Differential Utilization Patterns of Total Ankle Arthroplasty vs Arthrodesis: A United States National Ambulatory Database Analysis.

Background: End-stage ankle osteoarthritis is a condition that can be treated with ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The goal of this study is to estimate the 2016-2017 United States' utilization of TAA and AA in specific ambulatory settings and delineate patient and hospital factors associated with the selection of TAA vs AA for treatment of ankle osteoarthritis. Methods: TAA and AA procedures performed for ankle osteoarthritis were identified in the 2016-2017 Nationwide Ambulatory Surgery Sample (NASS) Database. Notably, the NASS database only examines instances of ambulatory surgery encounters at hospital-owned facilities. As such, instances of TAA and AA performed at privately owned or freestanding ambulatory surgical centers or those performed inpatient are excluded from this analysis. Cases were weighted using nationally representative discharge weights. Univariate analyses and a combined multiple logistic regression model were used to compare demographic, hospital-related, and socioeconomic factors associated with TAA vs AA. Results: In total, 6577 cases were identified, which represents 9072 cases after weighting. Of these, TAA was performed for 2233 (24.6%). Based on the logistic regression model, several factors were associated with increased utilization of TAA vs AA. With regard to patient factors, older patients were more likely to undergo TAA, as well as females. Conversely, patients with a higher comorbidity burden were less likely to receive TAA over AA.With regard to socioeconomic factors, urban teaching and urban nonteaching hospitals were significantly more likely to use TAA compared to rural hospitals. Similarly, privately insured patients and those with a median household income of $71 000 or more were also more likely to receive TAA over AA. Private hospitals ("not-for-profit" and "investor-owned") were significantly more likely to offer TAA over AA. Conclusion: Using a large nationally representative cohort, the current data revealed that during 2016-2017, 24.6% of operatively treated cases of end-stage ankle osteoarthritis in the ambulatory setting are treated with TAA. Associations between socioeconomic and hospital-level factors with TAA utilization suggest that nonclinical factors may influence surgical treatment choice for ankle osteoarthritis. Level of Evidence: Level III, retrospective cohort study.

Successful treatment of advanced Freiberg's disease with a modified Weil osteotomy, 5-year follow up: A Pilot case series with a review of the literature.

INTRODUCTION: Treatment for Freiberg's disease is largely conservative. For severe disease and refractory cases, there are various surgical options. The purpose of this study was to report the 5-year clinical outcomes of a modified Weil osteotomy in the treatment of advanced Freiberg's disease. METHODS: Twelve patients (12 feet), with a mean age of 30.7 years (range 17-55), were treated with synovectomy and modified Weil osteotomy of the affected distal metatarsal head. There were 10 females and 2 males. Clinical outcomes were independently evaluated pre and postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and a subjective satisfaction score. Radiological union was evaluated postoperatively. Nine (75%) feet involved the 2nd metatarsal and 3 feet (25%) involved the 3rd metatarsal. According to the Smillie classification, 6 feet were Grade IV and 6 feet were grade V. RESULTS: No patients were lost to follow up and the mean follow-up time was 5.2 years (4-7). AOFAS scores improved from 48.1 + /- 7.4-88.9 + /- 10.1 postoperatively giving a mean improvement of 40.8 (p < 0.001). In total, 92% of patients were satisfied with their operation at latest follow-up, reporting excellent or good results. All patients had postoperative radiological union. One patient had a superficial postoperative infection that was successfully treated with oral antibiotics. CONCLUSION: Modified Weil osteotomy is an effective treatment for advanced Freiberg's disease with good outcomes and few complications.

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

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

The association between preoperative COVID-19-positivity and acute postoperative complication risk among patients undergoing orthopedic surgery.

