. RESULTS: There were more patellar components with ≥75% zones of fibrous tissue (50%) compared to the femur (18%) or tibia (5%) (P < .001). There were a greater number of patellar implants with poor cement integration (18%) compared to the femur (1%) or tibia (1%) (P < .001). MRI findings showed more evidence of patellar component loosening (8%) compared to the femur (1%) or tibia (1%) (P < .001). Anterior knee pain was correlated with worse patella cement integration (P = .01), with women predicted to have better integration (P < .001). CONCLUSION: The quality of the patellar cement-bone interface after TKA is worse compared to the femoral or tibial component interface. Poor patellar cement-bone interface may be a source of anterior knee pain after TKA, but further investigation is required.

COVID-19 disruptions to elective postoperative care did not adversely affect early complications or patient reported outcomes of primary TKA.

INTRODUCTION: Elective orthopedic care, including in-person office visits and physical therapy (PT), was halted on March 16, 2020, at a large, urban hospital at the onset of the local COVID-19 surge. Post-discharge care was provided predominantly through a virtual format. The purpose of this study was to assess the impact of postoperative care disruptions on early total knee arthroplasty (TKA) outcomes, specifically 90-day complications, 120-day rate of manipulation under anesthesia (MUA) and 1-year patient-reported outcome measures (PROMs). MATERIALS AND METHODS: Institutional records were queried to identify 624 patients who underwent primary, unilateral TKA for osteoarthritis and who were discharged home between 1/1/20 and 3/15/20. These patients were compared to 558 controls discharged between 1/1/19 and 3/15/2019. Cohort demographics and in-hospital characteristics were equivalent apart from inpatient morphine milligram equivalent (MME) consumption. Patient-reported access to PT (p < 0.001) and post-discharge care (p < 0.001) were worse among study patients. Study patients were prescribed fewer post-discharge PT sessions (19.8 vs. 23.5; p < 0.001) and utilized telehealth more frequently (p < 0.001). Mann-Whitney U, T, Fisher's Exact, and chi-squared tests were used to compare outcomes. RESULTS: Ninety-day CMS complications were lower among study patients (3.5% vs. 5.9%; p = 0.05). Rates of MUA were similar between groups. Study patients reported similar PROMs and marginally inferior VR-12 mental and LEAS functional outcomes at 1 year. CONCLUSION: Disruptions to elective orthopedic care in March 2020 seemed to have had no major consequences on clinical outcomes for TKA patients. Our findings question the usefulness of pre-pandemic post-discharge protocols, which may over-emphasize in-person visits and PT.

Clinical Outcomes and Rotational Correction of First Metatarso-Cuneiform Fusion With First Metatarsal to Second Cuneiform Fixation.

Background: The modified Lapidus procedure (first metatarso-cuneiform fusion) is a powerful technique for correcting triplanar deformity in hallux valgus. Although traditionally fixed with cross-screws (CS), growing awareness of intercuneiform stability and pronation deformity has led to fixation using a plate and first metatarsal-second cuneiform (1MT-2C) screw fixation (PS). We investigated Lapidus patient cohorts using CS vs PS fixation to understand patient-reported outcomes, angular and rotational correction, and complication rates. Methods: We retrospectively reviewed cases of modified Lapidus for hallux valgus by a single surgeon. Patients were divided into CS or PS groups according to fixation. All patients had preoperative Patient Reported Outcome Measurement Information System (PROMIS) scores and minimum 12 months of follow-up. PROMIS scores in 6 key domains were compared within and between groups. Radiographic assessment of hallux valgus angle and intermetatarsal angle were performed on pre- and postoperative XR. Pronation of the first ray was measured on pre- and postoperative weightbearing computed tomography. Results: We compared 42 patients with PS fixation to 43 with CS fixation. Both groups had significant improvement in hallux valgus angle and intermetatarsal angle (P < .001), with no difference between groups. PS patients experienced a greater correction of first metatarsal pronation, an average reduction of 11 degrees, compared to 8 degrees in the CS group (P < .039). Both cohorts experienced improvement in PROMIS physical function, pain interference, pain intensity, and global physical function. There were no differences in PROMIS score improvements between the cohorts. The CS group started weightbearing at 6 weeks vs 3.6 weeks for the PS group. Complication and revision rates were similar. Conclusion: A plate and 1MT-2C screw fixation provides safe, robust fixation of Lapidus procedure and prevents instability through the intercuneiform joint. We observed similar improvement in PROMIS compared with patients treated with cross-screws. Complications did not increase despite the PS group weightbearing much earlier. PS patients achieved greater first ray rotational correction. Level of Evidence: Level III, retrospective cohort study.

Retrospective Comparison of Midterm Survivorship, Radiographic, and Clinical Outcomes of the INBONE II and Salto Talaris Total Ankle Arthroplasty Systems.

