The Impact of Concomitant LOW Back Pain (LBP) on Functional Outcomes in Total Ankle Arthroplasty (TAA).

Although numerous studies have demonstrated that concomitant low back pain (LBP) is associated with worse functional outcomes in patients undergoing total hip and knee arthroplasty, no study has analyzed its impact on patients undergoing total ankle arthroplasty (TAA). The aim of this study was to determine the prevalence of LBP in people undergoing TAA and analyze its impact on patient reported functional outcome measures (PROMs). A retrospective review was performed on data from the Vancouver End Stage Ankle Arthritis Database. In total, 87 patients undergoing TAA were studied, with patient demographics collected preoperatively, including the absence or presence of LBP. Postoperative follow-up was performed at 5 years, primarily analyzing disease-specific PROMs including the Ankle Osteoarthritis Score and Ankle Arthritis Score. The Short Form-36 was used as a secondary outcome measure to assess global function. Multivariable linear mixed-effects regression models were conducted to compare the PROM between patients with LBP with those without LBP. In total, 30 patients (35%) presented with concomitant LBP. There were no significant differences at baseline between the LBP group and no LBP group in terms of demographics or baseline primary disease-specific PROMs. At 5 years, the patients with LBP had significantly worse Ankle Arthritis Score (32 ± 23 vs 22 ± 17, p = .03), Ankle Osteoarthritis Score Total (34 ± 23 vs 22 ± 16, p = .01), and Short Form-36 physical (PCS) components summaries (33 ± 12 vs 44 ± 9, p = .001) compared to the no-LBP group. Both groups improved significantly from baseline across all outcome measures. Our study demonstrated that the prevalence of concomitant LBP in end stage ankle arthritis undergoing TAA is similar to that described in arthritic knees and hips. If present, it can be associated with worse functional outcomes in the intermediate term. However it is not a contraindication to surgery, with patients still experiencing significant improvements from baseline. Further studies are needed to evaluate if LBP influences complications, implant failure rates and survival.

Successful fifth metatarsal bulk autograft reconstruction of thermal necrosis post intramedullary fixation.

Reamed intramedullary (IM) screw fixation for proximal fifth metatarsal fractures is technically challenging with potentially devastating complications if basic principles are not followed. A case of an iatrogenic fourth-degree burn after elective reamed IM screw fixation of a proximal fifth metatarsal fracture in a high-level athlete is reported. The case was complicated by postoperative osteomyelitis with third-degree soft-tissue defect. This was successfully treated with staged autologous bone graft reconstruction, tendon reconstruction, and local bi-pedicle flap coverage. The patient returned to competitive-level sports, avoiding the need for fifth ray amputation. Critical points of the IM screw technique and definitive reconstruction are discussed. Bulk autograft reconstruction is a safe and effective alternative to ray amputation in segmental defects of the fifth metatarsal.Level of evidence V.

Heterotopic Ossification in Total Ankle Arthroplasty: Case Series and Systematic Review.

Heterotopic ossification after total ankle arthroplasty (TAA) is a known sequela and has been reported to contribute to reduced range of motion and poor functional outcomes. However, conflicting results have been reported in the literature. The present study documents the incidence of heterotopic ossification for a novel fourth-generation fixed-bearing 2-component prosthesis and reports a systematic review of the literature. We reviewed the incidence and functional outcome of consecutively enrolled patients who underwent primary Infinity TAA between 2013 and 2015 in a prospective observational study. Preoperative and postoperative radiographic and functional outcome data were collected. A systematic review was also conducted investigating all published studies between 1998 and 2018 reporting the incidence of heterotopic ossification after TAA. The incidence of heterotopic ossification was 70.5% in the 61 patients who underwent primary TAA in the case series. There was no association between heterotopic ossification and American Orthopaedic Foot and Ankle Society (AOFAS) score, foot function index (FFI), visual analogue scale (VAS), and ankle osteoarthritis scale (AOS). Sixteen studies on 1339 TAA implants were included. The overall incidence of heterotopic ossification after TAA was 66.0% at average 3.6 years (range 22.2% to 100%). Four studies (299 ankles) did not address functional outcomes. Eleven studies (960 ankles) reported no association between heterotopic ossification and functional outcomes. One study (80 ankles) reported a statistically significant difference in range of motion (7°) and AOFAS score (7 points). In conclusion, although the incidence of heterotopic ossification after TAA is considerable, there is insufficient literature to suggest that heterotopic ossification after TAA impacts range of motion or functional outcome.

