Lateral Instability in Total Ankle Arthroplasty: A Comparison Between the Brostrom-Gould and Anatomic Lateral Ankle Stabilization (ATLAS).

BACKGROUND: Lateral ankle instability is not uncommon after osseous cuts and soft tissue releases are performed during Total Ankle Arthroplasty (TAA), particularly with varus malalignment. The purpose of the present study was to compare the outcomes of ankles that underwent TAA with concurrent Brostrom-Gould (BG) or Anatomic Lateral Ankle Stabilization (ATLAS) at a minimum of 1-year follow-up. METHODS: Thirty-eight TAAs underwent BG (21 INFINITY, 4 CADENCE) or ATLAS (13 INBONE-2) between August 2015 and February 2019 at a single institution and were at least 1 year postoperative (mean 18.3 months, range: 12-40). Baseline patient demographics, characteristics, and operative factors were assessed via medical record and chart reviews. Radiographs parameters were measured preoperatively, at 6 weeks postoperative, and during the latest follow-up. Revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook et al, respectively. Univariate and multivariate analyses were performed. RESULTS: Survivorship for TAA with concurrent BG/ATLAS was 97%. Overall, TAA with concurrent BG had higher incidences of early TAA revision (4%), recurrent instability (4%), reoperation (16%), and complications (29%) compared to ATLAS. Postoperative coronal and sagittal tibiotalar alignment changes were significant for both groups (P < .001, P = .014); however, the differences were greater for ATLAS (P = .045, P < .001). CONCLUSION: The present study is the first to compare outcomes between techniques for addressing ankle instability in the TAA population. At short-term follow-up, anatomic reconstruction produced better outcomes than the traditional BG procedure. Additional comparative studies between techniques to address instability in the TAA population are warranted. LEVEL OF EVIDENCE: Level III: Retrospective cohort study.

Consumer Interest in Total Ankle Replacements Over the Last 10 Years: A Google Trends™ Analysis From 2009 to 2019.

With an aging population, the incidence of osteoarthritis (OA) continues to grow. After exhausting conservative therapy for many forms of OA, patients regularly opt for surgical intervention in the form of total joint replacement surgery. One form, total ankle replacement, has continued to gain favorability in the medical community. Improved implant design and surgical technique have enabled success rates of total ankle replacements to approach those of the hip and knee. As a new and improving therapy to address end-stage ankle OA, knowledge of patient-interest has yet to be determined. We used search inquiry data for the keywords "ankle arthritis" "ankle replacement" and "ankle fusion" available from Google Trends™ to identify trends in patient and geographic interest from 2009 to 2019. Search inquiries significantly increased for all keywords over time (p < .001). Trend analysis over this 10-year period revealed a strong correlation for ankle arthritis (0.88) and ankle replacement (0.76). Moreover, the correlation between "ankle arthritis" and "ankle replacement" was strong (0.83) during this period. The geographic distribution of these search terms showed the greatest increase in interest for the keywords "ankle arthritis" "ankle replacement" and "ankle fusion" in Arizona, New York, and Virginia respectively. Results of this study illustrate a similar increasing patient interest in ankle arthritis and ankle replacements. This data can be used effectively identify, educate, and treat populations interested in ankle replacements. To the best of our knowledge, this is the first study to utilize Google Trends™ to analyze patient interest in foot and ankle surgery.

Preliminary Report of a Hybrid Total Ankle Arthroplasty Combining a Stemmed Intramedullary Tibial Component With Chamfer-Cut Talar Dome.

Total ankle arthroplasty (TAA) is a viable treatment for end-stage ankle arthritis. In our experience, a stemmed intramedullary tibial component combined with a chamfer-cut talar component provides the most stable construct for TAA. We present our technique for placement of this hybrid prosthesis utilizing the INBONE tibial component in combination with the INFINITY talar component. This technique differs from the standard protocol by minimizing use of both patient-specific and standard intraoperative guides. The primary aim of this study is to report our preliminary outcomes with our novel technique. Secondarily, we aim to demonstrate that placement of this hybrid prosthesis is radiographically reproducible and accurate. The first 10 patients undergoing this technique with at least 1 year of follow-up were retrospectively reviewed. Average visual analog pain scale decreased from 7.4 preoperatively to 0.5 at 1 year postoperatively. The average time to weightbearing was 6.4 weeks. Complications were minimal, and no implant-related complications were encountered. First weightbearing ankle radiographs postoperatively were evaluated by 3 reviewers to determine accuracy of the tibial intramedullary stem in relation to the anatomical axis of the tibia. We found that the deviation of the tibial implant from the anatomic axis was on average 0.9°± 0.5° in the coronal plane, and 2.2°± 2.7° in the sagittal plane. Inter-rater reliability was 83%. We conclude that this hybrid technique utilizing a stemmed intramedullary tibial component in combination with a chamfer-cut talar component for TAA is reproducible, accurate, and safe.

