The risk-benefit profiles of simultaneous total ankle arthroplasty (TAA) compared with sequential TAA continue to be debated. There are limited case series reporting outcomes after bilateral TAA, ...with no previous comparison of simultaneous TAA with sequential TAA. Patients with bilateral pathology represent a unique population with an overall more debilitating condition. Thus, we aimed to compare bilateral simultaneous and sequential TAAs, including perioperative complications and patient-reported outcome measures.
We performed a comparative cohort study of patients who underwent primary bilateral TAA, performed in a simultaneous or sequential fashion, from 2007 to 2019 at a single academic center. Data on patient demographic characteristics, comorbidities, perioperative complications, reoperations, and implant failures were collected. Patient-reported outcome measures included preoperative and postoperative visual analog scale (VAS) scores for pain, Short Form-36 Health Survey (SF-36) scores, and Short Musculoskeletal Function Assessment (SMFA) scores.
A total of 50 patients (100 ankles) were included, with 25 patients (50 ankles) each in the bilateral simultaneous and sequential cohorts. The mean follow-up was 52.2 ± 27.3 months (range, 24 to 109 months). The mean time between sequential TAAs was 17.5 ± 20.1 months (range, 3 to 74 months). The mean patient age was 64.3 ± 10.6 years (range, 21 to 76 years), and 32 (64.0%) were men. The majority of patients (28 patients 56.0%) had primary osteoarthritis. Both cohorts had equivalent preoperative patient-reported outcome measures and experienced improvements in all measures, which were maintained at the final follow-up with no significant between-group differences (all p > 0.05). There were no differences between the simultaneous TAA group and the sequential TAA group in perioperative complication rates (22.0% compared with 24.0%; p = 0.7788), reoperations (12.0% compared with 10.0%; p = 0.7354), 5-year reoperation-free survival (88.0% compared with 90.0%; p = 0.4612), or failure-free survival (100%). One patient in the simultaneous TAA cohort required metal component revision at 8 years postoperatively.
The patient-reported outcome measures, complications, and prosthesis survival of patients who underwent bilateral simultaneous TAA were comparable with those of patients who underwent bilateral sequential TAA. We advocate that simultaneous bilateral TAA is a safe and effective method for the treatment of bilateral end-stage ankle osteoarthritis.
Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
Background:
End-stage ankle arthritis is a debilitating condition often necessitating total ankle replacement (TAR). Tendo-Achilles lengthening (TAL) and gastrocnemius recession (GR) are commonly ...performed with TAR to improve ankle dorsiflexion (DF). No studies to date have radiographically analyzed tibiopedal motion to guide surgical management. The purpose of this study is to determine the effect of a TAL or GR during TAR on radiographic tibiopedal range of motion (ROM).
Methods:
A retrospective review of a prospectively maintained database was conducted followed by a propensity score–matched analysis of 110 patients who underwent TAL (n = 26), GR (n = 29), or no lengthening procedure (n = 55) with TAR. Minimum of 1-year ROM radiographic follow-up was required. Exclusion criteria included (1) calcaneal osteotomies, (2) simultaneous or previous hindfoot or midfoot arthrodesis, (3) prior ankle arthrodesis, or (4) revision TAR. Demographic data were extracted from the TAR database. Radiographic assessment included tibiopedal dorsiflexion (DF) and plantarflexion (PF).
Results:
DF improved by 2.8 degrees (P = .0286) and by 6.0 degrees (P < .0001) in the TAL and GR cohorts, respectively, with no difference in the control group (+0.7 degrees, P = .3764). PF was decreased by 4.5 degrees (P = .0152) and by 7.2 degrees (P = .0002) in the TAL and GR cohorts, respectively, with no difference in the control group (–0.2 degrees, P = .8546). Minimal differences were observed for total arc of motion for all 3 groups (control 0.5 degrees, GR –1.2 degrees, TAL –1.7 degrees), all of which were nonsignificant (all P > .05). There was no between-group difference in the change in overall arc of motion between the groups (P = .3599). GR resulted in a greater increase in DF (6.0 vs 2.8 degrees; P = .1074), with a reciprocal greater decrease in PF (7.2 vs 4.5 degrees; P = .2416) compared with the TAL cohort.
Conclusion:
Both TAL and GR increased postoperative DF; however, this was accompanied by a reciprocal loss in PF. Minimal differences were observed for total arc of motion. Patients should be counseled that concomitant procedures performed to increase DF will do so at the expense of PF.
Level of Evidence:
Level III, retrospective review of prospectively collected data.
Background:
We present our results with an INBONE I (Wright Medical, Memphis, TN) prosthesis that have a minimum of 4 to 10 years of follow-up and include a preoperative deformity analysis on ...outcomes.
