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Background: Routine histopathologic examination of orthopaedic surgical specimens is a standard practice at many institutions. Previous studies have demonstrated that this practice seldom altered patient management for several orthopaedic procedures. As a result, the value of such practices has come into question. The purpose of this study is to determine the cost-effectiveness of routine histopathologic analysis of specimens obtained during total ankle arthroplasty (TAA). Methods: A retrospective analysis was performed of patients who underwent uncomplicated primary TAA at a large, academic, health system between January 2015 and December 2021. The postoperative histopathologic diagnoses were compared with the respective patient's preoperative clinical and intraoperative diagnoses. The prevalence of concordant, discrepant, and discordant diagnoses was determined. Cost-effectiveness analysis was conducted to assess the financial implications of obtaining routine specimens for histopathologic examination for TAA. Results: A total of 85 TAAs were identified in 85 individual patients and were included in the present study. A total of 172 specimens were sent for routine histopathologic review. On histopathologic analysis, a final diagnosis was confirmed in 82 (96.5%) of the total specimens reviewed. A discrepant diagnosis was discovered in 3 (3.5%; 2 cases of gout/pseudogout and 1 case of osteonecrosis) cases and 0 (0%) discordant diagnoses were discovered, corresponding to positive and negative predictive values of 97% and 100%, respectively The total estimate of costs incurred for the routine analysis of all specimens included in the study was between $12 299.20 and 17 846.00. The estimated cost to establish each discrepant diagnosis ranged between $4099.73 and $5948.67, and the cost for a discordant diagnosis was unable to be established. Conclusion: Routine histopathologic analysis of specimens obtained during TAA rarely revealed a discordant diagnosis and resulted in no alterations to patients' plan of care. Furthermore, the additional costs of routine histopathologic examination are significant. As such, it is recommended that such interventions in TAA should be performed on a per-case basis at the operating surgeon's discretion. [ABSTRACT FROM AUTHOR]

Background: There are limited data regarding risk factors associated with periprosthetic medial malleolar fractures in total ankle arthroplasty (TAA). This case-control study aimed to identify the risk factors and analyze the effect of prophylactic screw fixation in preventing a medial malleolar fracture after TAA. Methods: A case-control study was conducted on 149 patients who underwent primary TAA. Twenty patients with postoperative medial malleolar fractures >4 weeks postoperatively (cases) were identified. An additional 129 patients (controls) were randomly selected from the TAA database. Radiographic evaluation included tibial component coronal alignment and postoperative medial malleolar width. Demographics and radiographic variables were compared between cohorts. Logistic regression was used to investigate the association between medial malleolar fracture and postoperative coronal alignment, medial malleolar width, and prophylactic fixation of the medial malleolus. Results: Mean (SD) medial malleolar width was significantly smaller in the fracture cohort (8.52 mm [1.6]) than in the control group (11.78 mm [1.74]) (P <.001). Mean (SD) tibial component coronal alignment was 92.17 degrees (2.77) in the fracture cohort and 90.21 degrees (1.66) in the control group (P =.002). Regression analysis identified a significant negative association between postoperative medial malleolar width and the probability of fracture (OR = 0.06, 95% CI 0.01, 0.26, P <.001). Varus malalignment of the tibial component was positively associated with the probability of fracture (OR = 1.90, 95% CI 1.27, 2.86, P =.002). Prophylactic screw fixation resulted in more than 90% reduction in the odds of a fracture (OR = 0.04, 95% CI 0.01, 0.45, P =.01). ROC curve analysis determined a medial malleolar width of 10.3 mm as a potential threshold for predicting fracture. Conclusion: Decreased medial malleolar width and postoperative varus malalignment were associated with an increased risk of postoperative medial malleolar fracture. Therefore, surgeons should consider prophylactic screw fixation in patients with a medial malleolar width <10.3 mm or at risk of postoperative varus deformity. [ABSTRACT FROM AUTHOR]

Background: The literature on survivorship and outcomes after revision total ankle replacement (TAR) in the modern era is limited. This study aimed to describe the timing to revision and survivorship after revision TAR. We hypothesized that tibial-sided failures would occur earlier after the primary TAR, and secondary revisions after failure of revision TAR would occur more due to talar-sided failures than tibial-sided failures. Methods: This is a single-institution retrospective study of TAR patients with minimum 2-year follow-up. Revision TARs (defined as exchange of tibial and/or talar components) for aseptic causes with any implant were included. Etiology of failure necessitating revision and ultimate outcomes after revision (survival of TAR revision, additional revision, conversion to fusion, and below-knee amputation [BKA]) were recorded. Results: There were 46 revision TARs, with mean age of 60.6 (range: 31-77) years and mean 3.5 years' follow-up postrevision. Revisions for tibial failure occurred significantly earlier (n = 22, 1.3 ± 0.5 years after index procedure) than those for talar failure (n = 19, 2.3 ± 1.7 years after index procedure) or combined tibial-talar failure (n = 5, 3.4 ± 3.4 years after index procedure) (P =.015). Revisions for tibial-only failure had better survival (95.5%) than revisions for talar or combined tibial-talar failures: 26% of talar failures and 20% of combined tibial-talar failures underwent ≥1 revisions. Of the 6 additional revisions after failure of the talar component, 1 ultimately underwent BKA, 2 were converted to total talus replacement, 2 were revised to modular augmented talar components, and 1 was treated with explant and cement spacer for PJI after the revision. Conclusion: TAR tibial failures occurred earlier than talar failures or combined tibial-talar failures. Revisions for talar failures and combined tibial-talar failures were more likely to require additional revision or ultimately fail revision treatment. This is important given the consequences of talar implant subsidence, bone necrosis, loss of bone stock, and limited salvage options. [ABSTRACT FROM AUTHOR]

Background: Prior literature has demonstrated that ipsilateral hindfoot arthrodesis may increase the risk for reoperation after total ankle arthroplasty (TAA) and that simultaneous hindfoot arthrodesis with TAA could result in short-term clinical and radiologic improvements. The purpose of this study is to compare the reoperation rates after TAA with prior hindfoot arthrodesis vs simultaneous arthrodesis and TAA. Methods: Patients who underwent primary TAA were identified in the PearlDiver database. Patients were sorted into 2 study cohorts: hindfoot arthrodesis prior to TAA and simultaneous arthrodesis and TAA. Propensity matched control cohorts were identified for each study group. Multivariate analysis was conducted to account for any confounding variables and covariates when identifying differences in complications between cohorts. Results: 297 patients underwent TAA with prior hindfoot arthrodesis and 174 underwent TAA and hindfoot arthrodesis concurrently. The incidence of reoperation (13.8% vs 5.2%, P <.001) and infection (12.6% vs 5.9%, P =.011) for the simultaneous cohort was higher when compared to the matched control cohort. In contrast, there was no statistically significant difference when comparing the prior arthrodesis cohort to the matched control cohort in reoperation rates (5.1% vs 4.7%, P =.787) or infection rates (4.4% vs 4.8%, P =.734). Those undergoing simultaneous procedures had increased incidences of reoperation, wound complications, infection, and emergency department visits (P <.0167) when compared to the TAA with prior arthrodesis cohort. Conclusion: Patients undergoing TAA and hindfoot arthrodesis concurrently were found to have higher rates of reoperation and infection when compared to the matched control cohort. In contrast, there was no difference in these rates in patients undergoing TAA with prior hindfoot arthrodesis compared with their matched control cohort. Patients undergoing simultaneous procedures had increased rates of reoperations, wound complications, infection, and emergency department visits compared to the TAA with prior arthrodesis cohort. [ABSTRACT FROM AUTHOR]