BACKGROUND: Prior studies on the INBONE II and Salto Talaris total ankle arthroplasty (TAA) systems have reported promising outcomes for both implants. This retrospective study aimed to compare the midterm differences between INBONE II and Salto Talaris TAA. METHODS: Between 2007 and 2015, a total of 44 INBONE II consecutive cases and 85 Salto Talaris consecutive cases had minimum 5-year clinical and radiographic follow-up. Preoperative and midterm survivorship, postoperative Foot and Ankle Outcome Score (FAOS), and radiographic measures including tibiotalar alignment (TTA), medial distal tibial angle (MDTA), and sagittal tibial angle (STA) were compared. RESULTS: Survivorship to revision was 97.6% (95% CI, 93.1%-100%) for the INBONE II group and 97% (95% CI, 93%-100%) for the Salto Talaris group (P = .93). Survivorship to reoperation was significantly different: 95.5% for the INBONE II and 76.4% for Salto Talaris (P = .021). Postoperative FAOS pain (P = .01), symptoms (P = .004), and sports activity (P = .02) scores were significantly higher in the INBONE II group. The INBONE group had greater preoperative deformity (varus TTA P < .001, valgus TTA P = .02, valgus MDTA P = .005). CONCLUSION: Although both implants had similar longevity and postoperative alignment, the INBONE II resulted in greater clinical improvement and fewer reoperations than the Salto Talaris at midterm follow-up. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Radiographic Cutoff Values for Predicting Lateral Bony Impingement in Progressive Collapsing Foot Deformity.

BACKGROUND: Lateral bony impingement is a major cause of lateral foot pain in progressive collapsing foot deformity (PCFD). Weightbearing computed tomography (WBCT) provides better sensitivity than standard radiographs for detecting impingement. However, many orthopaedic centers have not yet acquired WBCT imaging. This study aimed to (1) investigate the correlation of common radiographic parameters measured on standard weightbearing radiographs with talocalcaneal and calcaneofibular distance assessed with WBCT and (2) establish radiographic cutoff values to detect bony impingement as identified on WBCT. METHODS: Ninety-one patients treated for PCFD with standard preoperative radiographs and WBCT were identified. Patients with asymmetric ankle arthritis (talar tilt >2 degrees) were excluded. The talocalcaneal distance at the sinus tarsi and calcaneofibular distance were measured in multiplanar reconstructed WBCT images. Impingement was defined as direct abutment between bones. The relationships between WBCT measurements and 4 common parameters (talonavicular coverage angle [TNC], talo-first metatarsal angle, calcaneal pitch, and hindfoot moment arm [HMA]) in standard radiographs were assessed with Pearson correlations. Receiver operating characteristic curve analysis evaluated the ability of radiographic cutoffs to detect sinus tarsi or calcaneofibular bony impingement, and the area under curve (AUC), sensitivity, specificity, negative and positive predictive value (PPV) were calculated. RESULTS: Talocalcaneal distance narrowing at the sinus tarsi strongly correlated with TNC (r = 0.64, P < .001), and the calcaneofibular distance narrowing correlated with the HMA moderately yet best among the parameters (r = 0.55, P < .001). TNC (AUC = 0.837, 95% CI 0.745-0.906) and HMA (AUC=0.959, 95% CI 0.895-0.989) provided the best predictive ability for sinus tarsi and calcaneofibular bony impingement, respectively. A TNC threshold of 41.2 degrees had a 100% PPV for predicting sinus tarsi impingement, whereas an HMA threshold of 38.1 mm had a 100% PPV for calcaneofibular impingement. CONCLUSION: This study provides evidence that TNC and HMA measurements made on standing radiographs could be used to indicate potential lateral bony impingement in PCFD. Narrowing of talocalcaneal distance best correlated with abduction deformity of the foot, and the narrowing of calcaneofibular distance was best correlated with valgus hindfoot deformity. LEVEL OF EVIDENCE: Level III, case control study.

Assessment of Flatfoot Deformity Using Digitally Reconstructed Radiographs: Reliability and Comparison to Conventional Radiographs.

BACKGROUND: Digitally reconstructed radiographs (DRRs) generated from weightbearing computed tomography (WBCT) may potentially substitute for weightbearing plain radiographs (XRs) but have not been clinically validated. This study aims to test the reliability of 6 radiographic parameters of progressive collapsing foot deformity (PCFD) as measured on DRR, to investigate whether DRR represents comparably to XR through the same measurements, and to compare agreement of DRR and XR measurements of a standardized arch height parameter with reference measurements made on WBCT. METHODS: DRR generated from preoperative WBCT of 71 patients (72 feet) treated surgically for PCFD were retrospectively compared with preoperative weight-bearing XR after exclusion criteria were applied. Six radiographic measurements were performed, including Meary angle, calcaneal pitch (CPA), medial cuneiform height (MCH), AP talar-first metatarsal angle (T-1MT), talonavicular coverage (TNCA), and talar incongruency (TIA). Arch height was measured on XR, DRR, and WBCT using a validated, standardized, navicular-based index. Intraclass correlation coefficients assessed DRR intraobserver and interobserver reliability. Paired samples t tests tested differences between XR and DRR. Bland-Altman limits of agreement analysis compared DRR and XR agreement with WBCT measurements. RESULTS: Measurements were within standard PCFD ranges on XR and DRR. All measurements demonstrated excellent intrarater reliability and good to excellent interrater agreement, consistent with previous literature on XR. No differences were found for Meary, CPA, or TNCA. Minor differences were observed for MCH, T-1MT, and TIA. DRR measurements demonstrated greater agreement with WBCT than XR measurements. CONCLUSION: DRR from WBCT may be a promising substitute for XR in the clinical evaluation of PCFD. Radiographic measurements made on DRR demonstrated good to excellent reliability. Although small differences were found between XR and DRR for certain measurements, DRR more accurately represented medial arch anatomy compared to gold standard WBCT data than XR. If validated as a clinical substitute, DRR could eventually obviate XR where WBCT is available. LEVEL OF EVIDENCE: Level III, retrospective cohort study.