Comparison of Ankle Fracture Fixation Using Intramedullary Fibular Nailing Versus Plate Fixation.

Ankle fracture fixation using intramedullary fibular (IMF) nails has been shown to allow for earlier weightbearing, reduced wound complications, better union rates, and the absence of prominent hardware, compared to plates/screw (PS) constructs. The purpose of present retrospective cohort study was to compare outcomes of patients who underwent ankle fracture fixation using an IMF nail versus PS. Demographic, clinical, and radiographic data were recorded for patients who underwent ankle fracture fixation between May 2020 and May 2022, and who were at least 1 year postoperative. Toe-touch weightbearing was permitted immediately after surgery, protected weightbearing (PWB) at postoperative week 2, and weightbearing as tolerated in a brace at week 6. Radiographs were assessed preoperatively, and at 2, 6, 12, 24, and 48 weeks postoperative. Sixty-one ankle fractures (30 IMF, 31 PS) with a mean follow up of 14.7 and 18 (range, 12 to 23) months were included. Overall, the IMF nail cohort had less pain, faster time to union (11.4 vs 13.2 weeks), and less complications (23% vs 45%), reoperations (10% vs 16%), and surgical failures (9% vs 9.7%), compared to the PS cohort. The differences were not statistically significant. The PS cohort had a higher rate of symptomatic hardware irritation (p =< .001). Tobacco use adversely effected direct osseous healing (p < .001) and increased postoperative complications (p = .050). The present study lends credence to the previously reported advantages of IMF nailing over PS fixation for ankle fractures. Ankle fracture fixation using a fourth generation, IMF nail is a viable alternative to traditional PS fixation.

Lower Extremity Orthopedic Augmentation Utilizing a Synthetic Hybrid-Scale Fiber Matrix.

Introduction Lower extremity injuries represent about 15% of all emergency room visits in the United States, with ankle injuries accounting for 20% of these. Surgical site infections resulting from ankle reconstructive surgery can result in severe complications, including amputation. Depending on the procedure performed, surgical site infections of ankle reconstructive surgery can occur at a rate as high as 14%. A synthetic hybrid-scale fiber matrix with an engineered design resembling a native human extracellular matrix could be utilized to augment these difficult surgical procedures. Materials and methods A retrospective review of 10 patients who underwent orthopedic reconstructive surgeries of lower extremity injuries that were augmented with the synthetic hybrid-scale fiber matrix between October 2021 and February 2022 was conducted. Results Injuries included Achilles ruptures, bimalleolar and trimalleolar ankle fractures, ankle arthrodesis, and injuries of various other etiologies. All surgical wounds achieved complete closure and patients went on to fully recover. The average time to wound closure was 12.6 days after an average of 1.2 applications of the synthetic hybrid-scale fiber matrix. Post-reconstruction, two patients went on to have complications unrelated to the synthetic hybrid-scale fiber matrix, which then went on to heal uneventfully. Conclusions The positive results seen with the retrospective case series indicated that the synthetic hybrid-scale fiber matrix can promote healing and should be considered as an option in at-risk lower extremity reconstructive procedures.

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.

Intraoperative Radiation Exposure to U.S. Podiatric and Medicine Surgery Residents Annually: How Much Are We Really Getting?

As the number and complexity of operative techniques taught at U.S. podiatric medicine and surgical residencies (PMSR) with the added credential in reconstructive rearfoot and ankle (RRA) surgery has continued to increase, so to has the use of intraoperative fluoroscopy. The purpose of the present prospective observational pilot study was to quantify and compare the shallow dose equivalent (SDE), deep dose equivalent (DDE), and lens of the eye dose equivalent (LDE) exposures for podiatric medicine and surgery residents at a single PMSR-RRA over 12 consecutive months. Shallow-dose equivalent, DDE, and LDE exposures (in millirems) were measured using Landauer Luxel dosimeters from July of 2018 to July of 2019. Dosimeters were exchanged monthly, and mean monthly/annual SDE, DDE, and LDE exposures were calculated and compared. Overall, residents averaged 19 operative cases per month and 222 per year. More than half (53%) required intraoperative fluoroscopy, for which a mini C-arm was used in most cases. Monthly SDE, DDE, and LDE exposures averaged 7.3, 9.3, and 7.0 mrem, respectively; whereas annual SDE, DDE, and LDE exposures averaged 87.3, 112, and 84 mrem, respectively. No significant monthly (P = 1.0, P = .70, and P = .74) or annual (P = .67, P = .67, and P = .33) differences were identified between residents. The annual SDE, DDE, and LDE for residents at a single PMSR-RRA were well below the recommended dose limits of 50,000 mrem/year (SDE), 5,000 mrem/year (DDE), and 15,000 mrem/year (LDE) set by the National Council on Radiation Protection. However, given that the stochastic effects from low levels of ionizing radiation are cumulative, not well studied long-term, and relate both to the degree and duration of exposure, mini-C arm fluoroscopy, radiation tracking, and use of personal protective equipment provide simple means for residents to reduce any long-term potential for risk.

