Outcomes After Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy.

BACKGROUND: Surgical treatment of insertional Achilles tendinopathy (IAT) historically consists of Achilles tendon debridement with reattachment and excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. Zadek osteotomy (ZO) is an alternative to an open midline splitting approach. The purpose of this study was to analyze patient-reported outcomes and complications after percutaneously performed ZO with minimum 2 years' follow-up. METHODS: One hundred eight cases treated with percutaneous ZO with a minimum 2-year follow-up were retrospectively reviewed. Postoperative complications and patient satisfaction were evaluated. Foot Function Index (FFI) and visual analog scale (VAS) scores were recorded at preoperative and follow-up appointments to measure patients' functional outcomes and pain, respectively. RESULTS: Mean follow-up was 41.2 months (range, 24-65). Mean age was 51.8 years (range, 28-81). The mean FFI score improved from 56.1 (range, 47-88) to 11.0 (range, 7-59) postoperatively (P < .001). The mean VAS score improved from 7.7 (range, 5-10) to 0.4 (range, 0-7) postoperatively (P < .001). The overall complication rate was 3.8% (n = 4). Of 104 cases, 98.1% of patients said they were satisfied with their procedure (n = 102) when asked if they were satisfied with their ZO and recovery. CONCLUSION: We found the percutaneous ZO to be a safe and effective intervention for treatment of IAT. At a minimum of 2-year follow-up, this intervention is associated with minimal complications, improved function, reduced pain, and a high rate of patient satisfaction.

Percutaneous vs Open Zadek Osteotomy for Treatment of Insertional Achilles Tendinopathy and Haglund's Deformity: A Systematic Review.

Background: Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines. Methods: A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy, Calcaneus, Syndrome, Insertional, Achilles tendon, and Tendinopathy. Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies. Results: A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO. Conclusion: Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund's deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

Biomechanical Evaluation of Fourth Generation Minimally Invasive Distal First Metatarsal Osteotomy-Akin Osteotomy Technique on First Ray Articular Contact Properties.

BACKGROUND: Hallux valgus is a common deformity encountered but remains a complex clinical entity. Fourth-generation minimally invasive surgery (MIS) techniques consisting of a percutaneous distal metatarsal transverse osteotomy combined with an Akin osteotomy have been used to address mild to severe hallux valgus deformities. The benefits of an MIS approach include improved cosmesis, faster recovery, lower opiate requirement, immediate weightbearing, and favorable outcomes relative to a traditional, open procedure. An understudied area with respect to hallux valgus correction is the effect that osteotomies can have on the articular contact properties of the first ray following correction. METHODS: Sixteen paired cadaveric specimens were dissected to include the first ray and tested in a customized apparatus. Specimens were randomized to receive a distal transverse osteotomy translated either 50% or 100% of the width of the first metatarsal shaft. The osteotomy was performed with either a 0° or 20° distal angulation of the burr relative to the shaft in the axial plane. Specimens were tested in the intact state and following the distal first metatarsal osteotomy for peak pressure, contact area, contact force and center of pressure at the first metatarsophalangeal (MTP) and first tarsometatarsal (TMT) joints. An Akin osteotomy was then performed on each specimen, and peak pressure, contact area, contact force, and center of pressure were recalculated. RESULTS: There was a notable decrease in peak pressure, contact area, and contact force across the TMT joint with greater shifts of the capital fragment. However, at 100% translation of the capital fragment, distal angulation of the osteotomy by 20° appears to improve loading across the TMT joint. Addition of the Akin osteotomy at 100% translation also aids in increasing the contact force across the TMT joint. The MTP joint is less sensitive to changes in shifts and angulation of the capital fragment. The Akin osteotomy also leads to increased contact force across the MTP joint when the capital fragment is translated 100%. CONCLUSION: While the clinical significance is unknown, larger shifts of the capital fragment lead to greater load alterations at the level of the TMT joint than the MTP joint. Distal angulation of the capital fragment and the addition of an Akin osteotomy can aid in reducing the size of those changes. The Akin can lead to increased contact forces at the MTP joint with 100% translation of the capital fragment. LEVEL OF EVIDENCE: Not applicable, Biomechanical study.

