Comparing 4-Year Changes in Patient-Reported Outcomes Following Ankle Arthroplasty and Arthrodesis.

BACKGROUND: The rate of total ankle arthroplasty (TAA) is increasing relative to ankle arthrodesis (AA) for patients seeking surgical treatment for end-stage ankle arthritis. Patients and providers would benefit from a more complete understanding of the rate of improvement, the average length of time to achieve maximal function and minimal pain, and whether there is a greater decline in function or an increase in pain over time following TAA compared with AA. The objectives of this study were to compare treatment changes in overall physical and mental function and ankle-specific function, as well as pain intensity at 48 months after TAA or AA in order to determine if the improvements are sustained. METHODS: This was a multisite prospective cohort study that included 517 participants (414 TAA and 103 AA) who presented for surgical treatment. Participants were compared 48 months after surgery using the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living and Sports subscales (0 to 100 points), the Short Form-36 (SF-36) Physical and Mental Component Summary (PCS and MCS) scores (0 to 100 points), and pain scores (0 to 10 points). RESULTS: Both groups achieved significant improvement in the 2 FAAM measures, the SF-36 PCS score, and all of the pain measures at 48 months after surgey (p < 0.001). Mean improvements from baseline in patients undergoing TAA for the FAAM Activities of Daily Living, FAAM Sports, and SF-36 scores were at least 9 points, 8 points, and 3.5 points, respectively, which were higher than in those undergoing AA. Mean improvements in worst and average pain were at least 0.9 point higher in patients undergoing TAA than in those undergoing AA at 12, 24, and 36 months. These differences were attenuated by 48 months. For both treatments, all improvements from baseline to 24 months had been maintained at 48 months. CONCLUSIONS: When both procedures are performed by the same group of surgeons, patients who undergo TAA or AA for end-stage ankle arthritis have significant improvement in overall function, ankle-specific function, and pain at 48 months after surgery, with better functional improvement in the TAA group. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness and Safety of Ankle Arthrodesis Versus Arthroplasty: A Prospective Multicenter Study.

BACKGROUND: Newer designs and techniques of total ankle arthroplasty (TAA) have challenged the assumption of ankle arthrodesis (AA) as the primary treatment for end-stage ankle arthritis. The objective of this study was to compare physical and mental function, ankle-specific function, pain intensity, and rates of revision surgery and minor complications between these 2 procedures and to explore heterogeneous treatment effects due to age, body mass index (BMI), patient sex, comorbidities, and employment on patients treated by 1 of these 2 methods. METHODS: This was a multisite prospective cohort study comparing outcomes of surgical treatment of ankle arthritis. Subjects who presented after nonoperative management had failed received either TAA or AA using standard-of-treatment care and rehabilitation. Outcomes included the Foot and Ankle Ability Measure (FAAM), Short Form-36 (SF-36) Physical and Mental Component Summary (PCS and MCS) scores, pain, ankle-related adverse events, and treatment success. RESULTS: Five hundred and seventeen participants underwent surgery and completed a baseline assessment. At 24 months, the mean improvement in FAAM activities of daily living (ADL) and SF-36 PCS scores was significantly greater in the TAA group than in the AA group, with a difference between groups of 9 points (95% confidence interval [CI] = 3, 15) and 4 points (95% CI = 1, 7), respectively. The crude incidence risks of revision surgery and complications were greater in the AA group; however, these differences were no longer significant after adjusting for age, sex, BMI, and Functional Comorbidity Index (FCI). The treatment success rate was greater after TAA than after AA for those with an FCI of 4 (80% versus 62%) and not fully employed (81% versus 58%) but similar for those with an FCI score of 2 (81% versus 77%) and full-time employment (79% versus 78%). CONCLUSIONS: At 2-year follow-up, both AA and TAA were effective. Improvement in several patient-reported outcomes was greater after TAA than after AA, without a significant difference in the rates of revision surgery and complications. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Statistical Validation of the Grand Rapids Arch Collapse Classification.