The Safety Profile of Same-Day Outpatient Total Ankle Arthroplasty.

There has been significant change in the health care policy in the United States in recent years with an increasing focus on health care costs and patient satisfaction. One strategy of cost containment is to transition outpatient surgery away from high cost hospital environments. Total ankle arthroplasty has begun the evolution to outpatient settings; however, there is limited published literature on the results of outpatient total ankle arthroplasty (TAA). The purpose of the present study was to review the safety profile of same day outpatient TAA at an ambulatory surgery center. A review of consecutive patients who underwent same day outpatient TAA for end-stage ankle arthritis with a minimum of 12 months' follow-up was performed. The primary outcomes assessed were the incidence of perioperative adverse medical events, hospital admissions related to the procedure, and postoperative complications (minor and major). Univariate analyses were performed. Fifty-one patients who underwent same-day TAA between June 2016 and July 2018 were included; mean follow-up was 20.7 months (± 7.6). The mean age at time of surgery was 56.5 years (± 7.2), with a mean body mass index of 30.4 (± 5.3). Overall, there were no perioperative adverse medical events or hospital admissions related to the procedure. Five minor complications (9.8%) and 7 major (13.7%) were recorded. Of the major complications, only 1 required TAA revision. Implant survivorship during the most recent follow-up was 98%. The present study suggests that TAA can be performed safely in an outpatient ambulatory setting. Additional comparative studies with larger TAA cohorts and patient reported outcomes are warranted.

Risk Stratification for Revision Surgery Following Total Ankle Replacement.

As a result of improved implants total ankle replacement (TAR) is becoming a more reliable option for end stage ankle arthritis. As with any surgery there are numerous complications that can occur intraoperatively and postoperatively with TAR. The primary aim of this study is to use recent data on implants currently on the market to develop a well-defined and comprehensive complication classification system which stratifies risk of subsequent surgery for TAR. A systematic review of studies on TARs from 2013 to 2018 was performed. Inclusion criteria were studies published between 2013 and August 2018, studies having at least 20 patients, data with at least 1-year follow-up and use of implants currently on the market. Studies were excluded if they involved revision cases, case reports, basic science articles and studies published in non-peer-reviewed journals. Sixteen studies fit inclusion criteria involving 3,305 implants. Overall survival of all implants was found to be 93% with a pooled complication rate of 75.6% using criteria for classifying complications by Glazebrook et al. Previously published classification systems did not clearly define complication categories leading to inconsistency in complication reporting and inaccurate complication rates. There are also several complications that are unclassifiable with the classifications developed by Gadd et al and Glazebrook et al. Our proposed updated classification system provides more inclusive tier profiles to capture the complications that can occur with implants currently on the market. Furthermore, this system provides a stratification of risk that these complications pose to ultimate procedure success.

Total Ankle Arthroplasty With Anatomic Lateral Ankle Stabilization (ATLAS) in Moderate and Severe Pre-operative Varus Alignment.

The purpose of the present study was to assess the early clinical and radiographic outcomes for patients who underwent TAA and Anatomic Lateral Ankle Stabilization (ATLAS) using synthetic graft for instability in moderate and severe preoperative varus alignment. Seven ankles with moderate or severe varus alignment underwent TAA with a 3rd generation prothesis (INBONE-2) and ATLAS using synthetic graft between September 2018 and February 2019 at a single institution, and were at least 1 year postoperative (mean 13.3 months, range 12-15). Medical records and charts were reviewed for revisions, reoperations, and complications. Weightbearing radiographs were assessed using tibiotalar alignment parameters preoperatively, and during the latest follow-up. Survivorship for INBONE-2 with ATLAS was 100%; recurrent instability was not observed. Symptomatic talonavicular joint arthritis was recorded for a single patient 12 months postoperatively; no revisions, or reoperations were performed. Coronal alignment improved significantly from 17.7 ± 9.3 (range, 10.1-33.6) to 2.3 ± 1.2 (range, 0.9-4.4) degrees (p < .006), and all ankles achieved neutral alignment in a single stage. Regarding sagittal alignment, 2 ankles (28.5%) were translated anteriorly and the rest were neutral (71.5%) preoperatively. Significant posterior translation was observed and during the latest follow-up, 4 ankles were neutral (57.1%) and 3 posterior (42.9%) (p < .009). Satisfactory outcomes were observed at a minimum of 1-year follow-up for patients with moderate or severe varus alignment who underwent TAA with INBONE-2 and ATLAS. ATLAS may afford advantages over previously described repair techniques. Comparative studies between the Brostrum-Gould and ATLAS are warranted.