Validating the Foot and Ankle Outcome score for measuring foot dysfunction among hallux valgus surgery patients using item response theory.

BACKGROUND: There is an absence of high quality research validating instruments that measure foot and ankle related quality of life among hallux valgus (bunion) patients' perspectives. The Foot and Ankle Outcome Scale is a patient-reported outcome instrument, that when administered to patients with symptomatic hallux valgus, provides a patient-centric perspective of their foot function. The aim of this study is to assess the psychometric properties of the instrument's five subscales among preoperative bunion surgery patients. METHODS: The Foot and Ankle Outcome Scale instrument measures Pain, Symptoms, Activities of Daily Living, Sport and Recreational Activities and Foot/Ankle Related Quality of Life. Preoperative data is collected from a sample of patients scheduled for surgical treatment of their condition in Vancouver, Canada. Classical and item response theory methods are used to report on reliability, validity and differential item functioning among subgroups. RESULTS: This study included 249 surveys, representing an overall response rate of 44.1% among 564 eligible patients. The instrument demonstrated high reliability for all subscales, though 18 items across subscales, exhibited poor discrimination between item levels. Four items score differently according to patients' sex and one item scored differently by age. CONCLUSIONS: The instrument measures five domains of health important to bunion patients. These findings suggest that the current instrument can be used with an understanding of its limitations, including redundant questions and sex-based differences. Future research should revise a number of items. The results highlight the importance of the psychometric analyses of instruments in specific patient populations.

Nonanimal Hyaluronic Acid for the Treatment of Ankle Osteoarthritis: AProspective, Single-Arm Cohort Study.

Ankle osteoarthritis (OA) can cause disabling symptoms, and some patients prefer to be treated with minimally invasive procedures. Nonanimal hyaluronic acid (NASHA) is a cross-linked hyaluronic acid product that has a prolonged intra-articular residence time. The authors report the first study of NASHA for the treatment of ankle OA. Thirty-seven patients with Kellgren-Lawrence grade II or III ankle OA received an intra-articular injection of NASHA (1 mL). Outcomes included visual analogue scale (VAS) scores for pain and disability. At baseline, the mean VAS pain score was 50.1 ± 14.5mm. During the 26-week follow-up period, the least squares (LS) mean change from baseline in the ankle OA VAS pain score was -20.5mm (95% confidence interval [CI] -25.5 to -15.6 mm), an LS mean percentage reduction of 40.0% (95% CI 30.2% to 49.9%). The LS mean change from baseline in the VAS disability score during 26 weeks was -19.2mm (95% CI -24.8 to -13.6 mm), a percentage reduction of 34% (95% CI 22.3% to 45.7%). Five participants experienced a total of 7 adverse events considered to be related to study treatment (injection site pain, n = 3; injection site joint pain, n = 3; plantar fasciitis, n = 1). This study shows promise for viscosupplementation with NASHA in the treatment of ankle OA. A single injection was associated with clinically meaningful reductions in pain and disability during a 26-week period and, in general, was well tolerated.

Disparities in HIV knowledge and attitudes toward biomedical interventions among the non-medical HIV workforce in the United States.