Aims: This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures. Methods: Using the National Surgical Quality Improvement Programme (NSQIP) database, patients who underwent common orthopaedic surgery procedures from 1 January to 31 December 2021 were extracted. Patient preoperative COVID-19 status, demographics, comorbidities, type of surgery, and postoperative complications were analyzed. Propensity score matching was conducted between COVID-19-positive and -negative patients. Multivariable regression was then performed to identify both patient and provider risk factors independently associated with the occurrence of 30-day postoperative adverse events. Results: Of 194,121 included patients, 740 (0.38%) were identified to be COVID-19-positive. Comparison of comorbidities demonstrated that COVID-19-positive patients had higher rates of diabetes, heart failure, and pulmonary disease. After propensity matching and controlling for all preoperative variables, multivariable analysis found that COVID-19-positive patients were at increased risk of several postoperative complications, including: any adverse event, major adverse event, minor adverse event, death, venous thromboembolism, and pneumonia. COVID-19-positive patients undergoing hip/knee arthroplasty and trauma surgery were at increased risk of 30-day adverse events. Conclusion: COVID-19-positive patients undergoing orthopaedic surgery had increased odds of many 30-day postoperative complications, with hip/knee arthroplasty and trauma surgery being the most high-risk procedures. These data reinforce prior literature demonstrating increased risk of venous thromboembolic events in the acute postoperative period. Clinicians caring for patients undergoing orthopaedic procedures should be mindful of these increased risks, and attempt to improve patient care during the ongoing global pandemic.

Offloading Plantar Pressures in Healthy Adults: Stirrup Cast vs Total Contact Cast.

BACKGROUND: Diabetic foot ulcers are associated with significant morbidity and mortality while posing a challenge for healthcare professionals. Offloading is considered the mainstay of treatment. Total contact casting (TCC) is widely used but does not effectively offload the hindfoot. Some studies suggest that a metal stirrup is effective at offloading midfoot and hindfoot ulcers. The primary purpose of this study is to compare the offloading mechanism of TCC to a stirrup cast. METHODS: A pilot observational study assessing 12 healthy volunteers who underwent casting with a TCC or stirrup cast. A sensor (Pedar; Novel GmbH) that measures maximum force, peak pressure, and contact time and area of each foot region, was placed inside the cast to assess the offloading mechanisms of the 2 interventions. RESULTS: We measured a reduction in all plantar foot loading parameters from the TCC to the stirrup cast. The highest reductions of 85% to 96% (±5%-13%) were noted in maximum force and peak pressure under the forefoot (P < .0001) and found reductions in maximum force, the contact area of all regions of the foot, peak pressure and contact time of the forefoot and midfoot, and contact area of the hindfoot (P < .05). CONCLUSION: In this experimental trial of healthy adults, the stirrup cast was more effective than the TCC by offloading the foot mostly in the forefoot and midfoot.

Sex Differences in End-Stage Ankle Arthritis and Following Total Ankle Replacement or Ankle Arthrodesis.

BACKGROUND: We investigated the influence of sex on patient-reported outcomes preoperatively and following total ankle replacement and ankle arthrodesis. METHODS: Patients who had undergone total ankle replacement or ankle arthrodesis for the treatment of end-stage ankle arthritis and who had ≥2 years of follow-up were identified from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database. Standard surgical techniques and implantation methods were followed, and STAR, Hintegra, Mobility, and Agility prostheses were used. Data were collected on patient demographics, revisions, secondary procedures, complications, Ankle Osteoarthritis Scale (AOS) scores, Short Form-36 (SF-36) scores, and expectations and satisfaction. Statistical analyses included 3-way repeated-measures analysis of variance (ANOVA) and multiple linear regression models controlling for inflammatory arthritis, age, preoperative scores, and surgery type. RESULTS: The study included 872 patients: 629 who had undergone total ankle replacement (316 men, 313 women) and 243 who had undergone ankle arthrodesis (154 men, 89 women). The mean duration of follow-up (and standard deviation) was 4.9 ± 2.4 and 4.0 ± 1.9 years for the total ankle replacement and ankle arthrodesis groups, respectively. Men were older than women (p ≤ 0.001). In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS pain scores (i.e., more pain) than men preoperatively (p < 0.05). Pain was reduced significantly in both sexes postoperatively (p < 0.05), with no significant difference between sexes. In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS disability scores (i.e., more disability) and lower SF-36 Physical Component Summary (PCS) scores (i.e., worse function) than men both preoperatively and postoperatively (p < 0.001). Postoperatively, AOS disability and SF-36 PCS scores improved significantly from baseline in both sexes (p < 0.001). After controlling for covariates, sex was not a significant predictor of postoperative SF-36 MCS (Mental Component Summary), AOS pain, or AOS disability scores (p > 0.05) but explained 0.5% of variance in SF-36 PCS scores (p = 0.03). Sex did not significantly influence preoperative expectations or postoperative satisfaction. When patients with inflammatory arthritis were excluded, preoperative and postoperative outcome measures, expectations, and satisfaction were similar. CONCLUSIONS: Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. Small differences in pain and function between men and women undergoing total ankle replacement and ankle arthrodesis mostly disappeared when controlling for potential confounding variables. Both total ankle replacement and ankle arthrodesis remain good options for men and women with end-stage ankle arthritis. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Two-Stage Diabetic Foot Salvage Using Synthetic Bone Void Filler and Lesser Toe Fillet Flap: A Case Report.