Methods:
A consecutive series of 149 patients, from 2007 to 2011, at a single institution were enrolled. Pain and patient-reported function were assessed preoperatively and at yearly follow-ups. We analyzed the data for complications, reoperations, and failures (defined as undergoing revision for exchange or removal of one or both metallic components for any reason). Patients were also grouped according to coronal plane tibiotalar alignment; either ≥10 degrees or <10 degrees, and these outcomes were compared. Our follow-up ranged from 48 to 113 months (average 5.9 years).
Results:
There was significant improvement (P < .05) in the visual analog scale for pain, American Orthopaedic Foot & Ankle Society hindfoot scale, Short Musculoskeletal Function Assessment, and Short Form 36-Item Health Survey scores at most recent follow-up. There were 14 implant failures with overall survivorship of 90.6% (135/149). Reasons for failure included cysts/loosening (7), talar subsidence (4), fractured component (1), impingement pain (1), and infection (1). Seventy-two patients (48.3%) with preoperative coronal plane deformity of ≥10 degrees varus or valgus were compared to 78 patients (51.7%) with <10 degrees deformity. There was no difference in patient outcome scores or revision rates between these patient groups. There was a statistically significant difference (P = .039) in reoperation rates among patients with ≥10 degrees deformity (22.2%) compared to those without such a deformity (37.7%)
Conclusion:
Patients who underwent INBONE I fixed-bearing total ankle arthroplasty demonstrated significant improvement in outcomes at a mean of 5.9 years. Catastrophic talar component collapse did occur (2.7% of cases), but relatively rarely. The patients with preoperative coronal plane tibiotalar deformity had similar pain relief, function, and need for revision of implant components. Despite the presumed shortcomings of the INBONE I’s design, this implant showed promising results, with or without deformity, at midterm follow-up with survivorship of 90.6%.
Level of Evidence:
Level III, comparative study.
Background:
Lateral ankle instability leads to an increased risk of tibiotalar joint osteoarthritis. Previous studies have found abnormal tibiotalar joint motions with lateral ankle instability that ...may contribute to this increased incidence of osteoarthritis, including increased anterior translation and internal rotation of the talus under weightbearing loading. Surgical repairs for lateral ankle instability have shown good clinical results, but the effects of repair on in vivo ankle motion are not well understood.
Hypothesis:
The modified Broström-Gould lateral ligament reconstruction decreases anterior translation and internal rotation of the talus under in vivo weightbearing loading conditions.
Study Design:
Controlled laboratory study.
Methods:
Seven patients underwent modified Broström-Gould repair for unilateral lateral ankle instability. Ankle joint kinematics as a function of increasing body weight was studied with magnetic resonance imaging and biplanar fluoroscopy. Tibiotalar kinematics was measured in unstable ankles preoperatively and postoperatively at a mean follow-up of 12 months as well as in the uninjured contralateral ankles of the same patients.
Results:
Surgical repair resulted in statistically significant decreases (expressed as mean ± standard error of the mean) in anterior translation of the talus (0.9 ± 0.3 mm; P = .018) at 100% body weight and internal rotation of the talus at 75% (2.6° ± 0.8°; P = .019) and 100% (2.7° ± 0.8°; P = .013) body weight compared with ankle kinematics measured before repair. No statistically significant differences were detected between repaired ankles and contralateral normal ankles.
Conclusion:
The modified Broström-Gould repair improved the abnormal joint motion observed in patients with lateral ankle instability, decreasing anterior translation and internal rotation of the talus.
Clinical Relevance:
Altered kinematics may contribute to the tibiotalar joint degeneration that occurs with chronic lateral ankle instability. The findings of the current study support the efficacy of this repair in improving the abnormal ankle motion observed in these patients.
Background:
Despite substantial increase in total ankle arthroplasty (TAA) nationwide, there are few studies comparing flat-cut vs chamfer-cut talar systems in TAA with regard to radiographic aseptic ...loosening rates of the implant.
Methods:
This retrospective study included 189 Salto-Talaris TAA and 132 INBONE II primary TAA with a minimum 1-year follow-up. Patient characteristics were obtained including gender, age at surgery, body mass index (BMI), smoking status, primary diagnosis, surgical time, and the presence of diabetes. Radiographic evidence for aseptic loosening was assessed. Statistical analysis was performed for comparison in outcomes between Salto-Talaris and INBONE II.
Results:
The mean age of the study population was 63.5 ± 9.8 years at surgery. Mean follow-up was 4.9 ± 3.0 years. Radiographic aseptic loosening of the tibial implant showed no significant difference between the 2 groups: Salto-Talaris, 18%, and INBONE II, 18.9% (P = .829). Aseptic loosening of the talar implant also showed no significant difference between the 2 groups: Salto-Talaris, 1.6%, and INBONE II, 1.5% (P = .959). No variables, including the implant type, were found to contribute to the aseptic loosening rate of either the tibia or talus.