Incidence of Scholarly Publication by Selected Content Experts Presenting at National Society Foot and Ankle Meetings From 2016 to 2020.

Continuing medical education (CME) is an important element to maintain licensing requirements, enhance professional competence, and disseminate up to date, evidence-based, treatment recommendations. A key resource of CME are the 2 annual society meetings hosted by the American College of Foot and Ankle Surgeons (ACFAS) and American Orthopedic Foot and Ankle Society (AOFAS). It is assumed that the selected speakers at these meetings are content experts, providing validated expertise on treatment recommendations, rather than anecdotal experience or opinion. Across all medical specialists, peer-reviewed publication(s) on a particular subject matter have long bestowed the ultimate validity of "expertise." The purpose of this study was to assess the incidence of scholarly publication for invited speakers at the ACFAS and AOFAS annual meetings from 2016 to 2020, in relation to the topic they were selected to present. A review of invited lectures given at the ACFAS and AOFAS annual meetings from 2016 to 2020 was conducted, and lecturer demographics were categorized into predetermined content areas for assessment. Selected speakers were individually cross-referenced with content-specific peer-reviewed published literature, and overall h-index using Scopus. Topic and society specific comparisons were then made. Overall, 1028 lectures were identified during the temporal period. Only 300 (29.18%) presentations were given by a speaker with least one or more publication on the society specific lecture-topic presented. The greatest proportion of lecturers with content-specific publications was Charcot reconstruction (67.57%) followed by ankle fusion/replacement (55%). The average presenter h-index was greatest among total ankle replacement/ankle fusion (12.16 ± 6.90) and Charcot reconstruction (11.27 ± 7.10) content. The results of the present study illustrate a disparity of expertise among different content areas. While both meetings provide well-published lecturers, this study reveals areas for improvement.

The Financial Implications of Being a Female Fellow: Does Another Year Help Close the Gap?

In 2018, the American College of Foot and Ankle Surgeons Compensation and Benefits Survey illustrated a wage gap between male and female doctors of podiatric medicine in the United States. The purpose of the present study was to assess if an additional year of fellowship training closes that gap. To calculate the net present value, weighted mean general income data from female doctors of podiatric medicine with and without fellowship training was obtained. Demographic and clinical income data (based on 2080 hours) for 17 female graduates from 14 American College of Foot and Ankle Surgeons recognized fellowship programs was collected using an anonymous online survey. Income from general payments was collected from manual searches of Open Source Payments. Socioeconomic data from the 2018 American College of Foot and Ankle Surgeons compensation and benefits survey was used to calculate the net present value of the nonfellowship trained doctors of podiatric medicine for comparison. Overall, the net present value of female doctors of podiatric medicine with and without fellowship training was $1.91 million and $2.4 million, respectively. The comparative net present value and cumulative net income difference over 30 years for female doctors of podiatric medicine with and without fellowships was -$492,159.00 and -$820,000.00, respectively. The mean comparative income difference for fellowship trained female doctors of podiatric medicine annually was as follows: clinical (-$26,082.00) and general (+$1101.54). Based on the data, with consideration to the limitations of the study, the financial implications of fellowship on the gender wage gap is currently unclear. Additional research is warranted.

Heterotopic Ossification Following Total Ankle Arthroplasty With Fourth-Generation Prostheses.