CASE: A 54-year-old type 2 diabetic man with a diabetic forefoot ulcer and osteomyelitis successfully underwent a staged reconstruction to salvage his foot. An antibiotic-carrying bone void filler was used to decrease the infection burden after initial debridement. The fifth toe fillet flap was performed to cover the large soft-tissue defect. The patient returned to baseline ambulation at the 1-year follow-up with a well-incorporated flap. CONCLUSION: This case highlights the utility of combining an antibiotic-carrying bone void filler and a toe fillet flap in a two-stage approach to salvage complex diabetic foot ulcers.

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

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

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

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

Safety and Effectiveness of Outpatient Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty (TAA) is a surgical procedure commonly reserved for patients suffering from symptomatic end-stage ankle arthritis. As the number of TAAs increases, so does the associated economic burden. Given these economic constraints, there has been interest in the feasibility of outpatient TAA. The purpose of this study is to evaluate the safety, efficacy, and satisfaction of patients undergoing outpatient TAA. METHODS: This is a retrospective case series of consecutive patients who underwent outpatient TAA from July 2018 to June 2019. Inclusion criteria included any patient undergoing a primary TAA in the outpatient setting. This was defined as discharge on the same day of surgery or within 12 hours of surgery. All surgeries were completed by a single experienced surgeon through an anterior approach using the Cadence Total Ankle System. Prior to surgery, all patients received a popliteal nerve block. Patients were then discharged home with oral analgesic and a popliteal nerve catheter, which they removed after 48 hours. The primary outcome of interest was postoperative pain control, which was measured using a numeric scale. Secondary outcomes included complication rate, readmission rate, and patient satisfaction. A review of the current literature was then completed to supplement our results. RESULTS: In total, 41 patients were included in our analysis. In terms of the primary outcome, the average numeric scale score was 1.98, indicating excellent pain control. Additionally, nearly all 41 patients stated they were very satisfied with their postoperative pain control regimen. In terms of secondary outcomes, the majority of patients stated they were satisfied with discharge on the same day as surgery. There were no readmissions or major complications in our outpatient TAA cohort. When asked if they would recommend the care they experienced to a friend with the same condition, 95% of patients said that they would recommend this care pathway. Our literature review included 5 original studies, which were all retrospective level IV studies. These studies uniformly demonstrated the safety and efficacy of outpatient TAA. CONCLUSIONS: The results of our study demonstrate the outpatient TAA is associated with excellent pain control using a multidisciplinary pain approach. The use of standardized outpatient postoperative pathways was effective in preventing readmissions and complications, while still resulting in high patient satisfaction scores. A review of the literature complemented our results, as there are largely no significant differences between outpatient and inpatient TAA.Level of Evidence: Level IV, case series.

Surgical interventions of Freiberg's disease: A systematic review.

BACKGROUND: Freiberg's disease is an osteonecrosis of the metatarsal head bone. Numerous surgical interventions can be provided; however, the literature is limited in systematic reviews discussing the various options. The study aimed to systematically review the quantity and quality of literatures exploring the surgical interventions. METHODS: Fifty articles were found to be relevant for assessing the efficacy of common surgical interventions. The articles were assigned a level of evidence (I-V) to assess their quality. Next, the studies were reviewed to provide a grade of recommendation (A-C, I). RESULTS: Two studies were found at level III that explored osteotomy and autologous transplantation; the other studies were level IV-V. There is poor evidence (grade C) in supporting of joint sparing and joint sacrificing for Freiberg's disease. CONCLUSION: Poor evidence exists to support the surgical interventions for Freiberg's disease, higher quality trials are needed to support the increasing application of these surgical techniques. LEVEL OF EVIDENCE: Level IV, Systematic review.