Conclusion:
In our cohort, we observed no difference in radiographic implant aseptic loosening between Salto-Talaris and INBONE II systems.
Level of Evidence:
Level IV, retrospective case series study.
Background:
The prevalence of obesity in the United States is staggering. Currently, the effect of obesity on third-generation total ankle replacement (TAR) is unknown.
Methods:
We prospectively ...identified a consecutive series of 455 primary TARs operated between May 2007 and September 2013 who had a minimum follow-up of 2 years. We identified 266 patients with a body mass index (BMI) <30 (control), 116 with a BMI between 30 and 35 (Obese I), and 73 with a BMI >35 (Obese II). Clinical outcomes including wound issues, infection rate, complications, and failure rates were compared. Functional outcomes including American Orthopaedic Foot & Ankle Society hindfoot score, Short Form–36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), Foot and Ankle Disability Index (FADI), and Foot and Ankle Outcome Score (FAOS) were compared. Average patient follow-up in the Obese I group was 44.7 ± 17.3 months, Obese II was 42.7 ± 16.4 months, and 45.2 ± 17.4 months in the control group.
Results:
Age, race, and smoking history in the obese group were not significantly higher than the control group; however, sex was significantly related to BMI. There was no difference in complication, infection, or failure rates between the groups. Preoperatively, the Obese II group had significantly lower SF-36 scores and higher SMFA function, FADI, and FAOS Symptoms scores. For each of the Obese I, Obese II, and control groups, all functional outcome scores 1 year postoperatively and at most recent follow-up were significantly improved. However, at most recent follow-up, Obese II patients had lower FAOS Pain and SF-36 scores and higher FADI and SMFA Functional scores.
Conclusion:
Total ankle arthroplasty in obese patients was a relatively safe procedure. Although obese patients after TAR had lower functional outcome scores compared to their nonobese counterpart, they did experience significant functional and pain improvements at most recent follow-up.
Level of Evidence:
Level III, comparative series.
Background:
The Salto Talaris total ankle replacement is a modern fixed-bearing implant used to treat symptomatic ankle arthritis with the goals of providing pain relief, restoring mechanical ...alignment, and allowing motion of the ankle joint. The goal of this study was to report the midterm clinical results of one of the largest cohort of patients in the United States who underwent ankle replacement with this prosthesis.
Methods:
This is a review of patients with a minimum of 5 years up to 10 years’ follow-up. At the preoperative visit and each annual assessment, patients rated their current level of pain using the visual analog score (VAS) and reported their functional level using the American Orthopaedic Foot & Ankle (AOFAS) ankle-hindfoot scores, the Short Musculoskeletal Function Assessment (SMFA), and the Short Form-36 (SF-36) Health survey. These scores were analyzed to assess differences between their levels preoperatively, 1 year postoperatively, and at their most recent follow-up. Criteria for failure was defined as revision requiring exchange or removal of the metallic components for any reason. We identified 106 patients having a Salto Talaris total ankle replacement. Seventy-two patients (mean age, 61.9 years) met the minimum requirement for follow-up (range 60-115 months, mean 81.1 months).
Results:
Significant improvements were seen in the VAS, SMFA, AOFAS score, and SF-36 from preoperatively to their final follow-up (P < .001). Survivorship was 95.8% for those with at least 5-year follow-up, with 2 patients undergoing revision arthroplasty for aseptic loosening and a third patient scheduled for revision for a chronic wound infection. Fourteen patients (19%) required an additional surgery for a total of 17 additional operative procedures on the ipsilateral ankle or hindfoot.
Conclusion:
Patients undergoing total ankle arthroplasty with the Salto Talaris prosthesis continued to show significant improvements in pain and functional outcomes at midterm follow-up. This prosthesis has shown to be an effective treatment option with durable results.
Level of Evidence:
Level IV, therapeutic, case series.
BACKGROUND:Excessive tibiotalar malalignment in the coronal plane has been considered by some to be a contraindication to total ankle replacement. The purpose of the present study was to compare ...clinical outcomes and physical performance measures according to preoperative tibiotalar alignment.
METHODS:One hundred and three patients undergoing total ankle replacement were grouped according to coronal plane tibiotalar alignment. Seventeen patients had an excessive deformity (>15° of varus or valgus), twenty-one had moderate valgus alignment (5° to 15° of valgus), twenty-seven had moderate varus alignment (5° to 15° of varus), and thirty-eight had neutral alignment (<5° of varus or valgus). Outcome measures, including the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the Foot and Ankle Disability Index (FADI), the Short Form-36 (SF-36), the timed up and go test (TUG), the four square step test (4SST), and walking speed, were assessed preoperatively and at one and two years after total ankle replacement.