Background: Although intraoperative ankle motion serves as a foundational reference for anticipated motion after surgery and guides the addition of procedures to enhance ankle motion in total ankle arthroplasty (TAA), the relationship between intraoperative and postoperative ankle motion remains unclear. This study aimed to investigate the discrepancy between intraoperative and postoperative ankle range of motion (ROM) following TAAs using the anterior-approach, fixed-bearing systems. Methods: This study retrospectively reviewed 67 patients (67 ankles) who underwent primary TAA at a single institution. Three different types of anterior-approach, fixed-bearing TAA systems were included. Intraoperative fluoroscopy was used to document the maximal dorsiflexion and plantar flexion at the end of the case. Standardized weightbearing maximum dorsiflexion and plantar flexion sagittal radiographs were obtained pre- and postoperatively, following a previously described method. The motion between 3 different time points (preoperative, intraoperative, and postoperative [mean 11.4 months]) was compared using pairwise t tests, and their differences were quantified. Results: The mean total tibiotalar ROM was 38.1 degrees (SD 7.8) intraoperatively, and the postoperative total tibiotalar ROM was 24.2 degrees (SD 9.7) (P <.001), indicating that a mean of 65.3% (SD 26.7) of the intraoperative motion was maintained postoperatively. Intraoperative dorsiflexion (mean 11.6 [SD 4.5] degrees) showed no evidence of difference from postoperative dorsiflexion (mean 11.4 [SD 5.8] degrees, P >.99), indicating that a median of 95.6% (interquartile range: 66.2-112) of the intraoperative maximum dorsiflexion was maintained postoperatively. However, there was a significant difference between intraoperative plantarflexion (mean 26.4 [SD 6.3]) and postoperative plantarflexion (12.8 [SD 6.9] degrees, P <.001), indicating a mean 50.6% (SD 29.6) of intraoperative motion maintained in the postoperative assessment. There was an improvement of 2.5 degrees in the total tibiotalar ROM following TAA with statistical significance (P <.043). Conclusion: This study revealed a significant difference between intraoperative ankle ROM and ankle ROM approximately 1 year after anterior-approach, fixed-bearing TAA, mainly due to plantarflexion motion restriction. Minimal difference in dorsiflexion suggests the importance of achieving the desired postoperative dorsiflexion motion during the surgery using the best possible adjunct procedures. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Background: Postoperative infection, aseptic loosening, and perioperative medical complications after total ankle arthroplasty (TAA) are all devastating problems. While previous studies have shown diabetes as a risk factor predisposing patients to postoperative complications, not all literature supports this association following TAA. The goal of this study is to determine if diabetes influences midterm outcomes following TAA. Methods: An insurance database was utilized to identify patients undergoing TAA for ankle arthritis with a concurrent diagnosis of diabetes based on Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10), diagnosis and procedure codes from 2010 to 2021. The postoperative outcomes of all-cause revision, periprosthetic joint infection (PJI), septic revision, and aseptic revision were compared between patients with and without diabetes with a minimum 2-year follow-up using Kaplan-Meier and multivariate Cox proportional hazards analyses. Patient demographics, comorbidities, and Charlson Comorbidity Index were analyzed via univariate and multivariate analysis. Results: The study population included 8317 patients, 345 (4.1%) of whom had a concurrent diabetes diagnosis, who underwent TAA. After multivariate Cox proportional hazards analysis, the 5-year cumulative incidence of being coded as having PJI was 7.3% in patients with known diabetes compared to 3.9% in patients without known diabetes, with a 95% increased risk (hazard ratio [HR] 1.95, 95% CI 1.15-3.30, P =.01). Patients with diabetes also demonstrated a 5-year cumulative incidence of septic revision of 1.4% compared to 0.4% in those without, with a 363% increased risk (HR 4.63, 95% CI 1.22-17.52, P =.02). However, there was no difference in the 5-year cumulative incidence of all-cause revision TAA with 4.6% in patients with diabetes and 4.3% in those without (HR 1.29, 95% CI 0.69-2.44, P =.42) Conclusion: In this database, the 5-year risk of PJI and septic revision was higher among patients with diabetes compared to those without, but cumulative incidence of all-cause revision TAA was not different between groups. Level of Evidence: Level III, retrospective cohort database study. [ABSTRACT FROM AUTHOR]

Background: Ankle arthritis differs from arthritis of the hip and knee in that 80% is posttraumatic and thus often occurs in a younger patient population. The literature supporting total ankle arthroplasty (TAA) in younger patients has increased over recent years and has bolstered the argument that in the short term, TAA in younger patients has successful outcomes that are comparable to older, lower-demand patients. The purpose of our study was to evaluate patient-reported outcomes (PROs) and implant survivorship at midterm after primary TAA in patients ≤ 50 years of age at the time of surgery. Methods: A retrospective chart review was conducted of patients ≤ 50 years of age who underwent primary TAA at a single institution from 2000 to 2017. Patient demographics, outcome measures, and complications were recorded. All patients had a minimum clinical follow-up of 5 years. PRO measures were evaluated at preoperative, 1-year postoperative, and final follow-up visits. Paired t tests were performed to compare individual patient changes in PROs from preoperative. Implant survivorship was evaluated based on need for revision of either the tibial or talar component. The need for additional surgery related to the TAA was also evaluated. Results: A total of 58 patients were included. The average age at the time of the index surgery was 43.3 years (range 22-50 years). All patients had a minimum follow-up of 5 years with a mean follow-up of 8.8 years. A total of 11 patients required additional surgery related to their TAA. Six patients (10.3%) required bone grafting of peri-implant cysts, 3 patients (5.2 %) required gutter debridement, and 1 patient underwent complete revision of metal components. Mean visual analog scale, 36-item Short Form Health Survey, Short Musculoskeletal Function Assessment, and American Orthopaedic Foot & Ankle Society hindfoot scores significantly improved from preoperative to 1-year postoperative and final postoperative follow-up. Conclusion: The patients aged ≤50 years treated with a TAA whom we have been able to observe for a minimum of 5 years showed generally maintained improvement in functional scores and thus far have had a relatively low rate of secondary surgeries. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Background: The INFINITY total ankle implant is a widely and successfully used option for total ankle arthroplasty. The purpose of this study is to assess the 2-year survivorship, complication rates, patient-reported outcomes, and radiologic findings of prospectively enrolled patients undergoing a fixed-bearing total ankle arthroplasty (TAA). This study sought to determine if factors such as traditional vs patient-specific instrumentation, preoperative degree of arthritis, deformity, or etiology of arthritis impact surgical or clinical outcomes. Methods: A total of 143 prospectively enrolled patients (148 ankles) underwent TAA with a fixed-bearing total ankle implant between 2017 and 2019 at 9 different institutions by 9 different surgeons. A total of 116 completed 2-year follow-up. Patients were stratified by instrumentation used, degree of preoperative deformity, the Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system, and etiology of arthritis. Outcomes used included implant survivorship and adverse events within 2 years of surgery. Additionally, patient-reported outcomes and radiographs were collected at 6-month, 1-year, and 2-year postoperatively. PROMs used included Ankle Osteoarthritis Score (AOS), Patient-Reported Outcomes Measurement Information System (PROMIS) global health score, the Foot and Ankle Outcome Score (FAOS), and patient satisfaction (rated from excellent to poor). Results: Implant survivorship at 2 years was 97.79%. There were 17 reoperations (11.5%), with 4 of the implants requiring revision (2.7%). Significant improvements in all PROMs were observed among all subgroups at all postoperative time points without significant variation between subgroups. Patients classified as COFAS type 2 arthritis preoperatively demonstrated significantly more improvement in FAOS Total Symptom Score at the 1- and 2-year measurements than COFAS type 3 patients at both time points. Conclusion: Total ankle arthroplasty with a fixed-bearing implant system is a safe and reliable treatment option for patients with end-stage arthritis regardless of degree of deformity or COFAS grading. Level of Evidence: Level II, prospective cohort study. [ABSTRACT FROM AUTHOR]