Clinical outcome results of total ankle replacement and ankle arthrodesis: a pilot randomised controlled trial.

BACKGROUND: Ankle arthrodesis (AA) and replacement (TAA) are widely accepted options in managing end-stage ankle arthritis (ESAA). We hypothesize that clinical outcomes would be similar for both interventions. METHODS: We conducted a multicenter randomized controlled trial that collected data on patient demographics, complication rates, Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) scores. We evaluated pre and postoperative scores within and between cohorts. RESULTS: The thirty-nine ankles enrolled had a mean follow-up of 5.1 ± 2.8 years. Total AOS scores improved significantly in both groups; 59.4 ± 15.9 to 38 ± 20 (p-value = 0.002) for TAA and 64.6 ± 19.7 to 31.8 ± 16.5 (p-value < 0.001) for AA at last follow-up. Complication rate was higher in the AA cohort with four major complications (20%). CONCLUSION: We observed a statistically significant benefit with TAA and AA. As a pilot trial, this study is meant to inform on design and feasibility of future RCTs. LEVEL OF EVIDENCE: II.

The Impact of Patient Age on Foot and Ankle Arthrodesis Supplemented with Autograft or an Autograft Alternative (rhPDGF-BB/ß-TCP).

A recent survey of orthopaedic surgeons asking about risk factors for nonunion following foot and ankle arthrodesis revealed that patient age is considered to be a relatively low risk factor, despite the potential for autologous graft quality to deteriorate with increasing age. The purpose of the current study was to evaluate the impact of patient age and graft type on fusion rates following hindfoot and ankle arthrodesis. METHODS: In this study, we analyzed data from a previously published clinical trial, comparing fusion success in 397 subjects who underwent hindfoot or ankle arthrodesis (597 joints) supplemented with either autograft or an osteoinductive autograft alternative, recombinant human platelet-derived growth factor-BB homodimer carried in beta-tricalcium phosphate (rhPDGF-BB/ß-TCP). The odds of fusion success were compared among subjects older or younger than age thresholds of 55, 60, 65, 70, and 75 years. The odds of fusion success were also compared between autograft and rhPDGF-BB/ß-TCP among subjects older than each age threshold. RESULTS: In the autograft group, the joints of subjects who were younger than the age thresholds of 60 and 65 years had >2 times the odds of successful fusion compared with those of older subjects. There was no significant difference in the odds of fusion success between the older and younger subjects at the age threshold of 55 years. In the rhPDGF-BB/ß-TCP group, there was no significant difference in the odds of successful fusion between older and younger subjects at any age threshold. When the odds of fusion success were compared between the 2 graft materials in subjects who were older than each age threshold, rhPDGF-BB/ß-TCP had approximately 2 times the odds of fusion success compared with autograft for all thresholds, except 55 years. CONCLUSIONS: The presented evidence suggests that age is an identifiable and concerning risk factor for hindfoot and ankle arthrodesis nonunion, a finding in contrast to the wider perception in the surgeon community. Notably, patients ≥60 years of age had significantly lower odds of fusion success with the use of autograft. The data reveal that use of rhPDGF-BB/ß-TCP as an alternative bone-healing adjunct may help mitigate the risk of nonunion when these procedures are performed in the elderly population. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Should 15° of valgus coronal-plane deformity be the upper limit for a total ankle arthroplasty?