Non-medical, community-based workers play a critical role in supporting people living with (or at risk of acquiring) HIV along the care continuum. The biomedical nature of promising advances in HIV prevention, such as pre-exposure prophylaxis and treatment-as-prevention, requires frontline workers to be knowledgeable about HIV science and treatment. This study was developed to: measure knowledge of HIV science and treatment within the HIV non-medical workforce, evaluate workers' familiarity with and attitudes toward recent biomedical interventions, and identify factors that may affect HIV knowledge and attitudes. A 62-question, web-based survey was completed in English or Spanish between 2012 and 2014 by 3663 US-based employees, contractors, and volunteers working in AIDS service organizations, state/local health departments, and other community-based organizations in a non-medical capacity. Survey items captured the following: respondent demographics, HIV science and treatment knowledge, and familiarity with and attitudes toward biomedical interventions. An average of 61% of HIV knowledge questions were answered correctly. Higher knowledge scores were associated with higher education levels, work at organizations that serve people living with HIV/AIDS or who are at a high risk of acquiring HIV, and longer tenure in the field. Lower knowledge scores were associated with non-Hispanic Black or Black race/ethnicity and taking the survey in Spanish. Similarly, subgroup analyses showed that respondents who were non-Hispanic Black or Hispanic (versus non-Hispanic white), as well as those located in the South (versus other regions) scored significantly lower. These subpopulations were also less familiar with and had less positive attitudes toward newer biomedical prevention interventions. Respondents who took the survey in Spanish (versus English) had lower knowledge scores and higher familiarity with, but generally less positive attitudes toward, biomedical interventions. In summary, low knowledge scores suggest the need for additional capacity-building efforts and training for non-medical HIV workers, particularly those who provide services in the communities most affected by HIV.

A study to evaluate the safety of platelet-derived growth factor for treatment of osteochondral defects of the talus.

PURPOSE: An arthroscopic procedure for the treatment of osteochondral defects using platelet-derived growth factor (PDGF) carried out in a matrix of tricalcium phosphate was developed. This prospective, case-series-based study was designed to evaluate the safety and clinical utility of this procedure. METHODS: Patients with an isolated osteochondral defect larger than 5 mm long, 3 mm wide, and 5 mm deep and smaller than 30 mm long, 25 mm wide, or 20 mm deep were considered for enrolment. Only patients with chronic lesions were enroled. Arthroscopic debridement was followed by the placement of recombinant human PDGF in a matrix of tricalcium phosphate. The Ankle Osteoarthritis Scale (AOS), visual analogue scale (VAS) for pain, and SF-36 questionnaires were administered at 0, 2, 6, 12, and 24 weeks. Magnetic resonance imaging (MRI) and computed tomography (CT) scans were taken before and after surgery. RESULTS: Five patients were ultimately enroled in this proof-of-concept trial. All outcome measures demonstrated marked improvement from baseline to final follow-up: The mean weight bearing VAS pain score improved by 49%, and the mean AOS functional score improved by 28%. Bone healing was seen on CT, and reduction in oedema signal was seen on MRI. CONCLUSION: This new procedure may offer a promising alternative for the treatment of osteochondral defects. Further high-quality studies are needed to confirm these results and to analyse the long-term effects of the procedure. The clinical relevance of this study is that the procedure may provide a less invasive option with improved bone healing compared to standard techniques . LEVEL OF EVIDENCE: IV.

Irreducible Fracture-Dislocation of the Ankle Associated With Interposition of the Tibialis Posterior Tendon in the Syndesmosis: A Case Report.

Although ankle fracture-dislocations are common orthopedic injuries, it is very uncommon for them to be irreducible, and such cases require special attention. We report the case of a closed fracture-dislocation of the ankle in a 17-year-old male that required 3 surgeries because of persistent anterior subluxation of the talus on the postoperative radiographs. After advanced radiologic investigations, tibialis posterior tendon interposition in the syndesmosis was identified as the cause of the subluxation. This is a very rare event, reported in only 5 patients in published studies. Once the diagnosis was identified by magnetic resonance imaging, the tendon was relocated to its anatomic position, and the tibiofibular and tibiotalar joints were reduced adequately. The patient was then able to regain a satisfactory level of function many months after the initial trauma.

Shared Decision Making in Hallux Valgus Surgery: A Prospective Observational Study.

Patient-physician communication has the potential to improve outcomes and satisfaction through the shared decision-making process (SDM). This study aims to assess the relationship between perception of SDM and demographic, clinical, and patient-reported outcomes in patients undergoing Hallux Valgus (HV) correction. A prospective analysis of 306 patients scheduled for HV surgery was completed. The CollaboRATE score was used to measure SDM. Multivariable linear regression model was used to assess whether SDM scores were associated with preoperative characteristics or postoperative outcome scores. The mean CollaboRATE score was 2.9 (SD 0.9) and did not differ by age, socioeconomic status, or sex. Lower CollaboRATE scores were associated with more symptoms of depression, lower socioeconomic status, and lower general health scores (p-value < 0.05). There was no association between SDM scores and postoperative outcome scores. In this study, patients with depressive symptoms and lower socioeconomic status had worse perceptions of SDM. There was no difference in postoperative outcomes among participants based on SDM scores. Level of Evidence: Level III, prospective observational study.