Background: As the number of total ankle arthroplasties (TAAs) performed annually increases, there is increased demand for modular revision implants. There is limited early survivorship and clinical outcome data for the INVISION Total Ankle Arthroplasty System (Wright Medical Technology/Stryker). This study aims to determine early implant survivorship, complications, and radiographic and patient-reported outcomes (PROs) of the INVISION implant in the revision setting. Methods: This is a single-institution retrospective review of adult patients who underwent revision TAA with the INVISION implant with minimum 2-year follow-up. Demographics, complications, radiographic data, and PROs (PROMIS) were collected. The primary outcome was implant survivorship. Secondary outcomes were reoperation, radiographic complications, and PROs. Results: Nineteen patients underwent revision INVISION TAA with mean follow-up of 3.5 years. INVISION revision TAA was used for tibial (n = 6) or talar (n = 7) component subsidence, recurrent tibiotalar malalignment (valgus = 1, varus = 3), and postinfection bone loss (n = 2). Two-year implant survivorship was 100%. There were no reoperations. One patient had lucency of the talar component at 6 months post TAA revision with INVISION. One patient had talar subsidence at final follow-up. Two-year postoperative follow-up PROMIS domains improved significantly (P <.05). Conclusion: There was excellent short-term survivorship of the INVISION TAA implant, with no failures. There were significant improvements in PROs and low rates of subsidence and lucencies. The results of this study support using the INVISION implant in the revision TAA setting. Level of Evidence: Level III, retrospective cohort. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The effect of tibiotalar joint line level (TTJL) on patient outcomes following total ankle arthroplasty (TAA) remains unclear. It was previously reported that patients with end-stage ankle arthritis have an elevated TTJL compared with nonarthritic ankles, and the TTJL post-TAA remains elevated compared with nonarthritic ankles. The objectives of this study were to (1) propose a reliable radiographic method to measure the TTJL absolute value and (2) determine the effect of TTJL alterations on tibiotalar range of motion (ROM) following TAA. Methods: A retrospective review was performed on patients who underwent TAA between January 2018 and April 2021 with a minimum of 1-year postoperative follow-up and complete perioperative ROM radiographs. Radiographic TTJL and ROM measurements were performed by 2 observers. The proposed TTJL measuring technique computes 4 measurements: high, low, center of the talus (center), and center of the axis (axis). Reliability of measurements and correlation between TTJL measurements and ROM were assessed. Results: A total of 33 patients were included. Postoperatively, 22 patients had a lowered TTJL compared to 11 patients with an elevated TTJL (2.2 ± 1.3 mm lowered vs 1.9 ± 1.2 mm elevated; P <.0001). Of the 4 TTJL measurements, 3 (low, center, axis) demonstrated a significant positive correlation between lowering the TTJL and improved tibiotalar dorsiflexion and 2 (low, axis) for total ROM (all P <.05). Plantarflexion was not significantly affected by TTJL alterations. Compared to patients with an elevated TTJL, patients with a lowered TTJL had improved tibiotalar dorsiflexion (8.8 vs 2.5 degrees; P =.0015) and total ROM (31.0 vs 22.9 degrees; P =.0191), respectively. The interrater reliability was nearly perfect (intraclass correlation r = 0.96-0.99). Conclusion: In this small series, we found that lowering the TTJL level may more closely reestablish the native TTJL and correlates with improved tibiotalar dorsiflexion and total ROM following TAA. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Background: Ankle arthritis leads to an elevated joint line compared to the nonarthritic ankle, as measured by the "joint line height ratio" (JLHR). Previous work has shown that the JLHR may remain elevated after total ankle arthroplasty (TAA). However, the clinical impact of this has yet to be determined. This study assessed the correlation between postoperative JLHR, post-TAA range of motion (ROM), and 1-year Patient-Reported Outcome Measurement Information System (PROMIS) scores. Methods: A retrospective review of 150 patients who underwent primary TAA was performed. Preoperative and postoperative JLHR, as well as postoperative dorsiflexion, plantarflexion, and total ROM, was calculated on weightbearing radiographs at a minimum of 1-year follow-up. Correlation between JLHR, post-TAA ROM, and 1-year PROMIS scores was investigated using Pearson correlation and multiple linear regression models. Interobserver reliability for the JLHR was also calculated. Results: Interobserver reliability for the JLHR was excellent (r = 0.98). Mean (SD) JLHR changed from 1.66 (0.45) to 1.55 (0.26) after TAA (P <.001), indicating that the joint line was lowered after TAA. An elevated joint line was correlated with decreased post-TAA dorsiflexion (r = −0.26, P <.001), total ROM (r = −0.18, P =.025), and worse 1-year PROMIS physical function (r = −0.22, P =.046), pain intensity (r = 0.22, P =.042), and pain interference (r = 0.29, P =.007). There was no correlation between the JLHR and post-TAA plantarflexion (r = −0.025, P =.76). Regression analysis identified a 0.5-degree reduction in post-TAA dorsiflexion with each 0.1-unit increase in JLHR (Coeff. = −5.13, P =.005). Conclusion: In this patient cohort, we found that an elevated joint line modestly correlated with decreased postoperative dorsiflexion, total ROM, and worse 1-year PROMIS scores. These data suggest that effort likely should be made toward restoring the native joint line at the time of TAA. In addition, future studies investigating the clinical outcomes after TAA may consider including a measure of joint line height, such as the JLHR, because we found it was associated with patient-reported outcomes. Level of Evidence: Level III, retrospective review of prospectively collected data. [ABSTRACT FROM AUTHOR]