Intermediate-Term Outcomes of a Third-Generation, 2-Component Total Ankle Prosthesis.

BACKGROUND: Short-term outcomes for the INBONE I and INBONE II tibial stems have been favorable. The INBONE-II talus has been shown to have lower reoperation and failure rates compared to its predecessor at short term follow-up. The purpose of the present study was to assess mid-term outcomes for the third generation, two component total ankle prosthesis at 5 to 9 years follow-up, evaluating both the tibial and talar components. METHODS: All patients who underwent primary total ankle arthroplasty (TAA) with INBONE-II between July 2010 and July 2014 at a single institution and who were at least 5 years postoperative were included. A total of 15 ankles with a mean follow-up of 85 months (range, 61-113 months) met the criteria. Radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 weeks postoperatively, and at the most recent follow-up. Medical records were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook et al, respectively. RESULTS: The survivorship of the prosthesis at a mean of 85 months was 93.7%. The coronal and sagittal tibiotalar alignments 6 weeks after surgery were 2.1 degrees (P = .081) and 36% (P = .15), respectively. Maintenance of this alignment was observed during the latest follow-up (P = .684 and P = .837, respectively). One ankle (6.7%) required early component revision, while 4 (26.7%) required a non-implant-related revision. Six complications (2 high grade, 1 intermediate, and 3 low) in 5 ankles (33.3%) were recorded according to the Glazebrook classification system. CONCLUSION: The present study is the first to report midterm follow-up after TAA with this third-generation, 2-component prothesis. High survivorship, maintenance of correction, and a low incidence of major complications were observed in this small case series. The most common complication overall was lateral gutter impingement, which accounted for the majority of the nonrevisional reoperations. LEVEL OF EVIDENCE: Level IV, case series.

Total Ankle Arthroplasty Survivorship: A Meta-analysis.

The gold standard for management of end-stage ankle arthritis was previously ankle arthrodesis; however, improvements in total ankle replacements are making this a more viable treatment option. The primary aim of this meta-analysis was to evaluate the survivorship of total ankle replacement implants currently in use. An extensive search strategy initially captured 20,842 citations that were evaluated for relevance. Abstract screening produced 97 articles to be read in entirety, of which 10 articles studying 1963 implants met all prospective inclusion criteria for analysis. Overall survivorship of all implants was 93.0% (95% confidence interval, 85.2-96.9) using a random effect model. There was significant heterogeneity between the studies (Q = 131.504). Meta-regression identified an inverse relationship between survivorship and study follow-up duration (p < .0001). Furthermore, age (p = .36) and implant type (fixed-bearing [95.6%, 95% confidence interval, 85.9-98.7] versus mobile-bearing ]89.4%, 95% confidence interval, 79.6%-94.8%]) did not have a statistically significant impact on survivorship, p = .213. However, patients with higher preoperative functional scores had improved survivorship (p = .001). Complications were inconsistently reported with varied definitions. In order of reported frequency, complications were classified into technical error (28.15%), subsidence (16.89%), implant failure (13.28%), aseptic loosening (6.3%), intraoperative fracture (5.67%), wound problems (4.3%), deep infection (1%), and postoperative fracture (0.0001%). Overall study quality was low, with only 10% being prospective and 90% from nonregistry data. The results from this meta-analysis revealed a promising overall survivorship of current implants in use for total ankle replacement; however higher quality studies with standardized outcomes measures are needed.

One-Year Outcome Study of Anatomic Reconstruction of Lesser Metatarsophalangeal Joints.