The Effect of Chilled vs Room-Temperature Irrigation on Thermal Energy Dissipation During Minimally Invasive Calcaneal Osteotomy of Cadaver Specimens.

Background: Minimally invasive (MIS) calcaneal osteotomy has grown in popularity in recent years to address hindfoot deformity. A potential complication is thermal bone necrosis secondary to heat generation from the burr that may lead to osteotomy nonunion. Irrigation is commonly employed to reduce this risk. The effect of irrigation on reducing heat accumulation remains an understudied area. The purpose of this study was to evaluate the effect of cooled vs room-temperature irrigation on thermal energy dissipation during calcaneal osteotomy using a Shannon burr. Methods: Fourteen cadaveric limbs at room temperature (68 °F) were randomized to receive either cooled saline (7 limbs) or room-temperature (7 limbs) irrigation during MIS calcaneal osteotomy. Two thermocouple probes were inserted 5 mm away from the plane of the osteotomy, on the proximal and distal sides, respectively. A 3 × 30-mm Shannon burr was used to perform the osteotomy. The burr was run continuously with continuous irrigation using either room-temperature (68 °F) or chilled (37 °F) irrigation, until the osteotomy was completed. Temperature was recorded at 0, 15, 30, 45, and 60 seconds for the 2 groups and used as a measure of thermal energy accumulation. Results: Both room-temperature and chilled irrigation were effective in minimizing temperature change. On the proximal side, an overall mean increase of 2.5 °F with room-temperature irrigation and a mean decrease of 1.0 °F with chilled irrigation were observed at the 60-second interval (P = .004). On the distal side, there was a mean increase of 1.3 °F with room-temperature irrigation and a mean increase of 0.5 °F with chilled irrigation (P = .05). Conclusion: For the duration of an MIS calcaneal osteotomy, both continuous room-temperature and chilled irrigation can minimize temperature increases and potentially reduce the risk of an osteotomy nonunion. Clinical Relevance: Both room-temperature and chilled irrigation can minimize bone temperature increases during MIS calcaneal osteotomy.

Open Reduction and Primary Subtalar Arthrodesis for Acute Intra-articular Displaced Calcaneal Fractures.

OBJECTIVE: To evaluate the rate of subtalar arthrodesis based on a computed tomography (CT) scan after open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneal fractures. DESIGN: Retrospective chart review. SETTING: Single tertiary care practice. PATIENTS: A retrospective chart review was performed to identify patients who sustained an acute, displaced, intra-articular calcaneal fracture and underwent open reduction and primary subtalar arthrodesis. Thirty-five patients participated in the study. INTERVENTION: Each patient included in the study was treated with open reduction and primary subtalar arthrodesis. MAIN OUTCOME MEASURES: All patients were evaluated with CT for arthrodesis of the posterior facet of the subtalar joint, which was quantitated. Other outcome measures included radiographic parameters, the Veterans RAND Item Health Survey, and the Foot and Ankle Ability Measure. RESULTS: The median patient age was 47.8 years (range 21.5-79.5 years). The median patient follow-up was 34.4 months (range 4.6-104.1 months). The Sanders classification was as follows: 3% (1/35) type II, 40% (14/35) type III, and 57% (20/35) type IV. Based on a CT scan, primary subtalar union occurred in 94.3% (33/35) of patients. CONCLUSIONS: Open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneus fractures has a high rate of union and good pain and function outcomes. It should be strongly considered for patients with significant cartilage injury and comminution of the posterior facet. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impact of COVID-19 Pandemic on Patients' Perceptions of Safety and Need for Elective Foot and Ankle Surgery in the United States.

BACKGROUND: With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the United States to divert health care resources and limit exposure. Little is known about the impact of COVID-19 on patient's willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision. METHODS: Patients across 6 US orthopedic institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient's decisions. RESULTS: A total of 150 patients participated in this study. Twenty-one (14%) opted not to proceed with surgery once restrictions were lifted. Forty-three percent (n = 9) listed concern for COVID infection as the reason; however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs 14%) and lower increase in pain medication used (5% vs 12%). CONCLUSION: COVID-19 has made a significant impact on the health care system. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic. LEVEL OF EVIDENCE: Level III.