Background: Total ankle arthroplasty (TAA) continues to be investigated as a primary treatment for end-stage ankle arthritis. The objective of this study is to report mid- to long-term results of the Salto Talaris TAA using prospectively collected patient-reported outcomes and implant survival rates with 4- to 13-year follow-up. Methods: This was a retrospective study of prospectively collected data from 2 multicenter cohort studies from 3 centers. Three hundred fourteen subjects who received a Salto Talaris TAA from 2005 to 2015 were included in the study. Follow-up ranged 4-13 years following index procedure. Outcomes included 36-Item Short Form Health Survey (SF-36) mental and physical component summary scores, pain scores, and adverse events including additional surgeries, revision, or removal of components. Results: Significant improvements were seen in pain and physical function scores at 2-year follow-up and were generally maintained through most recent follow-up. The survival rate of the prosthesis was >95% (n = 30/32 at >10 years, n = 272/282 at 4.5-10 years). Thirteen patients (4.1%) underwent revision or removal of their prosthesis. Time to revision ranged from 2 months to 6.5 years following the index procedure. Twenty-two patients (7.0%) had additional surgery that did not involve revision or removal of components. Conclusion: Treatment of end-stage ankle arthritis with this implant provided patients with improved pain and functional outcome scores at mid- to long-term follow-up. The significant improvements reported at 2-4 years appeared to endure through the extended follow-up period. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Background: The Infinity Total Ankle Arthroplasty (Stryker, Mahwah, NJ) is a low-profile fixed-bearing implant first introduced in 2014. Although the short-term survivorship (2-4 years follow-up) and complication rates of the Infinity TAA have been reported, there are limited midterm outcome reports. The aim of this study was to describe the survivorship and clinical outcomes of a single-center experience with the Infinity implant at minimum 5-year follow-up. Methods: Retrospective review of 65 ankles that underwent primary total ankle arthroplasty (TAA) with the Infinity implant was conducted. Mean clinical follow-up was 6.5 years (range, 5.0-8.0). Preoperative and postoperative radiographs were measured to assess tibiotalar alignment, periprosthetic lucencies, and cysts. Preoperative, 2-year, and 5-year postoperative Foot and Ankle Outcome Score (FAOS) subscores were compared to assess midterm clinical outcomes. Survivorship assessment was determined by removal of 1 or both metallic implant components. Results: Survivorship of the implant was 93.8% at final follow-up. There were 4 revisions: 2 for tibial implant loosening, 1 for talar loosening, and 1 for loosening of both components. Three of the 4 revisions occurred within the first 2 years following implantation, and the last failure occurred at 7 years postoperatively. There were 11 reoperations in 10 (15%) ankles and 3 wound complications. There were 17 ankles (26.2%) with radiographic abnormalities around the implants, including 14 cases with tibial component lucencies and 4 cases of periimplant cysts. FAOS outcome measurement showed general stability between 2 and 5 years and substantial improvement from preoperative status. Conclusion: To date this study is the largest midterm report on the Infinity total ankle prosthesis, with 65 implants at a mean follow-up of 6.5 years. We found good midterm implant survivorship, and patients experienced significant improvements in FAOS outcome scores and radiographic alignment at final follow-up. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Total ankle arthroplasty (TAA) is a preferred surgical option for end-stage ankle osteoarthritis; however, it is a demanding procedure with a higher historical rate of revision compared with ankle fusion. Patient-specific instrumentation (PSI) has been introduced to optimize prosthesis alignment and theoretically overall improve TAA outcomes. The goal of this study is to report on the experience and surgical outcomes of one implant with specific evaluation of the accuracy and reproducibility of the system with respect to prosthesis alignment and prediction of implant size. Methods: A retrospective, multicentered study involving 4 foot and ankle fellowship–trained orthopaedic surgeon's patients undergoing TAA between January 1, 2015, and December 31, 2018, using the PROPHECY PSI system. Results: 80 TAA procedures were performed. On average the postoperative tibial component alignment was 89.9 (range, 86.1-96.5) degrees in the coronal plane, with a mean sagittal alignment of 88.1 (range, 81.3-96.7) degrees. The mean deviation from neutral sagittal alignment improved from 4.9 ± 3.9 degrees preoperatively to 2.7 ± 1.7 degrees postoperatively, whereas the mean coronal alignment improved from 3.3 ± 2.5 degrees to 1.3 ± 1.1 degrees. The PSI software correctly determined the tibial implant size in 70 patients (89%). Prediction of talar implant sizing was less accurate than the tibial component, with 56 patients (71%) using the predicted sized implant. The overall implant survival at a mean follow-up of 45 months (range, 27-76) was 97.5%. Conclusion: We found that this PSI system accurately and reliably assisted in implant total ankle prosthesis positioning within a clinically acceptable margin and without significant outliers. Prediction of implant size was not as accurate as component orientation. Level of Evidence: Level III, retrospective study. [ABSTRACT FROM AUTHOR]

Background: Previous studies have examined the effect of concomitant triceps surae lengthening on ankle dorsiflexion motion at the time of total ankle arthroplasty (TAA). As plantarflexor muscle-tendon structures are important for producing positive ankle work during the propulsive phase of gait, caution should be exercised when lengthening triceps surae, as it may decrease plantarflexion strength. In order to develop an understanding of the work of the anatomical structures crossing the ankle during propulsion, joint work must be measured. The aim of this explorative study was to assess the effect of concomitant triceps surae lengthening with TAA on the resultant ankle joint work. Methods: Thirty-three patients were recruited to the study and divided into 3 groups of 11. The first group underwent both triceps surae lengthening (Strayer and TendoAchilles) and TAA (Achilles group), the second group underwent only TAA (Non-Achilles group), and the third group underwent only TAA, but had a greater radiographic prosthesis range of motion (Control group) compared to the first 2 groups. The 3 groups were matched in terms of demographic variables and walking speed. All patients underwent a 3D gait analysis 1 year after surgery to measure intersegmental joint work using a 4-segmented kinetic foot model. An analysis of variance (ANOVA) or Kruskal-Wallis test was used to compare the 3 groups. Results: The ANOVA showed significant differences between the 3 groups. Post hoc analyses suggested that (1) the Achilles group had less positive work at the ankle joint than the Non-Achilles and Control groups; (2) the Achilles group produced less positive work performed by all foot and ankle joints than the Control group; and (3) the Achilles and Non-Achilles groups absorbed less energy across all foot and ankle joints during the stance phase than the Control group. Conclusion: Concomitant triceps surae lengthening in TAA may reduce the positive work at the ankle joint. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Background: The current reference standard for postoperative evaluation of total ankle arthroplasty (TAA) positioning, weightbearing radiography (WBXR), is subject to technical bias. Weightbearing cone beam computed tomography (WBCT) enables visualization of the foot's complex 3-dimensional (3D) structure under standing load. To date, no WBCT-based system for TAA positioning has been validated. The purpose of this study was to (1) assess TAA positioning using WBCT 3D models and (2) evaluate the agreement levels between 2 raters and thus evaluate the intermethod reliability with respect to WBXR. Methods: Fifty-five consecutive patients were retrospectively reviewed. Two raters independently created a 3D WBCT model using dedicated software and recorded the following measurements: α angle, tibiotalar surface angle (TSA), hindfoot angle (HFA), tibiotalar ratio (TTR), β angle, γ angle, and Φ angle. Measurements were repeated 2 months apart in similar, independent fashion and compared to WBXR. Interobserver, intraobserver, and intermethod agreements were calculated. Results: All 7 measurements showed good to excellent intraobserver and interobserver reliability (ICC 0.85-0.95). The intermethod (WBCT vs WBXR) agreement showed good agreement for the γ angle (ICC 0.79); moderate agreement levels for the α angle, TSA angle, β angle, and TTR (ICC 0.68, 0.69, 0.70, and 0.69, respectively); poor agreement for the HFA (ICC 0.25); and negative agreement for the φ angle (ICC −0.2). Conclusion: Position analysis of TAA using WBCT demonstrated good to excellent interobserver and intraobserver agreement and can be reliably used. Additionally, a negative to moderate agreement between standard WBCT and standard WBXR was found. Level of Evidence: Level III, retrospective study. [ABSTRACT FROM AUTHOR]

