Isolated Talonavicular Arthrodesis as Treatment for Flexible Progressive Collapsing Foot Deformity: A Case Series.

Background: For the younger, more active patient with flexible symptomatic progressive collapsing foot deformity (PCFD), joint-sparing procedures may be preferred to preserve functional motion. Isolated talonavicular (TN) arthrodesis has been described for treatment of rigid and flexible PCFD for patients that are older and less active whose deformity is still correctable through the TN joint. The purpose of this study was to evaluate radiographic and clinical outcomes in patients with PCFD treated with isolated triplanar correction with a TN joint arthrodesis. Methods: Forty-nine patients (53 feet) with flexible PCFD underwent isolated TN arthrodesis. Weightbearing radiographs were performed pre- and postoperatively, and measurements included lateral talar-first metatarsal angle, calcaneal pitch, TN coverage angle, and the anteroposterior (AP) talar-first metatarsal angle. The Foot and Ankle Ability Measure (FAAM) and Veterans-Rand 12-Item Health Survey (VR-12) scores were also collected. Results: Thirty-five females and 14 males were evaluated with a mean age of 63 years, at an average follow-up of 41.3 months. Significant improvements were found radiographically. Lateral radiographs demonstrated improvements in lateral talar-first metatarsal angle from 25.2 degrees preoperatively to 9.5 degrees postoperatively (P < .001) and calcaneal pitch from 14.9 degrees preoperatively to 17.5 degrees postoperatively (P < .001). AP radiographs showed the TN coverage angle improving from 35.0 degrees to 4.9 degrees postoperatively (P < .001) and AP talar-first metatarsal angle improving from 17.3 degrees to 5.9 degrees postoperatively (P < .001). Clinical outcomes were improved in the FAAM pain score (48.6 to 39.2, P = .130), FAAM ADL score (53.8 to 69.2, P = .002), FAAM Sport score (29.5 to 40.7, P = .099), and the overall FAAM score (47.7 to 63.1, P = .006). Patient satisfaction with medical care was 85.2/100 postoperatively. Conclusion: Isolated TN arthrodesis is a viable surgical option for older, lower-demand patients with flexible PCFD. This study demonstrated significant improvements in radiographic alignment and FAAM scores. Comparative studies with other surgical procedures should be performed to determine which is the best technique for older, lower-demand patients with flexible PCFD. Level of Evidence: Level III, retrospective cohort study.

Takedown of Ankle Fusions and Conversion to Total Ankle Replacements.

BACKGROUND: With ankle replacements gaining credibility, there is a small subset of patients who might benefit from a conversion of an ankle fusion to a replacement. The objective of this study is to present clinical and radiographic results of patients who had their ankle fusion converted to total ankle arthroplasty (TAA). METHODS: Patients presented to the senior author with ongoing ankle pain following fusion or increasing pain after a period of relative comfort after an ankle fusion. Outcomes were evaluated preoperatively and postoperatively with the Veterans Rand Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS), and visual analog scale (VAS) pain scale. A patient satisfaction survey was also distributed. RESULTS: All ankle fusion conversions between April 2010 and December 2019 were included. Fifty-one patients (30 females) with the mean age of 62.6 (range, 37-83) years were followed. Mean follow-up was 4.2±2.3 (range, 2-11.5) years. Two patients were lost to follow-up (1 is deceased). Pre- and postoperative mean patient-reported outcome scores were all significantly different between groups except VR-12 mental subscale scores. VR-12 physical scores improved from 28.7±8.9 preoperatively to 38.9±9.9 (P < .001) postoperatively; VR-12 mental score was stable. AOS pain and disability subscales similarly improved: 55.9±24.4 to 27.9±25.4 (P < .001) and 61.7±21.1 to 31.1±25.7 (P < .001), respectively. VAS pain improved from a mean of 64.5±27.3 to 29.4±27.7 (P < .001). There was no tibiotalar dorsiflexion or plantarflexion with the ankle fusion. Initial postoperative visit revealed that average dorsiflexion was 10.9±5.93 degrees and average plantarflexion was 14.1±5.22 degrees. At the latest follow-up, dorsiflexion improved significantly to 15.5±6.33 degrees (P < .001), with no significant improvement in plantarflexion (P = .980). CONCLUSION: In this single-surgeon longitudinal study of 51 patients with a painful, malaligned, or nonhealed ankle fusion treated with an ankle replacement, we found highly satisfactory functional outcomes at an average of 4.2 years. Continued long-term follow-up will reveal whether the longevity of these replacements is comparable to primary replacements.