AIMS: Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°. METHODS: A matched cohort of patients similar for demographics and components used but differing in preoperative coronal-plane tibiotalar valgus deformity ≥ 15° (valgus, n = 50; 52% male, mean age 65.8 years (SD 10.3), mean body mass index (BMI) 29.4 (SD 5.2)) or < 15° (control, n = 50; 58% male, mean age 65.6 years (SD 9.8), mean BMI 28.7 (SD 4.2)), underwent TAA by one surgeon. Preoperative and postoperative radiographs, Ankle Osteoarthritis Scale (AOS) pain and disability and 36-item Short Form Health Survey (SF-36) version 2 scores were collected prospectively. Ancillary procedures, secondary procedures, and complications were recorded. RESULTS: At mean 5.1 years follow-up (SD 2.6) (valgus) and 6.6 years (SD 3.3) (controls), mean AOS scores decreased and SF-36 scores increased significantly in both groups. Improvements in scores were similar for both groups - AOS pain: valgus, mean 26.2 points (SD 24.2), controls, mean 22.3 points (SD 26.4); AOS disability: valgus, mean 41.2 points (SD 25.6); controls, mean 34.6 points (SD 24.3); and SF-36 PCS: valgus, mean 9.1 points (SD 14.1), controls, mean 7.4 points (SD 9.8). Valgus ankles underwent more ancillary procedures during TAA (40 (80%) vs 13 (26%)) and more secondary procedures postoperatively (18 (36%) vs 7 (14%)) than controls. Tibiotalar deformity improved significantly (p < 0.001) towards a normal weightbearing axis in valgus ankles. Three valgus and four control ankles required subsequent fusion, including two for deep infections (one in each group). CONCLUSION: Satisfactory mid-term results were achieved in patients with preoperative valgus malalignment ≥ 15°, but they required more adjunctive procedures during and after TAA. Valgus coronal-plane deformity ≥ 15° is not an absolute contraindication for TAA if associated deformities are addressed. Cite this article: Bone Joint J 2020;102-B(12):1689-1696.

Effect of Novel Anteromedial Approach on Wound Complications Following Ankle Arthroplasty.

BACKGROUND: The purpose of this study was to evaluate all wound complications following total ankle arthroplasty (TAA) before and after the implementation of a novel extensile anteromedial surgical approach. We further investigated patients and operative factors associated with wound complications. METHODS: A series of 660 TAAs were collected. The median follow-up was 84 months (range, 12-204 months). Minor wound complications included discoloration, swelling, or clinical concern that merited bringing the patient back sooner for review. Major wound complications included plastic surgical consultation, debridement by the nurse specialist, negative pressure therapy, or reoperation. All major complications initially had a course of empirical oral antibiotics. Since 2011, higher-risk patients have had their TAA performed through an extensile anteromedial approach. RESULTS: Fifty-six patients (8.5%) had wound healing issues (17 major [2.6%], 39 minor [5.9%]). All issues became evident <21 days postoperatively. Inflammatory arthritis, smoking, and coronary disease were patient factors associated with major wound complications. Four patients were treated with negative pressure therapy, 4 with debridement in the operating room, and 2 eventually converted to fusions. Fourteen patients (82%) who had major complications had an ancillary procedure to balance the TAA through a separate incision. All major wound complications had an anterior surgical approach for their TAA. Before 2011, there were 13 major wound complications. Since 2012, there have been 4 major wound complications overall, with no wound complications in the anteromedial approach cohort. CONCLUSION: We recommend an extensile anteromedial approach for smokers and patients with heart disease or inflammatory arthritis undergoing TAA. If a wound complication developed, a multidisciplinary team to evaluate wounds was useful. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Long-term Autograft Harvest Site Pain After Ankle and Hindfoot Arthrodesis.

BACKGROUND: Pain following autograft harvest has been studied; however, published literature has typically focused on the iliac crest with follow-up limited to only a few years. It remains unknown if pain continues or improves over time. The purpose of this study was to evaluate long-term pain associated with autograft harvest to supplement hindfoot or ankle arthrodesis. METHODS: Subjects in the control arm of a previously conducted trial comparing autograft with a synthetic bone graft for hindfoot or ankle arthrodesis were invited back for a single visit at a minimum of 5 years following their initial surgery. Harvest site, fusion site, and weight-bearing pain were evaluated using a 100-point visual analog scale (VAS). Of the 130 invited subjects, 60 (46.1%) returned for assessment, 58 of whom completed pain assessments. RESULTS: At a mean follow-up of 9.0 years (range, 7.8-10.5), more than a third (36.6%) of subjects had some level of harvest site pain. Using VAS greater than 20 mm as a threshold of clinical significance, pain remained clinically significant in 5.2% of subjects. There was a significant correlation between harvest site pain and both weight-bearing and fusion site pain. There was not a significant correlation between harvest site pain and volume of graft harvested. CONCLUSION: Autograft harvest can result in chronic, clinically significant pain that can last up to 10 years. In the era of shared decision making, this information will help surgeons and patients quantify the risks of chronic pain after arthrodesis procedures that include a secondary operative incision for graft harvest. LEVEL OF EVIDENCE: Level II, prospective comparative study.