Background: There is limited literature comparing the publications on ankle arthrodesis (AA) and total ankle arthroplasty (TAA) in the setting of hemophilic arthropathy. Our objective is to systematically review the existing literature and to assess ankle arthroplasty as an alternative to ankle arthrodesis in this patient population. Methods: This systematic review was conducted and presented according to the PRISMA statement standards. A search was conducted on March 7-10, 2023, using MEDLINE (via PubMed), Embase, Scopus, ClinicalTrials.gov, CINAHL Plus with Full Text, and the Cochrane Central Register of Controlled Studies. This search was restricted to full-text human studies published in English, and articles were screened by 2 masked reviewers. Systematic reviews, case reports with less than 3 subjects, letters to the editor, and conference abstracts were excluded. Two independent reviewers rated study quality using the MINORS tool. Results: Twenty-one of 1226 studies were included in this review. Thirteen articles reviewed the outcomes associated with AA in hemophilic arthropathy whereas 10 reviewed the outcomes associated with TAA. Two of our studies were comparative and reviewed the outcomes of both AA and TAA. Additionally, 3 included studies were prospective. Studies showed that the degree of improvement in American Orthopaedic Foot & Ankle Society hindfoot-ankle score, visual analog scale pain scores, and the mental and physical component summary scores of the 36-Item Short Form Health Survey were similar for both surgeries. Complication rates were also similar between the 2 surgeries. Additionally, studies showed a significant improvement in ROM after TAA. Conclusion: Although the level of evidence in this review varies and results should be interpreted with caution, the current literature suggests similar clinical outcomes and complication rates between TAA and AA in this patient population. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: It is unknown whether perioperative bisphosphonate (BP) use reduces revision rates in total ankle replacement arthroplasty (TAR) although its effect has been demonstrated to be effective in reducing revision rates in total knee or hip replacement arthroplasty. Methods: We reviewed National Health Insurance Service data based on national health insurance service claims data and health care utilization, health screening, sociodemographic variables, medication history, operation codes, and mortality data for 50 million Koreans. From 2002 to 2014, 6391 of 7300 patients who underwent TAR were BP nonusers, whereas 909 patients were BP users. The revision rate according to BP medication and comorbidities was investigated. The Kaplan-Meier estimate and extended Cox proportional hazard model were also used. Results: The revision rate of TAR was 7.9% for BP users and 9.5% for BP nonusers, which showed no significant difference (P =.251). Implant survival over time decreased constantly. Adjusted hazard ratio for hypertension was 1.242 (P =.017), whereas other comorbidities such as diabetes had no effect on the revision rate of TAR. Conclusion: We found that the perioperative BP use did not reduce the revision rate of TAR. Comorbidities (except hypertension) did not affect the revision rate of TAR. More research regarding various factors affecting the revision of TAR could be warranted. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Background: The number of total ankle arthroplasty (TAA) procedures increased rapidly in the last years and so have its complications. The main pillars in treating failed TAA are revision total ankle arthroplasty (RTAA), revision total ankle arthrodesis (RAA), or revision tibiotalocalcaneal fusion (RTTC). To evaluate these options, we compared clinical, radiologic, and patient-reported outcomes. Methods: A single-center, retrospective review of 111 cases of revision procedures of failed TAA from 2006 to 2020 was performed. Patients undergoing polyethylene exchange and revision of one metallic component were excluded. Demographic data, failure, and survival rates were analyzed. The European Foot and Ankle Society (EFAS) score and radiographic changes in the subtalar joint were evaluated. The average follow-up was 67.89 ± 40.51 months. Results: One hundred eleven patients underwent removal of TAA. The procedures included 40 revisions of both metallic components, 46 revision total ankle arthrodesis and 25 revision tibiotalocalcaneal fusion. The overall failure rate in the cohort was 5.41% (6/111). The failure rate after RAA was 4.35 times higher than that of RTAA, whereas RTTC did not show failures. RTAA and RTTC lead to a 1-year and 5-year survival rate of 100%. RAA resulted in a 1-year survival rate of 90% and a 5-year survival rate of 85%. The mean EFAS score in the cohort was 12.02 ± 5.83. Analysis of the EFAS score showed that RTTC provided the most reliable pain reduction, and RTAA achieved the best gait pattern. RAA resulted in poorer clinical results. Subtalar joint degeneration occurred significantly less in the RTAA group (P =.01). Conclusion: This retrospective study suggests lower failure rates, increased short-term survival and a better clinical outcomes of revision arthroplasty and tibiotalocalcaneal fusion than ankle arthrodesis. Revision arthroplasty is a promising solution in treating failed total ankle arthroplasty considering lower rate of subsequent adjacent joint degeneration. Level of Evidence: Level III, non-randomized observational study. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Total ankle arthroplasty through the anterior approach (TAR-AA) is an increasingly popular treatment for ankle arthritis, but it carries a known risk for wound complications. Several products have been investigated to mitigate this risk; however, most are either costly or invasive. Noninvasive skin expansion strips (NSESs) were designed to transfer tension away from the incision and induce new skin growth at the edges of the strips. We hypothesize that postoperative application of NSESs will decrease unplanned clinic visits and wound complications after TAR-AA. Methods: This is a prospective cohort study of 41 patients at a single institution (3 surgeons) treated with NSESs after undergoing TAR-AA. An additional 41 consecutive historical patients treated without NSESs were retrospectively included as a control group. Patients received application of NSESs in the operating room after routine wound closure and again 2 weeks postoperatively. No other changes were made to the surgeons' wound closure technique, immobilization, follow-up timing, or rehabilitation protocols. Primary outcomes included (1) additional clinic visit required for wound assessment or suture removal, (2) superficial wound complication, and (3) deep infection. Results: Baseline demographics did not differ significantly from our 41 consecutively treated historical controls. Additional clinic visits for suture removal or wound evaluation were significantly lower for patients treated with NSESs (15%, 6 of 41) compared to the control group (49%, 20 of 41) (P =.001). There was also a significant difference in the superficial wound complication rate in the treatment group vs control group, 2% and 12%, respectively (P =.04). There were no deep infections in either group. Conclusion: Noninvasive skin expansion strips placed after TAR-AA with an anterior approach have the potential to decrease wound complications and unplanned clinic visits. Further high-volume or randomized studies are needed to clarify their cost effectiveness and effect on long-term outcomes. Level of Evidence: Level II, prospective cohort study. [ABSTRACT FROM AUTHOR]

Background: Ankle arthrodesis has been the mainstay treatment for end-stage ankle arthritis. The popularity of total ankle arthroplasty (TAA) has been on the rise due to improved implant design and postoperative outcomes. The purpose of this study was to describe the basic epidemiology and trends of annual procedure volumes and incidence in the general American population as well as in different population subgroups from 2009 to 2019. We hypothesize that the incidence of TAA has significantly risen while the median length of hospital stay has decreased nationwide. Methods: The IBM MarketScan database was queried for patients who underwent TAA from January 2009 to December 2019 based on Current Procedural Terminology coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of TAA. Procedural volume and incidence were calculated for annual sums, gender, age subgroups, inpatient and outpatient TAA, as well as in four statistical geographic regions in the United States. Median length of hospital stay was calculated and trended annually for inpatient TAA. Results: A total of 41,060 primary TAAs were identified in the database from 2009 to 2019, in which 52.5% were performed in males. Annual volumes increased by 136.1%, from 2180 to 5147 procedures nationwide. Incidence reported per 100 000 population increased by 120.8%. Both inpatient and outpatient procedures have increased, by 242.5% and 86.6%, respectively. Median length of hospital stay decreased from 3 days in 2009 to 1 day in 2019 and did not differ between genders. Growth in incidence was demonstrated in males and females above the age of 54 years with the largest growth in annual incidence found between 65 and 74 years. Incidence rose in the South and West of the United States by 111.8% and 136.5%, respectively. Conclusion: We found that annual volumes and incidence rates of primary TAA has increased between 2009 and 2019. Although both inpatient and outpatient surgery have become more frequent, inpatient volumes and incidence have increased almost 3 times more than those of outpatient surgery. Length of hospital stay decreased over the study years. When adjusted for the same study period, the cumulative annual growth rates of TAA were found to be 2 times greater than total knee arthroplasty and 3.6 times greater than total hip arthroplasty. Level of Evidence: Level III, retrospective database review. [ABSTRACT FROM AUTHOR]

Background: The Cadence Total Ankle System is a 2-component, fixed-bearing fourth-generation total ankle arthroplasty (TAA) system that was introduced for clinical use in 2016. The purpose of this study was to report non–inventor, non–industry funded survivorship, radiographic and clinical outcomes, and early complications following use of this implant at a minimum of 2 years. Methods: This single-center retrospective study included patients who underwent TAA by 2 surgeons with this novel fixed-bearing system between January 2017 and September 2018. Forty-eight patients were evaluated at an average of 33.6 months. Radiographic outcomes included preoperative and postoperative tibiotalar angle on anteroposterior radiographs of the ankle, sagittal tibial angle (STA) on lateral radiographs of the ankle, and periprosthetic lucency formation and location. Revision and reoperation data were collected, and patient-reported outcomes were assessed using Patient Reported Outcomes Measurement Information System (PROMIS). Subgroup analysis assessed associations between preoperative deformity, postoperative implant alignment, PROMIS scores, and periprosthetic lucency formation. Results: Survivorship of implant was 93.7%, with 3 revisions, 1 due to infection and 2 due to loosening of the implant (1 tibial and 1 talar component). Three patients had reoperations (6.3%): 2 for superficial infection and 1 for gutter debridement due to medial gutter impingement. Fifteen patients (35.8%) developed periprosthetic lucencies, all on the tibial side. PROMIS scores improved after surgery in all domains except Depression. Patients with significant postoperative periprosthetic lucency had worse postoperative PROMIS Physical function scores than patients without lucency (P <.05). Conclusion: This study demonstrated excellent minimum 2-year clinical and radiographic outcomes and low revision and reoperation rates of this new fourth-generation TAA system. Future studies with longer follow-up, especially on patients with periprosthetic lucency, are necessary to investigate the long-term complications and understand the long-term functional and radiographic outcomes of this implant. [ABSTRACT FROM AUTHOR]