Level of Evidence for the Treatment of Chronic Noninsertional Achilles Tendinopathy.

BACKGROUND: Noninsertional Achilles tendinopathy affects both athletes and sedentary individuals, and its incidence is rising. Conservative management is the mainstay of treatment, but a variety of operative techniques have been described to treat recalcitrant cases. We seek to outline the current available evidence for surgical management of noninsertional Achilles tendinopathy. STUDY DESIGN AND METHODS: A systematic review was performed using the MEDLINE and EMBASE databases, and all articles were reviewed by at least 2 authors. Each article was assigned a level of evidence in accordance with the standards of Journal of Bone and Joint Surgery. The available data were reviewed and a level of evidence was assigned to each intervention of interest, based on the revised classifications of Wright. RESULTS AND CONCLUSION: A total of 46 articles met inclusion and exclusion criteria. There is fair evidence (grade B) in support of open debridement with 1 level II study, 1 level III study, and 8 level IV studies. There is fair evidence (grade B) in support of arthroscopic or minimally invasive surgical techniques. There is poor evidence (grade C) in support of flexor hallucis longus transfer, longitudinal tenotomy, peritenolysis, gastrocnemius recession, and plantaris excision. There is insufficient evidence (grade I) to provide a recommendation about other surgical treatment methods for noninsertional Achilles tendinopathy.Levels of Evidence: Level III: Systematic review.

Responsiveness and validity of the SF-36, Ankle Osteoarthritis Scale, AOFAS Ankle Hindfoot Score, and Foot Function Index in end stage ankle arthritis.

BACKGROUND: We examined four commonly used scores, the SF-36, the Ankle Osteoarthritis Scale (AOS), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Score, and the Foot Function Index (FFI) to determine their responsiveness and validity. METHODS: Patients with end stage ankle arthritis were recruited into a prospective multicenter cohort study and baseline and one year outcome scores were compared. The Standardized Response Mean and Effect Size for the AOS, AOFAS, and FFI were calculated and the three region- or disease-specific scores were compared with the SF-36 to determine their criterion validity. RESULTS: All four scores showed acceptable responsiveness, and when using the validated SF-36 as the standard the three region or disease specific scores all showed similar criterion validity. CONCLUSION: All four scores are responsive and can be considered for use in this population. The objective component of the AOFAS Ankle Hindfoot Score may make it harder to perform than the other three scores which have subjective components only, and as yet its objective component has not been shown to demonstrate reliability. We recommend use of a purely subjective score such as the Ankle Osteoarthritis Scale or Foot Function Index as the region- or disease-specific score of choice in this population. As the SF-36 shows acceptable responsiveness, using it alone could also be considered.

Cohort Comparison of Radiographic Correction and Complications Between Minimal Invasive and Open Lapidus Procedures for Hallux Valgus.

BACKGROUND: The Lapidus procedure corrects hallux valgus first ray deformity. First tarsometatarsal (TMT) fusion in patients with hallux valgus deformity using minimally invasive surgery (MIS) is a new technique, but comparative outcomes between MIS and open techniques have not been reported. This study compares the early radiographic results and complications of the MIS with the open procedure in a single-surgeon practice. METHODS: 47 MIS patients were compared with 44 open patients. Radiographic measures compared preoperatively and postoperatively were the intermetatarsal angle (IMA), hallux valgus angle (HVA), foot width (FW), distal metatarsal articular angle (DMAA), sesamoid station (SS), metatarsus adductus angle (MAA), first metatarsal to second metatarsal length, and elevation of the first metatarsal. Early complications were recorded, as well as repeat surgeries. RESULTS: The mean follow-up was 82 (range, 31-182) months for the open group and 29 (range, 14-47) months for the MIS group. In both techniques, postoperative measures (IMA, HVA, DMAA, FW, and sesamoid station) were significantly improved from preoperative measures. When comparing postoperative measures between both groups, the IMA was significantly lower in the open group (4.8 ± 3.6 degrees vs 6.4 ± 3.2 degrees, P < .05). Differential between pre- and postoperative measures for both techniques were compared, and the open group was associated with more correction than the MIS group for IMA (12.4 ± 5.3 degrees vs 9.4 ± 4.4 degrees, P = .004) and HVA (25.5 ± 8.3 degrees vs 20 ± 9.9 degrees, P = .005). Wound complication and nonunion rates trended higher in the open group (4 vs 0) (P = .051). CONCLUSION: Both techniques resulted in good to excellent correction. However, the open technique was associated with lower postoperative IMA values and more correction power for IMA and HVA, than the MIS.