BACKGROUND: The purpose of the present study was to assess the radiographic incidence, location, and classification of heterotopic ossification (HO) in patients who underwent total ankle arthroplasty (TAA) with a 4th generation prostheses at a minimum of 1-year follow up. Baseline demographic, radiographic, and operative factors between patents with and without HO were compared. METHODS: Ninety ankles that underwent TAA with a 4th generation protheses, INFINITY (n = 62) or CADENCE (n = 28) were followed for an average of 23.7 (range, 12-49) months. Incidence and location of HO was assessed on weightbearing radiographs, and severity graded according to the modified Brooker classification. Data was compared between patents with and without HO to identity any predisposing factors. RESULTS: In 90 ankles that underwent 4th generation TAA, HO incidence was 55.6% (n = 50); 56.5% (n = 35) for INFINITY, and 53.6% (n = 15) for CADENCE. Twenty-five cases of HO were observed posteriorly, 16 anteriorly, and 9 combined. Severity was as follows; class I in 19 cases (38%), class II in 20 (40%), class III in 9 (18%) and class IV in 2 (4%). A single ankle required a non-revisional reoperation for HO debridement; reoperation rate of 2%. CONCLUSION: The present study suggests a similarly high incidence of HO after TAA with two different 4th generation protheses (INFINITY 56.5%, CADENCE 53.6%). A trend for differences in location and severity between the protheses may also be present. Given the paucity of literature, additional studies with longer follow-up are warranted to discern the significance of HO following TAA with 4th generation protheses. LEVEL OF EVIDENCE: Level III: Retrospective cohort study.

The INFINITY Total Ankle Prosthesis: Outcomes at Short-Term Follow-up.

BACKGROUND: The INFINITY total ankle prothesis remains the most widely used fourth-generation total ankle arthroplasty (TAA) system in the United States. The purpose of the present study was to assess radiographic outcomes for INFINITY at short-term follow-up. METHODS: All patients who underwent primary TAA with INFINITY between August 2015 and June 2018 at a single institution and who were at least 1 year postoperative were included. A total of 55 ankles with a mean follow up 22 months (range, 12-43 months) met the criteria. Weightbearing radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 to 8 weeks postoperatively, and at the most recent follow-up. Medical records and charts were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook at el, respectively. RESULTS: Overall, INFINITY survivorship was 98.2%. Coronal and sagittal tibiotalar alignment improved after surgery (P < .001, P = .09, respectively), and was maintained during the latest follow-up (P = .62, P = .47, respectively). Only 1 ankle (1.8%) required early revision; while 5 (9.1%) indicated non-implant-related revision; 85.5% required no reoperation. In nineteen ankles (34.5%), postoperative periprosthetic lucency was observed; most were not progressive (17 ankles, 89.5%). Twelve complications (3 high grade, 3 intermediate, and 6 low grade) in 11 ankles (20%) were recorded according to the Glazebrook classification system. CONCLUSION: INFINITY survivorship was 98.2% at a mean of 1.8 years of follow-up, and only 1 ankle required prosthetic revision. Additional studies with longer follow-up are warranted for fourth-generation TAA prostheses. LEVELS OF EVIDENCE: Level IV: Case series.

Does Proximal Placement of the Syndesmotic Reduction Clamp Affect the Optimal Position for the Medial Tine? A Cadaveric Pilot Study.

Sagittal plane syndesmotic malreduction is associated with off-axis, eccentric reduction clamping and preferential placement of the medial tine anteriorly has been proposed to minimize the malreduction risk. Although clamp placement 1cm proximal to the plafond is recommend, no previous study has assessed whether differences in the anatomic position of the fibula within the incisura (eccentric 1cm superior and concentric 2 cm superior to the tibial plafond) affect the optimal position for the clamps medial tine during reduction of the syndesmosis. The purpose of the present cadaveric pilot study was to evaluate and compare the sagittal syndesmotic malreduction rate with various clamping vectors, 1cm and 2cm from the tibial plafond, respectively. Six through the knee cadaveric specimens were obtained. Kirschner wires and a surgical maker were used to denote placement of the reduction clamp laterally on the peroneal ridge of the fibula, and medially within the anterior, middle, and posterior thirds (Zones A, B, C) of tibia's width; 1 cm and 2 cm from the plafond. CT scans were obtained as controls, followed by destabilization of the syndesmosis. Reductions were then performed sequentially at each level (1 cm, 2 cm) and zone (A, B, C); and CT scans repeated for assessment. In most specimens (n = 5), an eccentric (1 cm) to concentric (2 cm) positional transition was observed within incisura fibularis. The transition altered the resulting fibular displacements in some specimens (2A anterior, vs 2B posterior), resulting in a higher malreduction rate with anterior (zone 2A, 33%) vs central (Zone 2B, 17%) positioning of medial tine. Although no definitive conclusions can be reached from the present pilot study, future studies with a greater number of specimens and clamping vectors are warranted to determine whether positional transitions of the fibula within the incisura fibularis affect the optimal position for the clamps medial tine.