Background: With ankle replacements gaining credibility, there is a small subset of patients who might benefit from a conversion of an ankle fusion to a replacement. The objective of this study is to present clinical and radiographic results of patients who had their ankle fusion converted to total ankle arthroplasty (TAA). Methods: Patients presented to the senior author with ongoing ankle pain following fusion or increasing pain after a period of relative comfort after an ankle fusion. Outcomes were evaluated preoperatively and postoperatively with the Veterans Rand Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS), and visual analog scale (VAS) pain scale. A patient satisfaction survey was also distributed. Results: All ankle fusion conversions between April 2010 and December 2019 were included. Fifty-one patients (30 females) with the mean age of 62.6 (range, 37-83) years were followed. Mean follow-up was 4.2±2.3 (range, 2-11.5) years. Two patients were lost to follow-up (1 is deceased). Pre- and postoperative mean patient-reported outcome scores were all significantly different between groups except VR-12 mental subscale scores. VR-12 physical scores improved from 28.7±8.9 preoperatively to 38.9±9.9 (P <.001) postoperatively; VR-12 mental score was stable. AOS pain and disability subscales similarly improved: 55.9±24.4 to 27.9±25.4 (P <.001) and 61.7±21.1 to 31.1±25.7 (P <.001), respectively. VAS pain improved from a mean of 64.5±27.3 to 29.4±27.7 (P <.001). There was no tibiotalar dorsiflexion or plantarflexion with the ankle fusion. Initial postoperative visit revealed that average dorsiflexion was 10.9±5.93 degrees and average plantarflexion was 14.1±5.22 degrees. At the latest follow-up, dorsiflexion improved significantly to 15.5±6.33 degrees (P <.001), with no significant improvement in plantarflexion (P =.980). Conclusion: In this single-surgeon longitudinal study of 51 patients with a painful, malaligned, or nonhealed ankle fusion treated with an ankle replacement, we found highly satisfactory functional outcomes at an average of 4.2 years. Continued long-term follow-up will reveal whether the longevity of these replacements is comparable to primary replacements. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study is to determine whether the use of closed suction drains after total ankle arthroplasty (TAA) is associated with lower wound complications in the first postoperative year as compared to no drain usage. Methods: A total of 324 TAA were reviewed and included for analysis. One hundred forty-four did not have a postoperative drain placed, whereas 180 did have a postoperative drain. Demographic data, including age, sex, tobacco or alcohol use, and various medical comorbidities, were obtained. Follow-up data were collected and reviewed at 2, 6, and 12 weeks; 6 months; and 1 year postoperatively for minor and major wound complications, as well as wound-related reoperations. Results: At the 2-week mark, the use of a drain demonstrated a significant increase in wound complications. No significant difference in wound complications was found at each subsequent follow-up visit. Within the first postoperative year, a total of 46 patients (31.9%) without drains and 69 patients (38.3%) with drains had a wound complication. This was not statistically significant. Most wound complications were minor, and no significant difference in reoperation rates occurred between the 2 groups. Conclusion: A postoperative closed suction drain may increase wound complications in the first 2 weeks after TAA and should therefore be used with caution. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing total ankle replacement (TAR) often have symptomatic adjacent joint arthritis and deformity. Subtalar arthrodesis can effectively address a degenerative and/or malaligned hindfoot, but there is concern that it places abnormal stresses on the TAR and adjacent joints of the foot, potentially leading to early TAR failure. This study hypothesized that ankle and talonavicular joint kinematics would be altered after subtalar arthrodesis in the setting of TAR. Methods: Thirteen mid-tibia cadaveric specimens with neutral alignment were tested in a robotic gait simulator. To simulate gait, each specimen was secured to a static mounting fixture about a 6-degree of freedom robotic platform, and a force plate moves relative to the stationary specimen based on standardized gait parameters. Specimens were tested sequentially in TAR and TAR with subtalar arthrodesis (TAR-STfuse). Kinematics and range of motion of the ankle and talonavicular joint were compared between TAR and TAR-STfuse. Results: There were significant differences in kinematics and range of motion between TAR and TAR-STfuse groups. At the ankle joint, TAR-STfuse had less internal rotation in early-mid stance (P <.05), with decreased range of motion in the sagittal (–2.7 degrees, P =.008) and axial (–1.8 degrees, P =.002) planes in early stance, and increased range of motion in the coronal plane in middle (+1.2 degrees, P <.001) and late (+2.5 degrees, P =.012) stance. At the talonavicular joint, there were significant differences in axial and coronal kinematics in early and late stance (P <.05). Subtalar arthrodesis resulted in significantly decreased talonavicular range of motion in all planes in early and late stance (P <.003). Conclusion: In ankles implanted with the TAR design used in this study, kinematics of the ankle and talonavicular joint were found to be altered after subtalar arthrodesis. Aberrant motion may reflect altered contact mechanics at the prosthesis and increased stress at the bone-implant interface, and affect the progression of adjacent joint arthritis in the talonavicular joint. Clinical Relevance: These findings may provide a correlate to clinical studies that have cited hindfoot arthrodesis as a risk factor for TAR failure. [ABSTRACT FROM AUTHOR]

Background: Existing literature on the superiority of patient-specific instrumentation (PSI) in total ankle arthroplasty (TAA) over standard referencing (SR) is limited. Advantages presented include better implant alignment, shorter operating times, and increased accuracy of implant size prediction. The aim of this retrospective study was to analyze PSI in the hands of an experienced foot and ankle surgeon new to both PSI and SR for this specific implant, in regard to determining implant alignment, operative times, and radiologic short-term outcome and predicting implant size for tibial and talar components. Methods: Twenty-four patients undergoing TAA using PSI were compared to 25 patients using SR instrumentation. Outcome measures included alignment of the tibial component (α coronal plane, γ sagittal plane), the tibiotalar tilt (β), and the talar offset x on the sagittal view as well as the presence of radiolucent lines, operation time, and wound healing. Postoperative outcome was assessed at 6 weeks, 4 months, and 1 year postoperatively. Results: Implant positioning was similar in both groups, and no advantage in regard to the operative time could be seen when comparing TAA using PSI to SR. Implant size prediction was more reliable for the tibia than for the talus. Three patients (1 from the SR group and 2 from the PSI group) showed radiolucent lines around the tibial component. Two patients (both SR group) suffered delayed wound healing, albeit not requiring any additional measures. Conclusion: The PSI method did not show an advantage over SR in regard to positioning of the components or the duration of the surgery. The current study suggests that no initial advantage of PSI over SR are to be expected in standard total ankle replacement. Level of Evidence: Level III, retrospective study. [ABSTRACT FROM AUTHOR]