Background: Lesser metatarsophalangeal joint (MTPJ) and plantar plate pathologies are commonly seen forefoot conditions. Traditional rebalancing techniques are commonly used but can have concerning adverse effects. The purpose of this study was to analyze the 1-year outcomes of a new technique consisting of anatomic repair of the plantar plate and collateral ligaments involving lesser MTPJs. Methodology: A retrospective cohort study of 50 consecutive patients treated with anatomic plantar plate and collateral ligament reconstruction were evaluated for lesser MTPJ imbalances between 2013 and 2016. The primary outcome was postoperative digital stability defined as a normal dorsal drawer test and normal paper pull-out test. Secondary outcomes included pre- and postoperative visual analogue scale pain measurements, MTPJ radiographic alignment, and ACFAS Forefoot module scores. Results: All patients had digital instability prior to the surgical intervention. Final follow-up revealed that 92% of patients showed improved digital stability, P = .0005. Multivariate regression found statistically significant improvement in pain reduction via the visual analogue scale of 51.2 mm (P < .0001) and ACFAS Forefoot module scores improved to 92 (P < .0001). The 45 joints with preoperative abnormal transverse plane deformity, had either complete (n = 29) or partial (n = 16) radiographic MTPJ correction. Conclusion: These results suggest that anatomic repair of lesser MTPJ improved digital stability, pain, function and radiographic alignment with greater than one year of follow-up.Levels of Evidence: Level IV: Retrospective cohort study.

Reproducibility and Reliability of the Radiographic Angles Used to Assess Tailor's Bunions.

BACKGROUND: Tailor's bunion, or bunionette, deformity is a common condition of the lateral forefoot. To aid in assessing the deformity, radiographic angular measurements are frequently used. The objective of this study was to determine the reliability and reproducibility of these angular measurements. METHODS: Thirty unique weightbearing dorsoplantar digital radiographs of pathologic feet were compiled. For these 30 radiographs and for ten repeated radiographs, six practicing clinicians measured the following angles: the fourth to fifth intermetatarsal angle, the lateral deviation angle, and the fifth metatarsophalangeal angle. Both traditional and modified versions of the fourth to fifth intermetatarsal angle were included. RESULTS: Intraclass correlation coefficient values were calculated for each of the angles studied. Intrarater reliability was highest for the fifth metatarsophalangeal angle and lowest for the lateral deviation angle. Intrarater reliability was higher for the traditional fourth to fifth intermetatarsal angle than for the modified version. The interrater reliability calculations revealed parallel findings. CONCLUSIONS: Accurate assessment is critical when planning for surgical intervention. Awareness of the relative reliability of these radiographic angular measurements can aid in preoperative planning and may be of benefit in procedure selection.

Long-Term Outcomes of Corrective Osteotomies Using Porous Titanium Wedges for Flexible Flatfoot Deformity Correction.

Common corrective osteotomies used in flexible flatfoot deformity reconstruction include Cotton and Evans osteotomies, which require structural graft to maintain correction. Auto-, allo-, and xenografts are associated with a number of limitations, including disease transmission, rejection, donor site morbidity, technical challenges related to graft fashioning, and graft resorption. Porous titanium is a synthetic substance designed to address these flaws; however, few studies have been reported on the efficacy, safety, and long-term outcomes. A multicenter retrospective cohort of 63 consecutive preconfigured porous titanium wedges (PTWs) used in flexible flatfoot reconstructions from June 1, 2009 to June 30, 2015 was evaluated. The primary outcome measure was the pre- to postdeformity correction efficacy. The secondary outcomes included maintenance of correction at a minimum follow-up point of 12 months, complications, graft incorporation, and graft safety profile. Multivariate linear regression found a statistically significant improvement in all radiographic parameters from preoperatively to the final weightbearing radiographs (calcaneocuboid 18.850 ± 4.020 SE, p < .0001; Kite's, 7.810 ± 3.660 SE, p = .04; Meary's 13.910 ± 3.100 SE, p = .0001; calcaneal inclination, 5.550 ± 2.140 SE, p = .015). When restricted to patients with >4 years of follow-up data, maintenance of correction appeared robust in all 4 measurements, demonstrating a lack of bone or graft resorption. No patients were lost to follow-up, no major complications or implant explantation or migration occurred, and all implants were incorporated. Minor complications included hardware pain from plates over grafts (8%), 1 case of scar neuritis, and a 5% table incidence of transfer pain associated with the PTWs. These results support the use of PTWs for safety and degree and maintenance of correction in flatfoot reconstruction.

Amnion: The Ideal Scaffold for Treating Full-Thickness Wounds of the Lower Extremity.

Amnion and amniotic tissue has been studied for more than 100 years in the treatment of acute and chronic wounds. Recent studies have focused on the use of amnion tissue in the management of full-thickness diabetic wounds, particularly of the lower extremities. With new harvesting, processing, and distribution technologies, amnion is increasingly available in treating these wounds. Current data and research show increased healing potential and decreased healing times, pain, drainage, and infection in wounds treated with amnion products. There are a variety of amnion products with varying differences and purposes, requiring additional research and comparison trials.