Percutaneous Techniques in Orthopedic Foot and Ankle Surgery.

This article presents the indications, contraindications, preoperative surgical planning, surgical technique, and postoperative management of some of the most common percutaneous procedures in orthopedic foot and ankle surgery. The background of each procedure also is presented, supported by the latest in published literature to educate surgeons. Such topics include percutaneous bunionectomy, lesser toe deformity and bunionette correction, calcaneal osteotomy, cheilectomy, and first metatarsophalangeal joint arthrodesis.

Clinical and Radiographic Outcomes of Revision Total Ankle Arthroplasty Using an Intramedullary-Referencing Implant.

BACKGROUND: Treatment of failed total ankle arthroplasty (TAA) is challenging. Limited literature is available on options and outcomes of revision arthroplasty despite failure rates ranging from 10% to 23% within 10 years after primary TAA. This study reports the clinical and radiographic outcomes of revision TAA using a fixed-bearing, intramedullary-referencing implant. METHODS: A retrospective review was performed of 18 consecutive revision TAA cases between 2008-2015 using an intramedullary-referencing, fixed-bearing, 2-component total ankle system. Demographic and radiographic data were collected preoperatively, immediately postoperatively, and at the most recent follow-up. Functional outcome data were collected immediately postoperatively and at mean follow-up 47.5 months. RESULTS: Eighteen patients underwent revision TAA, with 77.8% (14/18) implant survival. Index revision was performed most commonly for aseptic talar subsidence (55.6%) or implant loosening (tibia, 29.4%; talus, 58.9%). Following revision, 22.2% (4/18) patients required reoperation at a mean 57.3 (39-86) months. Osteolysis of the tibia, talus, and fibula was present preoperatively in 66.7% (12/18), 38.9% (7/18), and 38.9% (7/18) of patients, respectively, with progression of osteolysis in 27.8% (5/18), 11.1% (2/18) and 11.1% (2/18) of patients, respectively. Subsidence of the tibial and talar revision components was observed in 38.9% (7/18) and 55.6% (10/18) of patients, respectively. The median American Orthopaedic Foot & Ankle Society (AOFAS) score was 74.5 (26-100) and Foot Function Index (FFI) score 10.2 (0-50.4). CONCLUSION: Early results of intramedullary-referencing revision TAA demonstrated good patient-reported outcomes with maintenance of radiographic parameters at mean follow-up of 47.5 months. Aseptic talar subsidence or loosening were the main postoperative causes of reoperation. Revision arthroplasty utilizing an intramedullary-referencing implant was a viable option for the failed TAA. LEVEL OF EVIDENCE: Level IV, case series.

Nitinol Compression Staples in Foot and Ankle Surgery.

Nitinol compression implants are fast and simple to insert and have a high radiographic union rate for midfoot and hindfoot arthrodeses. Applications of nitinol technology in orthopedic surgery are rapidly expanding with the improved and broadened portfolio of implants available.

Evaluation of Total Ankle Arthroplasty Using Highly Crosslinked Ultrahigh-Molecular-Weight Polyethylene Subjected to Physiological Loading.

BACKGROUND: Highly crosslinked polyethylene (HXLPE) was developed for its superior wear properties in comparison to conventional polyethylene (CPE). Concern over fatigue resistance has prevented widespread adoption of HXLPE for use in total ankle arthroplasty (TAA). The aim of this study was to determine whether HXLPE has sufficient fatigue strength for total ankle arthroplasty under simulated physiologically relevant motion profiles and loading in the ankle. METHODS: Physiologic load and motion profiles representative of walking gait were incorporated into a computational model of a semiconstrained, fixed-bearing TAA to determine the loading state with highest stresses in the HXLPE bearing. Subsequent fatigue testing to 10 million cycles (Mc) at 5600 N was performed to assess bearing strength. RESULTS: Peak stresses in the bearing were predicted at peak axial load and peak dorsiflexion during gait, occurring near heel off. All samples withstood 10 Mc of fatigue loading at that orientation without polyethylene bearing fracture. CONCLUSION: HXLPE had sufficient fatigue strength to withstand 10 Mc of loading at more than 5 times body weight at the point of peak stresses during simulated gait in total ankle arthroplasty. CLINICAL RELEVANCE: HXLPE may be mechanically strong enough to withstand the in vivo demands of the ankle. Improvements in wear afforded by HXLPE can be obtained without compromising sufficient polyethylene strength properties in total ankle arthroplasty.