RESULTS:Coronal plane alignment improved following the procedure, with 36.9% of patients having neutral alignment preoperatively as compared with 95% postoperatively. To achieve this alignment, adjunctive procedures, including deltoid ligament release, lateral ligament reconstruction, and posterior soft-tissue releases, were necessary. Significant improvements were seen for the Page3 AOFAS pain, function, alignment, and hindfoot scores (p < 0.001) and the SF-36 subscales of body pain, physical function, and role physical (p < 0.001) following total ankle replacement. Walking speed and the FADI, TUG, and 4SST scores also improved significantly (p < 0.001). Subgroup analysis demonstrated no significant differences in clinical outcomes and physical performance measures based on preoperative coronal plane alignment.
CONCLUSIONS:Total ankle replacement improves clinical and functional outcomes independent of preoperative tibiotalar alignment when postoperative alignment is restored to neutral at the time of arthroplasty.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background:
There is limited data evaluating the effect of obesity on outcomes following total ankle arthroplasty (TAA), especially in adequate sample sizes to detect impacts on patient-reported ...outcomes (PROs). The purpose of this study was to assess the effect of obesity on complication rates and PROs.
Methods:
This was a single-institution, retrospective study of 1093 primary TAA performed between 2001 and 2020. Minimum follow-up was 2 years. Patients were stratified by body mass index (BMI) into control (BMI = 18.5-29.9; n = 615), obesity class I (BMI = 30.0-34.9; n = 285), and obesity class II (BMI > 35.0; n = 193) groups. Patient information, intraoperative variables, postoperative complications, and PRO measures were compared between groups using univariable statistics. Multivariable Cox regression was performed to assess risk for implant failure. Mean follow-up was 5.6 years (SD: 3.1).
Results:
Compared to control and class I, class II patients had the lowest mean age (P = .001), highest mean ASA score (P < .001), and greatest proportion of female sex (P < .001) and Black/African American race (P = .005). There were no statistically significant differences in postoperative complications (infection, implant failure, or impingement) across the BMI classes (P > .05).
Preoperatively, class II had lower (worse) mean scores for Foot and Ankle Outcome Score pain and ADL subscales than controls (post hoc pairwise P < .001 for both). At final follow-up, both class II and class I had lower (worse) mean Short Musculoskeletal Function Assessment (post hoc pairwise P < .001 and P = .030, respectively) and 36-Item Short Form Health Survey scores (post hoc pairwise P < .001 and P = .005, respectively) than controls.
Conclusion:
At midterm follow-up, obesity was not associated with increased rates of complications after TAA. Patients with obesity reported worse musculoskeletal function and overall quality of life after TAA but there was no differential improvement in PROs across BMI classes. To our knowledge, this is the largest single-institution study to date examining the effect of obesity on outcomes after primary TAA.
Level of Evidence:
Level III, retrospective comparative study.
Background:
Infection is a serious complication of primary total ankle arthroplasty (TAA) and can lead to implant failure and revision surgery. Various demographic, comorbidity, and surgical factors ...have been associated with an increased risk of infection. However, the evidence base remains limited, and further research is needed regarding infection in TAA. This study aims to analyze risk factors of infection and explore outcomes following infected TAA.
Methods:
A retrospective cohort study was conducted using data from a single institution from 2002 to 2022. Patients who underwent primary TAA and had subsequent infection were identified through annual registry surveillance and matched using propensity score matching (PSM) based on various demographic, comorbidity, and surgical factors. Demographics were compared between the matched groups using Mann-Whitney U test and Fisher exact test. The outcomes following infection were identified and summarized using descriptive statistics.
Results:
A total of 1863 patients who underwent primary TAA were identified, and 19 were diagnosed with an infection. The identifiable overall infection rate was 1.0%. After PSM, there were no significant differences in the difference in age, gender, BMI, and smoking status between the infected and control cohort. There was a statistically significant increase in the rate of diabetes in the infected cohort. The subsequent surgical intervention resulted in limb salvage in 18 (94.7%) cases. Out of the total number of cases, 2-stage revision to total ankle replacement was performed in 7 cases, whereas revision to arthrodesis and isolated polyethylene exchange were each carried out in 4 cases. One patient had to undergo amputation; however, at the time of the most recent follow-up, all patients were found to be free of infection.
Conclusion
This study demonstrated high rates of a history of smoking and diabetes in the infected TAA cohort. The diabetes rate in the infected group was significantly higher than the noninfected controls. Two-stage revision to total ankle replacement was performed in 7 cases, and revision to arthrodesis and isolated polyethylene exchange were each carried out in 4 cases. Overall, a high rate of limb salvage was reported.
Level of Evidence:
Level III, case-control study.
PDF