High Pain Catastrophizing Scale Predicts Lower Patient-Reported Outcome Measures in the Foot and Ankle Patient.

BACKGROUND: Postoperative outcomes may be affected by the patient's preoperative morbidity. It is hypothesized that patient's pain catastrophization prior to foot and ankle surgery may affect their patient-reported outcomes. Methods: This study prospectively assessed a consecutive cohort of 46 patients undergoing foot and ankle reconstruction to describe the relationship between Pain Catastrophizing Scale (PCS) and patient-reported outcomes measured by 12-item Short Form Health Survey and Foot and Ankle Outcome Score (FAOS). RESULTS: The 1-year postoperative FAOS pain, activities of daily living, and quality of life scores correlated significantly with all baseline PCS subcategories. We found that the mental domain of the SF-12 had a statistically significant correlation with the rumination and helplessness PCS subcategories. CONCLUSION: This study showed a significant association between a high preoperative PCS and a worse 1-year FAOS. As such, catastrophization could be screened for and potentially treated preoperatively to improve patient-reported outcomes in elective foot and ankle surgery. LEVEL OF EVIDENCE: Therapeutic, Level III Evidence.

Arthroscopic Versus Open Ankle Arthrodesis: A 5-Year Follow Up.

BACKGROUND: End-stage ankle arthritis has long been managed surgically with open ankle arthrodesis (OAA). Since the first published report in 1983, arthroscopic ankle arthrodesis (AAA) has been thought to be associated with improved patient-reported outcome measures (PROMs) and fewer complications. The purpose of the present study was to compare the long-term PROMs, major complications, and reoperations for these 2 approaches at up to 15 years of follow-up. METHODS: This longitudinal cohort study included patients at our institution who underwent primary ankle arthrodesis for the treatment of end-stage arthritis. Demographic data and preoperative COFAS (Canadian Orthopaedic Foot and Ankle Society) ankle arthritis type were collected for all patients. PROMs were completed preoperatively, at 6 months, and annually thereafter to 5 years. PROMs were compared at all time points with use of a mixed-effects regression model that adjusted for preoperative variables and scores. Major complications and reoperations at the site of the ankle arthrodesis were also compared. RESULTS: Of 1,294 patients who were screened for inclusion, 351 who had undergone ankle arthrodesis between 2003 and 2019 were eligible for the study. Of those, 223 had undergone AAA and 128 had undergone OAA. The 2 groups were similar preoperatively with respect to demographics, but COFAS Type-4 arthritis was relatively more common in the OAA group and Type-1 arthritis was relatively more common in the AAA group. In addition, the Ankle Osteoarthritis Scale (AOS) score and Ankle Arthritis Score (AAS) were better in the AAA group. In the mixed-effects model analysis, the differences in postoperative outcome scores between the groups were not significant. The risk of revision due to malunion or nonunion was similar in both groups (6% in the AAA group, compared with 4% in the OAA group). Deep infection and wound complications did not occur in the arthroscopic group but occurred in 4% of the patients in the OAA group. CONCLUSIONS: After adjustment for baseline patient characteristics, there were no differences in PROMs between the 2 techniques. Ankle arthrodeses done arthroscopically had a similar revision rate but lower infection rate compared with those done with the open technique. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Impact of Concomitant Ipsilateral Knee Pain on Functional Outcomes in Total Ankle Arthroplasty.