Outcomes After Primary Repair of Insertional Ruptures of the Achilles Tendon.

BACKGROUND: Achilles tendon insertional sleeve avulsions occur when the Achilles distal tendon sleeve ruptures off of its insertion into the calcaneal tuberosity, sometimes with a small bony fragment from calcific tendinosis. Little evidence exists describing the outcomes and rerupture rate after operative management of Achilles tendon sleeve avulsions. METHODS: A retrospective chart review was performed to identify patients who sustained an Achilles sleeve avulsion injury treated with operative repair between October 2005 and July 2014. A cohort of 16 patients from the general population and 12 professional athletes were included in the study. The primary outcome variable was rerupture of the Achilles tendon or need for revision surgery. Secondary outcome variables included the Coughlin Satisfaction Scale, visual VR-12, and Foot and Ankle Ability Measure (FAAM). RESULTS: In the general population cohort, median follow-up was 8.1 years (range, 3.2-11.1 years). The median FAAM Activities of Daily Living score was 100 (range, 42.9-106), and the median FAAM Sports score was 100 (range, 7.1-103.6). The median VR-12 Mental Component Score was 66.9 (range, 45.6-71.8), and the median VR-12 Physical Component Score was 53 (range, 30.8-57.5). In the cohort of professional athletes, preceding insertional Achilles symptoms were present in 91.7% (11/12) of athletes for more than 9 months prior to rupture. All athletes returned to play with an average time of 13.4 months. No patients sustained a rerupture in the follow-up period. CONCLUSION: Operative repair of Achilles tendon sleeve avulsions was safe and effective with high patient satisfaction and good clinical outcomes in patients from the general population. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Wear Characteristics of Conventional Ultrahigh-Molecular-Weight Polyethylene Versus Highly Cross-Linked Polyethylene in Total Ankle Arthroplasty.

BACKGROUND: The aim of this study was to compare the polyethylene wear rate, particle size, and particle shape of primary semiconstrained, fixed-bearing, bone-sparing total ankle arthroplasty using conventional ultrahigh-molecular-weight polyethylene (CPE) versus highly cross-linked polyethylene (HXLPE) by applying a level walking input using a joint simulator. METHODS: Two fixed-bearing total ankle replacement systems with different types of polyethylene liners were tested: (1) CPE sterilized in ethylene oxide, and (2) HXLPE sterilized with gas plasma after electron beam irradiation. Three implants for each design underwent wear testing using gravimetric analysis over 5 million simulated walking cycles. A fourth implant was used as a load soak control. Equivalent circle diameter (ECD) and equivalent shape ratio (ESR) were computed to determine particle size and particle shape, respectively. RESULTS: The mean wear rate from 1.5 to 5 million cycles (MC) was 2.0 ± 0.3 mg/MC for HXLPE and 16.7 ± 1.3 mg/MC for CPE ( P < .001). The total number of particles per cycle generated for HXLPE and CPE were 0.17 × 106 particles/cycle and 0.53 × 106 particles/cycle, respectively ( P < .001). The mean ECD of HXLPE particles (0.22 ± 0.11 µm) was significantly smaller than the mean ECD of CPE particles (0.32 ± 0.14 µm) ( P < .001). HXLPE particles were significantly more round than CPE particles ( P < .001). CONCLUSIONS: HXLPE liners had a significantly lower wear rate and produced significantly fewer and rounder particles than CPE liners. The results of this study suggest that HXLPE has more favorable wear characteristics for total ankle arthroplasty. CLINICAL RELEVANCE: Polyethylene wear particles have been linked to osteolysis after total ankle arthroplasty. There is no consensus on the importance of highly cross-linked polyethylene in total ankle arthroplasty with regard to implant wear. This is the first nonindustry study to compare the polyethylene wear rate, particle size, and particle shape of fixed-bearing total ankle arthroplasty conventional polyethylene versus highly cross-linked polyethylene. The lower wear rate and different particle size/morphology of highly cross-linked polyethylene could be beneficial in vivo to decrease osteolysis.

