Total Ankle Arthroplasty: An Overview of the Canadian Experience.

Total ankle arthroplasty use has increased across Canada over the last two decades. Multiple implant designs are readily available and implanted across Canada. Although arthrodesis is a reliable procedure for treating end-stage ankle arthritis, ankle replacement is often the preferred surgical treatment by patients. A recent prospective study evaluated intermediate-term outcomes of ankle replacement and arthrodesis at multiple centers across Canada, with variability in prosthesis type, surgeon, and surgical technique. Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort in which treatment was tailored to patient presentation; however, rates of reoperation and major complications were higher after ankle replacement.

Cross-Sectional Contrast Between Individuals With Foot/Ankle vs Knee Osteoarthritis for Obesity and Low Education on Health-Related Quality of Life.

BACKGROUND: Improving health-related quality of life (HRQoL) necessitates an understanding of the influence of patient characteristics on, and interrelationship among, HRQoL domains. In osteoarthritis (OA), these associations have predominantly been examined in hip/knee populations. We investigated whether there were differences in these associations between foot/ankle and knee OA samples. METHODS: Individuals seeking orthopedic care for foot/ankle or knee OA completed a questionnaire pre-consultation, including HRQoL domains (bodily pain [BP], physical [PF] and social functioning [SF], and mental [MH] and general health [GH]), obesity, comorbidity, and sociodemographic characteristics. Associations were examined via stratified path analysis (foot/ankle vs knee). Foot/ankle: n = 180, mean age = 55 (range: 25 to 82), 52% female. Knee: n = 253, mean age = 62 (range: 26 to 92), 51% female. RESULTS: The interrelationship among HRQoL domains was generally similar between groups. However, the influence of patient characteristics differed. Low educational status was associated with worse scores for GH, MH, and SF in the foot/ankle group, whereas no significant effects were found in the knee group. Obesity was associated with worse scores for SF, BP, and GH in the foot/ankle compared to the knee group. Patient characteristics explained considerably more of the variation in domain scores in the foot/ankle group. CONCLUSION: There are significant differences in the impact of patient characteristics on HRQoL domains in foot/ankle versus knee OA patients. Therefore, a universal approach to patient education/intervention to improve HRQoL in lower-extremity OA is not likely to achieve optimal results. Based on these findings, we recommend joint-specific patient education, with a particular emphasis on patient characteristics among the foot/ankle OA population. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The postoperative COFAS end-stage ankle arthritis classification system: interobserver and intraobserver reliability.

End-stage ankle arthritis is operatively treated with numerous designs of total ankle replacement and different techniques for ankle fusion. For superior comparison of these procedures, outcome research requires a classification system to stratify patients appropriately. A postoperative 4-type classification system was designed by 6 fellowship-trained foot and ankle surgeons. Four surgeons reviewed blinded patient profiles and radiographs on 2 occasions to determine the interobserver and intraobserver reliability of the classification. Excellent interobserver reliability (κ = .89) and intraobserver reproducibility (κ = .87) were demonstrated for the postoperative classification system. In conclusion, the postoperative Canadian Orthopaedic Foot and Ankle Society (COFAS) end-stage ankle arthritis classification system appears to be a valid tool to evaluate the outcome of patients operated for end-stage ankle arthritis.

Prospective clinical pilot trial in a single cohort group of rhPDGF in foot arthrodeses.

BACKGROUND: Augment Bone Graft, a fully synthetic bone graft material composed of recombinant human PDGF and a calcium phosphate matrix (rhPDGF/TCP), has been considered as a possible alternative to autogenous bone graft. Before proceeding with randomized control studies comparing rhPDGF/TCP to autograft bone, a human trial to assess efficacy and safety was required. MATERIALS AND METHODS: The current study was a prospective, open-label, multi-center trial designed to evaluate rhPDGF in a calcium phosphate matrix (Augment Bone Graft). Sixty patients requiring hindfoot or midfoot fusion were prospectively followed for 36 weeks. All patients received 0.9 to 2.7 mg of rhPDGF at the fusion sites and returned for clinical and radiographic review at Day 7 to 14 and Weeks 6, 9, 12, 16, 24, and 36. Computerized tomography (CT) scans of the fusion site were obtained at the 6- and 12-week postoperative appointment, with an additional CT scan at 16 weeks if required. RESULTS: No patients suffered a serious adverse event caused by rhPDGF. CT scan evaluation at 12- to 16-week time periods revealed moderate or complete osseous bridging of 75% (44/59) at 36 weeks. CONCLUSION: These results indicate that rhPDGF is a safe product and provides clinical/radiographic outcomes that justify the pursuit of randomized controlled studies comparing rhPDGF/TCP to autograft.

Inter- and intraobserver reliability of the COFAS end-stage ankle arthritis classification system.

BACKGROUND: End-stage ankle arthritis should have an appropriate classification to assist surgeons in the management of end-stage ankle arthritis. Outcomes research also requires a classification system to stratify patients appropriately. MATERIALS AND METHODS: Six fellowship trained foot and ankle surgeons met on two occasions to derive a classification system for end-stage ankle arthritis. A four-part classification system was designed. Four surgeons reviewed blinded patient profiles and radiographs on two occasions to determine the inter- and intraobserver reliability. RESULTS: Good interobserver reliability (kappa = 0.62) and intraobserver reproducibility (kappa = 0.72) was demonstrated for the classification system. CONCLUSION: The COFAS classification system appears to be a valid tool for the management and research of end-stage ankle arthritis.