BACKGROUND: The Grand Rapids Arch Collapse Classification system was devised in 2011 to assist physicians' and patients' understanding of the mechanisms underlying arch collapse. Five types of arch collapse are described, based on which part of the foot or ankle is affected. The purpose of this study was to determine the inter- and intrarater reliability of this classification system when used by physicians with various levels of training. METHODS: A senior author identified a stratified selection of 50 patients (10 per classification type) who presented with foot/ankle pain and suitable radiographs. A survey was designed using prediagnosis radiographs and clinical synopses of the patient's chart. The survey consisted of a description of the classification scheme and the 50 cases in a randomized order. Eight weeks later, they repeated the test to analyze for intra-rater agreement. RESULTS: Of the 33 physicians who received the survey, 26 completed the first round (16 attendings, 4 foot and ankle fellows, and 6 residents). Overall, there was substantial agreement among raters in all five types. Kappa scores for each type were 0.72, 0.65, 0.72, 0.70, 0.63, respectively. The combined kappa score was 0.68. After 8 weeks, 13 of the 26 participants repeated the study. A Kappa analysis was once again performed for the 13 respondents, which produced a substantial level of agreement with a value of 0.74 for intrarater reliability. CONCLUSION: The Grand Rapids Arch Collapse Classification system was designed to provide an accessible mechanism for physicians to consistently describe arch collapse, its effects, and the conditions associated with it. The utility of this system is wholly reliant on the repeatability among clinicians. This study has demonstrated that the classification system has substantial rates of reliability among physicians of different levels of experience and training. LEVEL OF EVIDENCE: Level IV.

Frequency and Impact of Adverse Events in Patients Undergoing Surgery for End-Stage Ankle Arthritis.

BACKGROUND: This study summarized the frequency and functional impact of adverse events (AEs) that occur after surgery for end-stage ankle arthritis (ESAA) to inform decision making. METHODS: This was a multisite prospective cohort study to compare ankle arthroplasty to ankle arthrodesis in the treatment of ESAA among 6 participating sites. We compared the risk and impact of nonankle AEs and ankle-specific AEs versus no AEs controlling for potential confounding factors, including operative procedure using multinomial logistic regression. We estimated differences in postoperative functional outcomes by AE occurrence using linear mixed effects regression. Among 517 patients who had surgery for ankle arthritis and completed the full baseline assessment, follow-up scores were available in 494 (95%) patients. RESULTS: There were a total of 628 reported AEs (477 in the arthroplasty group and 151 in the arthrodesis group). These occurred in 261 (63%) arthroplasty patients and 67 (65%) arthrodesis patients. There were 50 (8%) ankle-specific AEs. The risk of an ankle-specific AE was slightly higher in the arthrodesis group versus the arthroplasty group, odds ratio (OR) 1.84, 95% confidence interval (CI, 0.85, 3.98). The OR for the risk of non-ankle-specific AE versus no AE was 0.96, 95% CI (0.57, 1.61) for those receiving arthrodesis compared to arthroplasty. Compared to patients with no AEs, those experiencing ankle-specific AEs had significantly less improvement in Foot and Ankle Ability Measure Sports and activities of daily living (ADL) subscores and worst pain outcomes; however, both groups improved significantly in all measures except mental health. CONCLUSIONS: Ankle-specific AEs were infrequent and only weakly associated with operative procedure. Although patients improved in all functional outcomes except mental health, regardless of AE occurrence, ankle-specific AEs negatively impacted patient improvement compared to those with no AEs or a nonankle AE. The logistical effort and cost of tracking nonankle AEs does not seem to be justified. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Comparison of Treatment Outcomes of Arthrodesis and Two Generations of Ankle Replacement Implants.