In end-stage ankle arthritis, little is known about the impact of concomitant knee pathology, including the impact of ipsilateral knee pain on total ankle arthroplasty (TAA) outcomes. The aim of this study was to determine the prevalence of ipsilateral preoperative knee pain in patients undergoing TAA and analyze its impact on patient-reported functional outcome measures (PROMs). A retrospective review was performed on the Vancouver End Stage Ankle Arthritis Database at a single institution. In total, 114 patients were studied, with patient demographics collected preoperatively, including the presence or absence of knee pain. Postoperative follow-up was performed at 5 years, primarily analyzing disease-specific PROMs, including the Ankle Osteoarthritis Score (AOS) and Ankle Arthritis Score (AAS). Multivariate mixed-effects linear regression models compared the scores between the groups. In total, 31 patients (27.2%) presented with concomitant ipsilateral knee pain. Despite more females in the knee pain group (64.5% vs 36.1%) there were no other significant differences at baseline between the knee pain and no knee pain groups in terms of demographics or baseline primary disease specific PROMs. At 5 years, the patients with knee pain had significantly worse AAS (37.9 ± 23.8 vs 21.2 ± 16.3, P = .004) and AOS total scores (38.1 ± 24.1 vs 21.9 ± 15.5, P = .005) compared with the no-knee pain group. Both groups improved significantly from baseline across all outcome measures; however, the magnitude of improvement was less in the knee pain group. Our study demonstrated that over one-quarter of patients with end-stage ankle arthritis undergoing TAA present with ipsilateral concomitant knee pain. If present, it is associated with worse functional outcomes at the 5-year mark. Further studies are needed to evaluate if knee pain influences complications, implant failure rates, and survival.Levels of Evidence: Level III.

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.

Arthroscopic Repair of Talar Osteochondral Defects With Umbilical Cord Allograft: A Prospective, Single-Center, Pilot Study.

Cryopreserved umbilical cord (UC) allografts have been shown to promote postoperative wound healing by suppressing inflammation and reducing scar formation. The purpose of this study was to determine whether adjunctive use of UC may improve clinical and functional outcomes following arthroscopic repair of talar osteochondral defects (OCDs). A total of 10 patients with talar OCDs that failed nonoperative treatment were enrolled in this single-center, prospective, pilot study. Clinical and functional outcomes were assessed using the Ankle Osteoarthritis Scale (AOS), Foot and Ankle Ability Measure, and Visual Analog Scale (VAS) pain scale at 6, 12, 24, and 52 weeks postoperatively. Results showed a consistent improvement in all outcome measures. VAS pain scores significantly improved from 4.2 ± 2.9 to 1.3 ± 2.2 at 52 weeks (P = .015). AOS difficulty and pain scores nonsignificantly improved from 27.0 ± 24.6 and 33.1 ± 28.3 at baseline to 15.3 ± 20.5 and 14.8 ± 18.7 at 52 weeks, respectively. The clinical outcome improvement was accompanied by significant reduction in OCD defect size and associated bone marrow lesion. This pilot study suggests that adjunctive use of UC during arthroscopic repair of talar OCD may lead to clinical and functional improvement.Levels of Evidence: Level II: Prospective Cohort Study.

Effect of Patient Demographics on Minimally Important Difference of Ankle Osteoarthritis Scale Among End-Stage Ankle Arthritis Patients.

BACKGROUND: Ankle replacement and ankle arthrodesis are standard treatments for treating end-stage ankle arthritis when conservative treatment fails. Comparing patient-reported outcome scores to the instrument's minimal important difference (MID) helps physicians and researchers infer whether a meaningful change in health from the patient's perspective has occurred following treatment. The objective of this study was to estimate the MID of the Ankle Osteoarthritis Scale among a cohort of operatively treated end-stage ankle arthritis patients undergoing ankle replacement or arthrodesis. METHODS: A survey package including the Ankle Osteoarthritis Scale was completed by participants preoperatively and 2 years postoperatively. Distribution and anchor-based approaches to calculating the MID were used to estimate the MID of the Ankle Osteoarthritis Scale and its 2 domains. The distribution-based approaches used were the small and medium effect size methods, while the mean absolute change method and linear regression method were the anchor-based approaches. Bootstrap sampling was used to obtain the variance of MID estimates. The MID was estimated for sex, age, operative, and baseline health subgroups. The cohort comprised 283 participants, totaling 298 ankles. RESULTS: The MID did not vary with sex or operative procedure. Age-based differences in MID values may exist for the Ankle Osteoarthritis Scale total score, and MID values were generally smallest among the oldest patients. Patients with the best and worst ankle-related health preoperatively had higher MID values than patients reporting mid-range Ankle Osteoarthritis Scale values preoperatively. CONCLUSION: The best estimate of the MID of the Ankle Osteoarthritis Scale total score is 5.81. Our findings indicate that the MID of the Ankle Osteoarthritis Scale may not vary by sex or operative subgroups but likely varies by age and preoperative Ankle Osteoarthritis Scale score. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Total Ankle Arthroplasty Radiographic Alignment Comparison Between Patient-Specific Instrumentation and Standard Instrumentation.