Functional Outcome of Sesamoid Excision in Athletes.

BACKGROUND: Sesamoid injuries can have a significant effect on the ability of athletes to return to play. The literature shows mixed results with sesamoid excisions and the ability to return to sports. HYPOTHESIS/PURPOSE: The purpose was to describe patient-reported outcomes and return to sports in athletes after sesamoidectomy with a proper surgical technique and a well-structured rehabilitation protocol. It was hypothesized that sesamoid excision would demonstrate reproducible and encouraging long-term patient outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients from a single surgeon's practice who underwent sesamoidectomy between January 2006 and September 2015 were identified. Medial sesamoids were excised through a medial approach, and lateral sesamoids were excised through a plantar approach. The plantar structures were adequately repaired after excision. The Foot Function Index-Revised (FFI-R), 12-Item Short Form Health Survey (SF-12), and visual analog scale (VAS) were collected preoperatively and at subsequent follow-up appointments. A patient satisfaction survey and Single Assessment Numeric Evaluation (SANE) questionnaire were also collected. Athletes were defined as those who participated in sports at a high school level or higher. RESULTS: Of the 108 feet that met the inclusion criteria, 26 werelost to follow-up, leaving 82 feet for analysis at a mean 31.3 ± 26.0 months. There were 72 female patients and 10 male patients included in the final analysis, with a mean age of 44.9 ± 20.2 years. There were 54 medial, 18 lateral, and 10 medial and lateral sesamoid excisions. There were 26 competitive athletes with follow-up appointments (dancer, n = 12; pivot sport athlete, n = 8; runner, n = 6). Both the entire study population and the athletes demonstrated a significant improvement in SF-12, SANE, VAS, and FFI-R cumulative at the latest available follow-up (P < .05). Among the athletes, 80% were able to return to competitive sports at a mean 4.62 ± 1.01 months after surgery. The median satisfaction score among all patients was 97.5%. There was no difference in the success rate between the different etiologies at any of the follow-up intervals. CONCLUSION: Chronic sesamoid pain is difficult to treat, but this study confirms that with a meticulous surgical technique and a dedicated postoperative rehabilitation program, encouraging patient-reported outcomes can be expected with a minimal risk of complications. Moreover, in the current study, 80% of competitive athletes were able to return to sports at a mean of 4.62 months after surgery.

Early Patient Satisfaction Results on a Modern Generation Fixed-Bearing Total Ankle Arthroplasty.

BACKGROUND: This study presents patient-reported outcomes and patient satisfaction data for the largest series of US patients undergoing modern fixed-bearing total ankle arthroplasty (TAA). METHODS: We retrospectively reviewed the records of 300 consecutive patients who underwent 321 modern, fixed-bearing TAAs at a single institution. Veterans Rand 12-Item Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS), and the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot score were collected preoperatively and at subsequent follow-up appointments. A patient satisfaction survey was also distributed to each patient postoperatively. Of the 321 TAAs, 245 (232 patients) had a minimum of 2-year follow-up and a complete data set. Furthermore, 192 patients underwent concomitant procedures. The average follow-up was 38.9 months (24-84.5). Eight patients have been lost to follow-up (7 deceased and 1 refused further follow-up). RESULTS: The mean AOFAS score preoperatively was 41.1 and at latest follow-up was 84.6 (P < .01). The mean VR-12 score was 29.7 (Physical) and 54.1 (Mental) preoperatively and 42.7 (Physical) and 55.7 (Mental) at latest follow-up (P < .01 and P > .05, respectively). AOS pain and disability scores improved significantly after TAA (P < .01). The patient satisfaction survey indicated that 84% experienced very good to excellent pain relief, 78% reported improved ability to perform daily tasks, and 54% indicated improvement in their ability to perform heavy work or recreational activities. In addition, 94% would probably or definitely have the procedure on the contralateral ankle. Two patients underwent revision TAA at a minimum of 36 months; 8 patients failed the primary TAA and were converted to ankle fusions at a mean of 20.1 months (6.1-46.1). CONCLUSION: Early results of a large series of a modern TAA system demonstrate improvement in patient satisfaction, quality of life, activity, and pain for patients with end-stage ankle arthritis. Early revision was due to infection or loosening of the tibial component. LEVEL OF EVIDENCE: Level IV, case series.