BACKGROUND: We analyzed self-reported outcomes in a prospective cohort of patients treated with ankle arthrodesis or total ankle replacement (TAR) during a time of transition from older to newer-generation TAR implants. METHODS: We performed a prospective cohort study comparing outcomes in 273 consecutive patients treated for ankle arthritis with arthrodesis or TAR between 2005 and 2011. Adult patients with end-stage ankle arthritis who were able to walk and willing and able to respond to surveys were included in the study. Patients were excluded when they had another lower-limb problem that might affect walking. At baseline and at 6, 12, 24, and 36-month follow-up visits, participants completed a pain score, a Musculoskeletal Function Assessment (MFA), and a Short Form-36 (SF-36) survey. RESULTS: There was significant mean improvement in most outcomes after surgery regardless of procedure. In general, the greatest improvement occurred during the first 6 months of follow-up. Linear mixed-effects regression adjusted for differences at baseline in age, body mass index (BMI), and surgery type showed that at 6 months the scores were improved by a mean (and standard error) of 12.6 ± 0.7 (33%) on the MFA, 22.0 ± 1.4 (56%) on the SF-36 Physical Functioning (PF) scale, 32.4 ± 1.6 (93%) on the SF-36 Bodily Pain (BP) scale, and 4.0 ± 0.2 (63%) on the pain rating scale. The mean improvements in the MFA and SF-36 PF scores over the 3-year follow-up period were significantly better after the TARs than after the arthrodeses, with differences between the 2 groups of 3.6 ± 1.6 (p = 0.023) and 7.5 ± 2.9 (p = 0.0098), respectively. The differences between the 2 groups were slightly greater when only the newer TAR devices were compared with the arthrodeses (MFA = 3.8 ± 1.8 [p = 0.031], SF-36 PF = 8.8 ± 3.3 [p = 0.0074], SF-36 BP = 7.3 ± 3.6 [p = 0.045], and pain score = 0.8 ± 0.4 [p = 0.038]). CONCLUSIONS: Patients reported improved comfort and function after both surgical treatments. The average improvement in the MFA and SF-36 PF scores was better after TAR than after arthrodesis, particularly when the TAR had been done with later-generation implants. Younger patients had greater functional improvements than older patients. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Complications After Popliteal Block for Foot and Ankle Surgery.

BACKGROUND: A popliteal nerve block is a common analgesic procedure for patients undergoing surgery on their knee, foot, or ankle. This procedure carries less risk in a surgical setting compared with other forms of anesthesia such as a spinal block. Previous reports demonstrated few to no complications with the use of this nerve block, but it is unclear whether these data are consistent with the recent increase in use of this analgesic procedure for lower extremity surgery. METHODS: Retrospectively, a busy orthopedic foot and ankle practice performed a chart review examining for postoperative neuropathic complications possibly related to the popliteal nerve block. The 1014 patients who had undergone a popliteal block for foot and/or ankle orthopedic surgery were analyzed for short and long-term neuropathic complications. The collected data consisted of tourniquet time, pressure, and location as well as the method of finding the fossa nerve, adjuncts used, and patient medical history. Data were analyzed using chi-square, Fisher's exact, and t tests for analysis with a significance value of P < .05. RESULT: Of these 1014 patients, 52 patients (5%) developed deleterious symptoms likely resulting from their popliteal block, and 7 (0.7%) of these were unresolved after their last follow-up. No immediately apparent underlying causes were determined for these complications. CONCLUSION: The frequency of a neuropathic complication following a popliteal nerve block was notably higher in the early postoperative period than indicated in the past. The proportion of patients with unresolved neuropathic symptoms at last follow-up is comparable to that previously reported in the literature. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Surgical management and treatment algorithm for the subtle cavovarus foot.