The Role of Secondary Imaging Techniques for Assessing Bone Mineral Density in Elderly Ankle Fractures.

Elderly ankle fractures in the elderly represent a substantial healthcare burden. Dual-energy x-ray absorptiometry (DXA) is the gold standard for diagnosis of osteoporosis. However, there is emerging research regarding secondary imaging techniques to evaluate bone mineral density (BMD). The purpose of this systematic review was to summarize the role of secondary imaging techniques for measuring BMD in elderly ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Eight studies were included in the systematic review. Computed tomography (CT) may have a role in preoperative surgical planning, provide an explanation for injury patterns in elderly patients, and may be correlated with clinical outcomes. High-resolution peripheral quantitative CT may be better suited than DXA for the assessment of ankle fractures due to the resolution of the image and its ability to distinguish between bone compartments, as well as provide a more accurate estimation of bone quality. Quantitative ultrasound has shown promise as a tool for measuring BMD in patients with osteoporosis, but is not able to detect osteoporosis in patients with ankle fractures. This paper helps define the role of each modality in the spectrum of care in the evaluation of osteoporosis as it pertains to elderly ankle fractures.

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.

The Financial Implications of Podiatric Foot and Ankle Fellowship: Is Another Year Worth It?

For prospective applicants many variables can factor into the decision to pursue fellowship level training. The purpose of the present study was to give prospective applicants an idea of the financial implications of podiatric foot and ankle fellowship. To calculate the net present value (NPV), weighted mean income data (clinical, general, research, associated research) from podiatric foot and ankle surgeon's (FAS's) with and without fellowship training was obtained. Income from general payments, research, and associated research was collected from manual searches of Open Source Payments. Demographic and clinical income data (based on 2080 hours) for graduate fellows from 4 programs was collected using an anonymous online survey. Socioeconomic data from the 2018 American College of Foot and Ankle Surgeons (ACFAS) compensation survey was used for comparison. The NPV of podiatric FAS's with/without fellowship training was $4.2 million and $3.03 million, respectively. The comparative NPV and cumulative net income difference over 30 years was $1.2 million and $2.5 million, respectively. The mean comparative income difference for fellowship trained podiatric FAS's annually was as follows: clinical (+$69,145.00), general (+$21,797.00), research (+$1,833.00), and associated research (+$414.00). The present study is the first attempt to provide prospective applicants with an idea of the financial implications of podiatric foot and ankle fellowship. Based on the positive NPV, pursuing an ACFAS recognized podiatric foot and ankle fellowship in advanced reconstruction could be considered an "acceptable financial investment", which may positively affect career earnings. Prospective applicants should be cognizant that the NPV varies between fellowship programs. Therefore, the data presented from graduate fellows of the programs included may not be generalizable to graduate fellows from other programs.

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.

Feeling the Burnout: Perceptions of Burnout, Anxiety, Depression, and Personal Achievement in US Podiatric Medical Students.

Medical student burnout is a significant problem, which has led to the introduction of institutional intervention initiatives to combat the phenomenon. However, the incidence of burnout among podiatric medical students has not been previously assessed. The purpose of this cross-sectional study was to determine the perceptions of burnout, anxiety, depression, and personal achievement among podiatric medical students. A 50-question anonymous survey containing the Maslach Burnout Inventory-Human Services Survey and the Hospital Anxiety and Depression Scale was distributed to all students of eight US podiatric medical schools. Demographic and personal information regarding the student's free time, study time, family support, class or exam failures, loan debt, and previous work experience were recorded. Four hundred and eighty students completed the survey, and 479 responses were eligible for inclusion (response rate of 22.2%). Overall, 65.1% reported moderate or high self-perceived rates of burnout, a rate comparable to allopathic and osteopathic medical students. Respondents also reported high levels of emotional exhaustion and anxiety, but low levels of personal achievement. A predisposition for burnout was identified for third-year students between the ages of 26 to 35 years with borderline or abnormal levels of reported anxiety. The present study contributes to the growing body of literature regarding burnout with respect to the podiatric profession. Despite inherent limitations, the findings suggest institutional interventions for the promotion and development of protective factors may be 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.