BACKGROUND: Several benefits are published supporting patient-specific instrumentation (PSI) in total ankle arthroplasty (TAA). This study seeks to determine if TAA with PSI yields different radiographic outcomes vs standard instrumentation (SI). METHODS: Sixty-seven primary TAA patients having surgery using PSI or SI between 2013 and 2015 were retrospectively reviewed using weightbearing radiographs at 6-12 weeks postsurgery. Radiographic parameters analyzed were the medial distal tibia angle (MDTA), talar-tilt angle (TTA), anatomic sagittal distal tibia angle (aSDTA), lateral talar station (LTS), and talar component inclination angle (TCI). A comparison of the 2 groups for each radiologic parameter's distribution was performed using a nonparametric median test and Fisher exact test. Furthermore, TAAs with all radiographic measurements within acceptable limits were classified as "perfectly aligned." The rate of "perfectly aligned" TAAs between groups was compared using a Fisher exact test with a significance of .05. RESULTS: Of the 67 TAAs, 51 were done with PSI and 16 with SI. There were no differences between groups in MDTA (P = .174), TTA (P = .145), aSDTA (P = .98), LTS (P = .922), or TCI angle (P = .98). When the rate of "perfectly aligned TAA" between the 2 groups were compared, there was no significant difference (P = .35). CONCLUSION: No significant radiographic alignment differences were found between PSI and SI implants. This study showed that both techniques achieve reproducible TAA radiographic coronal and sagittal alignment for the tibial component when performed by experienced surgeons. The talar component's sagittal alignment is similar whether or not PSI was used but is noticeably different from normal anatomic alignment by design. LEVEL OF EVIDENCE: Level III, retrospective cohort study using prospectively collected data.

Effect of Dexamethasone in Peripheral Nerve Blocks on Recovery of Nerve Function.

BACKGROUND: Peripheral nerve blocks (PNBs) have revolutionized distal extremity surgery reducing pain and improving hospital efficiency. Perineural dexamethasone has been administered with PNBs to prolong their effects, although the safety of dexamethasone has not been established in the literature. This study aimed to determine if the addition of dexamethasone affected the postoperative neurological sensory status for foot and ankle surgeries and the recovery of nerve injuries. We hypothesized that the rate of persistent nerve injury would be higher in the dexamethasone group. METHODS: This is a retrospective observational cohort study of prospectively collected data of all patients from a single foot and ankle surgeon's practice. Perineural dexamethasone was routinely used as an adjunct by the regional anesthesia group until a clinical trend of increased paresthesia was found on short-term follow-up, which led to the discontinuation of its use. In this study, the cohort that received dexamethasone with ropivacaine was compared with the cohort that received ropivacaine alone. The primary outcome was a separate sensory nerve status sheet that was completed for every distal nerve territory for every patient at their follow-up visits at 2 weeks, 6 weeks, 3 months, and 6 months. Univariate analysis and a logistic regression model were used to determine the association between dexamethasone and delayed nerve recovery. A total of 250 patients were included in the study, with 117 patients in the dexamethasone group and 133 in the ropivacaine-only group. RESULTS: The rates of nerve injuries were not different between the groups (72 [62%] in the dexamethasone group vs 79 [59%] in the ropivacaine-only group). However, nerve injury symptoms were more likely to persist and not fully recover in the dexamethasone group (n = 47, 65%) compared with the ropivacaine-only group (n = 32, 41%) (OR, 2.12; P = .006). CONCLUSION: Perineural dexamethasone added to PNBs may be associated with delayed nerve recovery after foot and ankle surgery. It may be prudent to avoid its use until its full safety profile is established in larger prospective trials. LEVEL OF EVIDENCE: Level III, retrospective comparative study.