BACKGROUND: Subtle cavovarus foot is a condition that can lead to significant foot pain and disability. We review the results of our treatment algorithm at medium-term followup. MATERIALS AND METHODS: Thirty-five consecutive patients with lateral based symptoms due to an underlying congenital subtle cavovarus foot type were surgically corrected. Various procedures were utilized, including some combination of the following: lateral displacement calcaneus osteotomy, peroneus longus to brevis transfer, dorsiflexion first metatarsal osteotomy, and Achilles tendon lengthening. Twenty-three patients, with 29 feet, returned for followup examination. The mean patient age at the time of surgery was 43.4 years, and the mean followup to date was 4.4 years. RESULTS: The mean AOFAS ankle hindfoot score preoperatively was 45, and postoperatively was 90. Radiographically, the medial cuneiform to floor height changed from 3.5 cm preoperatively to 3.0 cm postoperatively. The talo-first metatarsal angle improved 7.5 degrees postoperatively. There were no nonunions. No patients to date have gone on to fusions or revisions. Ten feet (34%) required hardware removal. All patients had resolution of their symptoms following hardware removal. CONCLUSION: The surgical management for the subtle cavovarus foot based on the proposed treatment algorithm provided symptomatic relief, longstanding correction, and high patient satisfaction.

Gastrocnemius recession to treat isolated foot pain.

BACKGROUND: Gastrocnemius recession is performed to correct an isolated gastrocnemius equinus contracture of the ankle that may accompany foot and ankle pathology in the adult. It has been proposed that this equinus deformity leads to excessive strain throughout the foot, thus causing pain. This can manifest itself in the form of plantar fasciitis, metatarsalgia, posterior tibial tendon insufficiency, osteoarthritis, and foot ulcers. The purpose of this retrospective study was to review the efficacy of the gastrocnemius recession in providing pain relief for patients who have foot pain without structural abnormality who have failed conservative treatment and have an isolated gastrocnemius contracture. MATERIALS AND METHODS: Twenty-nine patients (34 feet) who had chronic foot pain without any structural abnormality other than an isolated gastrocnemius contracture underwent a gastrocnemius recession and were available for follow up at an average of 19.5 (range, 7 to 44) months. The outcome measurements were related to pain relief (Visual Analog Scale) and patient satisfaction. RESULTS: Preoperatively the average pain score was 8/10 which improved postoperatively to 2/10. Twenty-seven patients (93.1%) said they would recommend this procedure for isolated foot pain to a friend. Twenty-seven patients (93.1%) said they were satisfied with the results of the procedure. Twenty-three of 25 patients (92%) who had a unilateral procedure stated they would have the contralateral leg done if needed. CONCLUSION: Gastrocnemius recession was found to be an effective procedure when used to relieve recalcitrant foot pain in those patients with an isolated gastrocnemius contracture without deformity.

Tibial compartment syndrome and the cavovarus foot.

Compartment syndrome of the leg is an orthopedic emergency that requires a high index of suspicion for diagnosis and a low threshold for surgical management to prevent devastating complications. Where the clinical findings are subtle, continuous monitoring of compartment pressures, with clinical correlation, is the key to diagnosis. Surgical management should include decompression of all four compartments and early rehabilitation to prevent ischemic contracture. If contracture develops, it may cause varying degrees of equinocavovarus deformity of the foot and ankle. Appropriate evaluation and careful surgical planning that considers all components of this complex deformity are essential for obtaining good clinical results.

First ray injuries.

The first ray differs from the other rays in its position and its importance with weight bearing. Because it is a critical structure in the formation of the tripod of the foot, injuries to this ray can cause critical alterations in the biomechanics of the foot. This allows for pathologic weight-bearing points of contact and deformity that lead to a disabling gait. Physicians who are involved in the care of the foot and ankle should be familiar with the spectrum of injuries that concern the first ray. These injuries, their management, and sequelae are reviewed.

Calcaneus fractures: a review article.

Calcaneus fractures are a significant burden to society. Assessment and treatment of these injuries has improved significantly. The use of CT scanning has allowed a greater understanding of the pathologic anatomy of these fractures, and has provided for prognostic classification systems with respect to outcome. The treatment options are diverse and are reviewed.