Radiographic Results of Nitinol Compression Staples for Hindfoot and Midfoot Arthrodeses.

BACKGROUND: The purpose of this study was to determine the radiographic union rate after midfoot and hindfoot arthrodeses using a new generation of nitinol staples, and to compare outcomes between a nitinol staple construct and a nitinol staple and threaded compression screw construct. METHODS: A retrospective chart review was performed to identify patients who underwent hindfoot or midfoot arthrodesis using a new generation of nitinol compression staples with or without a partially threaded cannulated screw with minimum 3-month radiographic follow-up. The primary outcome variable was radiographic evidence of arthrodesis on radiographs and, when available, computed tomographic scan in patients who underwent midfoot or hindfoot arthrodesis using nitinol staples. Ninety-six patients and 149 joints were eligible for analysis. Median radiographic follow-up was 5.7 months. RESULTS: Radiographic union was seen in 93.8% (60/64) of patients and 95.1% (98/103) of joints using the nitinol staple construct. Radiographic union was seen in 90.6% (29/32) of patients and 95.7% (44/46) of joints using the nitinol combined staple and screw construct. There was no significant difference in radiographic union rate or revision surgery between the 2 groups. Seven patients developed nonunion, 4 in the nitinol staple construct group and 3 in the staple and screw group. CONCLUSIONS: New-generation nitinol staples were safe and effective for hindfoot and midfoot arthrodeses, with a high radiographic union rate. The use of a partially threaded screw for additional fixation was not found to either significantly increase or decrease radiographic fusion with nitinol staple fixation. LEVEL OF EVIDENCE: Level III, comparative cohort study.

Histological Analysis of Early Osteolysis in Total Ankle Arthroplasty.

BACKGROUND: The purpose of this study was to perform a histological comparative analysis of tibiotalar joint samples taken from areas of osteolysis adjacent to total ankle arthroplasties vs control synovial specimens to determine the reaction to and presence of polyethylene (PE) particles. METHODS: A total of 57 pathology samples were identified in the osteolysis group, while 11 were identified in the control group. For each sample, hematoxylin and eosin, Oil Red O (ORO), and macrophage marker CD163-stained slides were created. Polarized light and ORO stain were used to identify PE particles. The presence of metal particles and giant cell reaction to PE particles were also scored. RESULTS: Macrophages, PE particles, metallosis, and foreign body giant cell reaction scores were significantly higher in the osteolysis group compared with the control group. In the osteolysis group, ORO staining was positive in 93% (53/57), birefringent material was present in 96.5% (55/57), and macrophage infiltrates were present in 96.5% (55/57). Foreign body giant cell reaction with giant cells surrounding PE particles was present in 49.1% (28/57) of osteolytic specimens. The presence of foreign body giant cell reaction was associated with significantly higher macrophage, ORO, and polarizable material scores. The average time to surgery for osteolysis from the index ankle replacement was 6.0 (range, 0-15) years for the 57 patients in the osteolysis group. CONCLUSION: This study is the largest ankle arthroplasty histological analysis to show that areas of osteolysis consist of abundant polyethylene wear particles, present both intracellularly and extracellularly. Furthermore, these areas were associated with a CD163+ macrophage infiltrate and frequently a foreign body reaction with giant cells engulfing PE particles. It is likely that implant wear particles play a significant role in osteolysis based on the histopathology. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Ankle Block vs Single-Shot Popliteal Fossa Block as Primary Anesthesia for Forefoot Operative Procedures: Prospective, Randomized Comparison.