Implantable direct-current bone stimulators in high-risk and revision foot and ankle surgery: a retrospective analysis with outcome assessment.

Efficacy and morbidity of a surgically implanted direct-current bone stimulator were evaluated in 38 patients (40 feet) with fracture nonunion or at high risk for nonunion; 14 of these patients had Charcot (diabetic) neuroarthropathy. Union occurred in 26 (65%) of the 40 feet; complications other than nonunion occurred in 16 feet (40%). Two amputations (5%) were performed in cases of intractable neuritis and deep infection. Of the 6 cases of deep infection (15%), 5 resolved with device removal, and the sixth case required below-knee amputation. Use of a bone stimulator in patients with diabetes may be problematic, but the device did not have any adverse effects in other high-risk patients.

Reconstruction of failed ankle fractures.

Ankle fractures are some of the most common injuries that are treated by orthopedic surgeons. Optimal long-term results of ankle fractures require accurate reconstruction, a thorough understanding of the mechanism of injury, and accurate radiographic assessment. Failure to reduce and maintain fractures and dislocations around the ankle properly predisposes to instability and late osteoarthritis. This article focuses on the reconstruction of failed ankle reconstruction that results in malunion or nonunion. The indications for fusion or arthroplasty to treat end-stage degenerative changes are discussed. The treatment of concomitant infection and neuropathic fractures are outlined.

Electrical bone stimulation: an overview and its use in high risk and Charcot foot and ankle reconstructions.

Since early work done in the 1950s on the "piezoelectricity of bone," a growing body of basic science and clinical evidence suggests the use of electrical bone stimulation as an adjunct in the treatment of foot and ankle nonunions, fusions, and Charcot arthropathy. Both implantable designs (that allow for direct constant stimulation of bone) and nonimplantable (such as pulsed and combined electromagnetic fields) devices have been studied. Ongoing research continues to support the potential usefulness of these modalities.

Results of an Internet survey determining the most frequently used ankle scores by AOFAS members.

BACKGROUND: With technological advances in ankle arthroplasty, there has been parallel development in the outcome instruments used to assess the results of surgery. The literature recommends the use of valid, reliable, and responsive ankle scores, but the ankle scores commonly used in clinical practice remain undefined. METHODS: An internet survey of members of the American Orthopaedic Foot and Ankle Society (AOFAS) was conducted to determine which three ankle scores they perceived as most commonly used in the literature, which ones they believe are validated, which ones they prefer, and which they use in practice. RESULTS: According to respondents, the three most commonly used scores were the AOFAS Ankle score, the Foot Function Index (FFI), and the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS). The respondents believed that the AOFAS Ankle score, FFI, and MODEMS were validated. The FFI and MODEMS are validated, but the AOFAS ankle score is not validated. CONCLUSIONS: Most respondents preferred using the AOFAS Ankle score. The use of the empirical AOFAS Ankle score continues among AOFAS members.

Modifications of the Weil osteotomy have no effect on plantar pressure.

Previous studies have shown that increasing angulation of the Weil osteotomy produces greater plantar translation of the metatarsal head. Modifications have been proposed to reduce plantar translation. However, there is no evidence that the increased plantar translation with a Weil osteotomy is clinically significant or that these modifications are required. Ten lower extremities consisting of five matched pairs were used to evaluate whether different configurations of the Weil osteotomy altered plantar pressure in a dynamic cadaver model. For each pair, an oblique Weil osteotomy with a 5-mm shift was done on one side and a standard (parallel) Weil osteotomy with a 5-mm shift was done on the matched foot. A 4-mm slice resection and a metatarsal head resection then were done sequentially. Plantar pressures were measured with cyclic loading to 700 N at a frequency of 1 Hz with an F-scan in-shoe sensor on the intact specimens and after each intervention. Increased plantar translation of the metatarsal head with a more oblique Weil osteotomy did not significantly increase plantar pressure, and the 4-mm slice resection did not significantly unload the metatarsal head. Only complete metatarsal head resection significantly unloaded the metatarsal head.

Significant variation exists in home care services following total joint arthroplasty.

OBJECTIVE: To determine a preliminary profile of the variation in rehabilitation and home care services for patients with total joint arthroplasty (TJA) in Ontario in 2001. METHODS: A cross-sectional survey was conducted of directors at the 43 regional community care access centers (CCAC). RESULTS: One-third (36%) of CCAC had existing care pathways, 54% had defined discharge criteria, and 32% had predetermined the length of home care services. The intensity and frequency of services provided were variable. CONCLUSION: There is a need to standardize rehabilitation protocols to maintain quality of care and contain costs.

Posterior tibial nerve--primary.

Tarsal tunnel is an uncommon disorder of the foot that presents as a burning or tingling pain that is located diffusely on the plantar aspect of the foot. Many investigators have considered tarsal tunnel syndrome to be analogous to carpal tunnel syndrome. As more becomes known about tarsal tunnel syndrome, it is evident that this is not purely an entrapment neuropathy. It differs from carpal tunnel syndrome in anatomy, etiology, clinical presentation, and response to nonoperative and operative treatment.