Background: Periprosthetic cysts can occur in up to 95% of total ankle arthroplasties (TAA) and have been correlated with implant failure. The aim of this study was to determine the clinical and radiologic outcomes, using computed tomographic (CT) scan, after periprosthetic cyst bone grafting and assess for the minimum cyst size that should be grafted. Methods: A retrospective review was performed of all TAA procedures performed between 2007 and 2014 (n=93). A CT scan was done to assess cyst size and operative planning. Eight patients with 9 periprosthetic cysts larger than 1.75 cm3 were grafted and specimens sent for histology. The mean time to bone grafting was 7.3 (3.8-9.5) years. Functional outcome was assessed using the American Orthopaedic Foot & Ankle Society ankle score, visual analog scale, and Self-reported Foot and Ankle Score. A CT scan was performed at follow-up to assess graft incorporation and cyst size progression. The mean time to CT scan post grafting was 3.0 (0.7-4.7) years. Results: There was no implant malalignment identified and no differences in the pre- and postoperative functional scores. Preoperatively cysts had a mean volume of 8.16 (2.04-14.03) cm3. The mean percentage incorporation was 89% (69%-100%). Eight of the grafted cysts were considered successful on CT, with the ninth having 69% incorporation. Five cysts were not grafted, as they were below 1.75 cm3, and remained the same size or had minimal enlargement. Conclusion: The satisfactory results in this small cohort suggests that prophylactic bone grafting may extend implant survival. We recommend that periprosthetic cysts greater than 1.75 cm3 be prophylactically bone grafted, and that cysts smaller than 1.75 cm3 be monitored for progression in size. Level of Evidence: Level IV, Case Series. [ABSTRACT FROM AUTHOR]

Background: Total ankle arthroplasty (TAA) is an increasingly popular option for the operative treatment of ankle arthritis. The Cadence TAA entered clinical use in 2016 and was designed to address common failure modes of prior systems. We report early complications and radiographic and clinical outcomes of this total ankle system at a minimum of 2 years of follow-up. Methods: We performed a retrospective review of a consecutive cohort of patients undergoing primary Cadence TAA by a single surgeon from 2016 to 2017. Complications and reoperations were documented using the American Orthopaedic Foot & Ankle Society (AOFAS) TAA reoperation coding system. Patients completed the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sport subscales, SF-12 Mental (MCS) and Physical (PCS) Component Summaries, and visual analog scale (VAS) pain rating (0-100). Radiographic evaluation was performed to assess postoperative range of motion (ROM) of the sole of the foot relative to the long axis of the tibia, alignment, and implant complications. Results: Fifty-eight patients with a mean age of 63.3 years and mean body mass index of 31.9 kg/m2 were included. Twelve of 58 patients (20.7%) underwent an additional procedure(s) within 2 years, including 3 (5.2%) who required removal of one or both components, 2 for infection and 1 for osteolysis. Forty-three patients were followed for a minimum of 2 years with radiographic imaging; 1 patient's (2.3%) radiographs had signs of peri-implant osteolysis, with no cases demonstrating loosening or subsidence. FAAM-ADL, FAAM-Sport, SF-12 PCS, and VAS pain scores all improved at a mean of 27.4 months postoperatively, with mean score changes (± SD) of 16.3 (± 22.0), 25.3 (± 24.5), 6.0 (± 11.1), and −32.3 (± 39.8), respectively. Radiographic analysis revealed that average coronal alignment improved from 6.9 degrees from neutral preoperatively to 2.3 degrees postoperatively. The average ROM of the foot relative to the tibia was 36.5 degrees total arc of motion based on lateral radiographs. Conclusion: Early experience with this 2-component total ankle replacement was associated with a high component retention rate, improved coronal plane alignment, good postoperative ROM, radiographically stable implants, and improved patient function. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Background: While anemia has been associated with poor surgical outcomes in total knee arthroplasty and total hip arthroplasty, the effects of anemia on total ankle arthroplasty remain unknown. This study examines how preoperative anemia affects postoperative outcomes in total ankle arthroplasty. Methods: A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from 2011 to 2018 for total ankle arthroplasty procedures. Hematocrit (HCT) levels were used to determine preoperative anemia. Results: Of the 1028 patients included in this study, 114 patients were found to be anemic. Univariate analysis demonstrated anemia was significantly associated with an increased average hospital length of stay (2.2 vs 1.8 days, P <.008), increased rate of 30-day readmission (3.5% vs 1.1%, P =.036), increased 30-day reoperation (2.6% vs 0.4%, P =.007), extended length of stay (64% vs 49.9%, P =.004), wound complication (1.75% vs 0.11%, P =.002), and surgical site infection (2.6% vs 0.6%, P =.017). Multivariate logistic regression analysis found anemia to be significantly associated with extended hospital length of stay (odds ratio [OR], 1.62; 95% CI, 1.07-2.45; P =.023) and increased reoperation rates (OR, 5.47; 95% CI, 1.15-26.00; P =.033). Anemia was not found to be a predictor of increased readmission rates (OR, 3.13; 95% CI, 0.93-10.56; P =.066) or postoperative complications (OR, 1.27; 95% CI, 0.35-4.56; P =.71). Conclusion: This study found increasing severity of anemia to be associated with extended hospital length of stay and increased reoperation rates. Providers and patients should be aware of the increased risks of total ankle arthroplasty with preoperative anemia. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

The number of total ankle replacements (TARs) performed in the United States has dramatically increased in the past 2 decades due to improvements in implant design and surgical technique. Yet as the prevalence of TAR increases, so does the likelihood of encountering complications and the need for further surgery. Patients with new-onset or persistent pain after TAR should be approached systematically to identify the cause: infection, fracture, loosening/subsidence, cysts/osteolysis, impingement, and nerve injury. The alignment of the foot and ankle must also be reassessed, as malalignment or adjacent joint pathology can contribute to pain and failure of the implant. Novel advanced imaging techniques, including single-photon emission computed tomography and metal-subtraction magnetic resonance imaging, are useful and accurate in identifying pathology. After the foot and ankle have been evaluated, surgeons can also consider contributing factors such as pathology outside the foot/ankle (eg, in the knee or the spine). Treatment of the painful TAR is dependent on etiology and may include debridement, bone grafting, open reduction and internal fixation, realignment of the foot, revision of the implants, arthrodesis, nerve repair/reconstruction/transplantation surgery, or, in rare cases, below-knee amputation. Level of Evidence : Level V, expert opinion or review. [ABSTRACT FROM AUTHOR]

Background: Information regarding the effect of total ankle arthroplasty (TAA) on midfoot function is extremely limited. The purpose of this study was to characterize midfoot region motion and power during walking in people before and after TAA. Methods: This was a prospective cohort study of 19 patients with end-stage ankle arthritis who received a TAA and 19 healthy control group participants. A motion capture and force plate system was used to record sagittal and transverse plane first metatarsal and lateral forefoot with respect to hindfoot motion, as well as sagittal plane midfoot region positive and negative peak power during walking. Parametric or nonparametric tests to examine differences and equivalence across time were conducted. Comparisons to examine differences between postoperative TAA group and control group foot function were also performed. Results: Involved-limb midfoot function was not different between the preoperative and 6-month postoperative time point in the TAA group (all P ≥.17). Equivalence testing revealed similarity in all midfoot function variables across time (all P <.05). Decreased first metatarsal and lateral forefoot motion, as well as positive peak power generation, were noted in the TAA group postoperative involved limb in comparison to the control group (all P ≤.01). Conclusion: The similarity of midfoot function across time, along with differences in midfoot function in comparison to controls, suggests that TAA does not change midfoot deficits by 6 months postoperation. Level of Evidence: Level II, prospective cohort study. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to evaluate gender differences in patient outcomes and complications following total ankle replacement (TAR). Methods: Consecutive patients who underwent primary TAR from July 2007 through May 2016 were prospectively followed and retrospectively reviewed. Demographic, operative, patient-reported outcomes (PROs), and complication data were collected and analyzed. PROs included the visual analog scale (VAS), 36-Item Short-Form Health Survey (SF-36), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale, and Short Musculoskeletal Function Assessment (SMFA). A total of 475 patients were evaluated, including 248 males (52.2%) and 227 females (47.8%) with an average of 56.8 months follow-up. Results: Women were more likely to have inflammatory arthritis (13.7% vs 2.8%; P <.01) and significantly worse preoperative SF-36 total, SF-36 mental health component, AOFAS total, AOFAS pain, SMFA function, and SMFA bother scores (all P <.05). Both genders demonstrated significant improvement in PROs at 1, 2, and 5 years. The magnitude of improvement was similar between genders for all PROs (all P <.05) with the exception of SF-36 physical function, which was greater in men. Females underwent more nonrevision reoperations (32.2% vs 22.6%; P =.0191), but there was no significant difference in failure rates (male 7.3% vs female 3.5%; P =.07). The reoperation and failure rates at 2 years postoperation were 10.1% and 1.6% for men and 18.5% and 0.9% for women, respectively. Conclusion: Women undergoing TAR were more likely to have worse preoperative PROs and higher rates of nonrevision reoperations, which remains true when controlling for their increased incidence of inflammatory arthritis. However, women reported similar improvements in PROs and had similar prosthetic survival rates as men. Increased understanding of these disparities, combined with gender-based interventions, may further advance patient outcomes. Level of Evidence: Level III, therapeutic, retrospective comparative series [ABSTRACT FROM AUTHOR]