BACKGROUND: Postoperative pain is often difficult to control with oral medications, requiring large doses of opioid analgesia. Regional anesthesia may be used for primary anesthesia, reducing the need for general anesthetic and postoperative pain medication requirements in the immediate postoperative period. The purpose of this study was to compare the analgesic effects of an ankle block (AB) to a single-shot popliteal fossa block (PFB) for patients undergoing orthopedic forefoot procedures. METHODS: All patients having elective outpatient orthopedic forefoot procedures were invited to participate in the study. Patients were prospectively randomized to receive either an ultrasound-guided AB or PFB by a board-certified anesthesiologist prior to their procedure. Intraoperative conversion to general anesthesia and postanesthesia care unit (PACU) opioid requirements were recorded. Postoperative pain was assessed using the visual analog scale (VAS) at regular time intervals until 8 am on postoperative day (POD) 2. Patients rated the effectiveness of the block on a 1 to 5 scale, with 5 being very effective. A total of 167 patients participated in the study with 88 patients (53%) receiving an AB and 79 (47%) receiving a single-shot PFB. RESULTS: There was no significant difference in the rate of conversion to general anesthesia between the 2 groups (13.6% [12/88] AB vs 12.7% [10/79] PFB). PACU morphine requirements and doses were significantly reduced in the PFB group ( P = .004) when compared to the AB group. The VAS was also significantly lower for the PFB patients at 10 pm on POD 0 (4.6 vs 1.6, P < .001), 8 am on POD 1 (5.9 vs 4.2, P = .003), and 12 pm on POD 1 (5.4 vs 4.1, P = .01). Overall complication rates were similar between the groups (AB 9% vs PFB 10.1%, P = .51) and there were no significant differences in residual sensory paresthesias (AB 2.3% [2/88] vs PFB 5.1% [4/79], P = .29), motor loss (0% vs 0%), or block site pain and/or erythema (AB 6.9% [6/88] vs PFB 5.1% [4/79], P = .44). The analgesic effect of the PFB lasted significantly longer when compared to the ankle block (AB 14.5 hours vs PFB 20.9 hours, P < .001). There was no significant difference in patient-perceived effectiveness of the block between the 2 groups, with both blocks being highly effective (AB 4.79/5 vs PFB 4.82/5, P = .68). CONCLUSION: Regional anesthesia was a safe and reliable adjunct to perioperative pain management and highly effective in patients undergoing elective orthopedic forefoot procedures. However, patients who received a PFB had significantly better pain management and decreased opioid requirements in the immediate perioperative period than patients who received an ankle block. LEVEL OF EVIDENCE: Level I, prospective randomized study.

Effect of Obesity on Total Ankle Arthroplasty Outcomes.

BACKGROUND: The purpose of this study was to evaluate the effect of obesity on intermediate- to long-term implant failure rates and survivorship after total ankle arthroplasty. METHODS: A chart review was performed for all patients who underwent primary total ankle arthroplasty between 2004 and 2009 with a minimum 5-year follow-up. Patients were separated into a reference group with a body mass index less than 30 kg/m2 and an obese group with an index greater than or equal to 30 kg/m2. Minimum 5-year follow-up outcomes were available for 49 patients in the obese group and 48 patients in the nonobese group. Mean follow-up was 8.2 ± 2.0 years (range, 5.1-11.5 years) in the reference group and 7.7 ± 2.0 years (range, 5.0-11.9 years) in the obese group (P = .26). RESULTS: Based on multivariable logistic regression, obese patients had a significantly greater probability of implant failure by final follow-up (adjusted odds ratio, 2.8 [95% CI, 1.04-7.53]; P = .04). Cox regression analysis of 5-year implant survivorship showed no significant difference between the 2 groups (adjusted hazard ratio, 1.89 [95% CI, 0.77-4.65]; P = .17). When compared with obese patients with inflammatory or posttraumatic arthritis, obese patients with osteoarthritis demonstrated a significantly decreased 5-year survivorship (adjusted hazard ratio, 3.73 [95% CI, 1.05-10.43]; P = .04). CONCLUSION: This study demonstrated an increased long-term risk of implant failure among obese patients that was not seen in the intermediate term. Furthermore, obese patients with primary osteoarthritis were found to have a significantly decreased 5-year implant survivorship after ankle arthroplasty as compared with obese patients with inflammatory or posttraumatic arthritis and therefore should be counseled appropriately when deciding between arthroplasty and arthrodesis. LEVEL OF EVIDENCE: Level III, retrospective comparative series.