Bone Mineral Density Testing in Patients Undergoing Total Ankle Arthroplasty: Should We Pay More Attention to the Bone Quality?

Total ankle arthroplasty (TAA) has become one of the standard treatments for end-stage ankle arthritis. Long-term TAA survivorship is reported from 63% to 95%, with aseptic loosening being the most common mode of failure. Several studies have shown that low bone mineral density (BMD) of the hip affects the longevity of prosthetic implants. The role of Dual energy X-ray absorptiometry for TAA has not been established. The purpose of this review was to define the role of BMD in TAA outcomes and the role of Dual energy X-ray absorptiometry in measuring periprosthetic BMD. There is a paucity of information and published literature regarding the relationship between BMD and TAA. From attempting this systematic review, we hope to highlight that much of the focus in total ankle arthroplasty has emphasized implants and relatively little has focused on the quality of bone into which the prostheses are implanted.

Risk Factors for Early Failure of Fourth Generation Total Ankle Arthroplasty Prostheses.

A number of 2-component, fourth generation total ankle arthroplasty (TAA) prostheses have been introduced to the market in the past few years, as the popularity and indications for TAA have continued to expand. The purpose of the present study was to identify independent risk factors for the early failure of fourth generation TAA prostheses. A total of 97 ankles underwent TAA with a fourth generation prostheses (INFINITY, CADENCE) between August 2015 and June 2018 at a single institution and were at least 6 months postoperative (mean 18.3 months, range 6-43). The primary outcome assessed was the need for revision surgery, defined as removal of 1 or both metal components for any reason, excluding infection. Baseline patient demographics, characteristics, radiographic alignment parameters, and distal tibia cortical bone thickness (CBT) were assessed. 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. Three ankles (3.1%) underwent revision surgery for aseptic loosening at a mean of 24.3 (range, 16-31) months; all had a CBT <4 mm. Independent predictors for reoperation were CBT <4 mm, presence of diabetes, and ipsilateral hindfoot fusion (p = .04). No associations were identified for purported risk factors (age, body mass index, and coronal deformity). The present study is the first to suggest a potential relationship between reduced CBT of the distal tibia, and TAA failure. Additional studies are warranted to better understand the role of bone density in TAA survivorship.

Early Experience With the CADENCE Total Ankle Prosthesis.

A number of 2-component, fourth-generation total ankle arthroplasty prostheses have been introduced to the market. The purpose of the present study was to present early experience with the CADENCE total ankle prosthesis. All patients who underwent primary total ankle arthroplasty using the prosthesis between August 2016 and June 2018 at a single institution and who were at least 1 year postoperative were included. A total of 32 ankles with a mean follow-up of 24 (range, 12-33) months met the criteria. Weightbearing radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 weeks postoperative, and at the most recent follow-up. Medical records and charts were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook et el, respectively. Coronal and sagittal tibiotalar alignment significantly improved after surgery (p < .001, p < .005), and was maintained during the latest follow-up (p = .44, p = .30). Two (6.3%) ankles underwent early revision for aseptic loosening; while 6 (18.8%) underwent a nonrevisional reoperation. Nine (28.1%) ankles presented a total of 13 (4 high grade, 2 intermediate, and 7 low) complications according to the Glazebrook classification. The most common was intraoperative periprosthetic medial malleolar fracture (5 ankles, 15.6%), a low-grade complication. The present study is the first to report early outcomes and experience with the CADENCE total ankle. Overall, survivorship was 94% at short-term follow-up of 2 years. As with all arthroplasty devices, surgeons new to the prosthesis should be cognizant of the potential learning curve. Intraoperative medial malleolar fracture was found to be the most common complication.

Hallux Varus Interphalangeus Following Osteochondral Fracture of the Proximal Phalanx: A Case Report.

Hallux valgus interphalangeus deformity has been previously reported in the literature following trauma and first metatarsophalangeal joint fusion. However, to the best of our knowledge, hallux varus interphalangeus deformity has not been previously reported. We present the case of a 26-year-old skeletally mature woman who sustained an acute, open hallux varus interphalangeus injury following an osteochondral fracture of the medial head of the proximal phalanx.