Background: Wound complications following total ankle arthroplasty (TAA) can have a significant impact on patient morbidity, particularly when they require flap coverage. We sought to determine the risk factors associated with the need for flap coverage after TAA and hypothesized that medical and operative risk factors such as diabetes and additional procedures would be associated with the need for flap coverage after TAA. Methods: We performed a single-center retrospective review of TAAs from April 2007 to February 2019. Patient demographics and medical comorbidities were collected, in addition to other procedures performed at the time of TAA. Patients were stratified by the need for flap coverage, and unadjusted inferential statistics were performed to evaluate the risk factors associated with subsequent need for flap coverage. Results: Among 2065 patients undergoing TAA, 28 (1.4%) patients required flap coverage after the index arthroplasty. Patients requiring flap coverage were older (P =.045), had higher Charlson comorbidity indices (P =.017), and had higher rates of diabetes and pulmonary disease (P =.038). Patients requiring flap coverage also had higher rates of additional procedures (P =.043, P =.007). The most common flap was a radial forearm free flap, which was performed in 14 (50%) patients. Twenty-one patients (75%) requiring flap coverage had a stable, plantigrade foot at median 1.5-year follow-up. Conclusion: Patient and operative risk factors, including advanced age, increased comorbidity burden, diabetes, pulmonary disease, and increased number of simultaneous procedures, were significantly associated with need for subsequent flap coverage. This should be considered as the indications for TAA expand. Level of Evidence: Level III, retrospective, prognostic cohort study. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to report on the radiographic outcomes, clinical outcomes, and implant survivorship following extramedullary-referenced (EMr) vs intramedullary-referenced (IMr) total ankle replacement (TAR). Methods: From May 2007 to February 2018, a consecutive series of patients with end-stage tibiotalar osteoarthritis undergoing TAR was enrolled in this study. Analyses were performed comparing IMr vs EMr components for patient-reported outcomes data, pre- and postoperative radiographic ankle alignment, concomitant procedures, and complications. Kaplan-Meier survivorship analyses served to determine implant reoperation and revision surgery. A total of 340 TARs were included with 105 IMr TAR and 235 EMr TAR. The mean follow-up was 5.3 years (±2.5, range 2-12). Results: The absolute value for preoperative coronal alignment was significantly greater for IMr compared to EMr TAR (13.0 vs 6.4 degrees; P <.0001), but both groups achieved near neutral alignment postoperatively (1.4 vs 1.5 degrees; P =.6655). The odds of having a concomitant procedure was 2.7 times higher in patients with an IMr TAR (OR 2.7, CI 1.7-4.4; P <.0001). There were similar improvements in patient-reported outcome scores at 1 year and final follow-up (all P >.05). The 5-year implant survivorship was 98.6% for IMr vs 97.5% for EMr at final follow-up. Conclusion: The IMr and EMr TAR components had comparable postoperative alignment, patient-reported outcome scores, and complications. The 5-year implant survivorship was similar between the IMr and EMr groups. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Background: Total ankle arthroplasty (TAA) is successful by both subjective patient-reported outcome measures (PROMs) and objective functional improvements of gait. Each is reproducible and valid, but they are entirely distinct methods. This study investigated the correlation between subjective and objective outcomes of TAA. Methods: Seventy patients underwent gait analysis preoperatively and 1 year after TAA. The 36-Item Short-Form Health Survey (SF-36) and visual analog score (VAS) for pain and American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scores were recorded at each interval. A Student t test, a multivariate regression, and a Pearson correlation coefficient were used to measure the correlation between parameters of gait and PROMs. Results: Patients had statistically significant improvements in gait velocity, total range of motion (ROM), maximum plantarflexion, ankle power, and SF-36 Physical, VAS, and AOFAS scores. The SF-36 Physical score had a moderate positive correlation with preoperative walking speed, step length, and ankle power and postoperative walking speed and ankle power. No correlation between VAS score and function was detected. The AOFAS score had a moderate positive correlation with postoperative walking speed, step length, and ankle power, and improvement in walking speed, cadence, and ankle power. Conclusion: Statistically significant correlations were found between numerous preoperative and postoperative comparisons of PROMs and the AOFAS score with the objective biomechanical outcomes of gait. Walking speed and ankle push-off power correlated most with patient perceptions of function and improvement, while pain and ROM did not. Subjective PROMs and objective biomechanical outcomes were complementary in the assessment of surgical outcomes and, combined, helped to address the dilemma of the confounding effect of other lower extremity pathologies on PROMs. Level of Evidence: Level III, comparative series. [ABSTRACT FROM AUTHOR]

Background: Total ankle arthroplasty (TAA) is advocated over ankle arthrodesis to preserve ankle motion (ROM). Clinical and gait analysis studies have shown significant improvement after TAA. The role and outcomes of TAA in stiff ankles, which have little motion to be preserved, has been the subject of limited investigation. This investigation evaluated the mid- to long-term functional outcomes of TAA in stiff ankles. Methods: A retrospective study of prospectively collected functional gait data in 33 TAA patients at a mean of 7.6 (5-13) years postoperatively used 1-way analysis of variance and multivariate regression analysis to compare among preoperative and postoperative demographic data (age, gender, body mass index, years postsurgery, and diagnosis) and gait parameters according to quartiles of preoperative sagittal ROM. Results: The stiffest ankles had a mean ROM of 7.8 degrees, compared to 14.3 degrees for the middle 2 quartiles, and 21.0 degrees for the most flexible ankles. Patients in the lowest quartile (Q1) also had statistically significantly lower step length, speed, max plantarflexion, and power preoperatively. Postoperatively, they increased step length, speed, max plantarflexion, and ankle power to levels comparable to patients with more flexible ankles preoperatively (Q2, Q3, and Q4). They had the greatest absolute and relative increases in these parameters of any group, but the final total ROM was still statistically significantly the lowest. Conclusion: Preoperative ROM was predictive of overall postoperative gait function at an average of 7.6 (range 5-13) years. Although greater preoperative sagittal ROM predicted greater postoperative ROM, the stiffest ankles showed the greatest percentage increase in ROM. Patients with the stiffest ankles had the greatest absolute and relative improvements in objective function after TAA, as measured by multiple gait parameters. At intermediate- to long-term follow-up, patients with stiff ankles maintained significant functional improvements after TAA. Level of Evidence: Level III, comparative study. [ABSTRACT FROM AUTHOR]

Background: Modern total ankle arthroplasty (TAA) prostheses are uncemented press-fit designs whose stability is dependent on bone ingrowth. Preoperative insufficient bone density reduces initial local stability at the bone-implant interface, and we hypothesized that this may play a role in periprosthetic osteolysis. We aimed to investigate the preoperative bone density of the distal tibia and talus and compare these in patients with and without osteolysis. Methods: We enrolled 209 patients (218 ankles) who underwent primary TAA using the HINTEGRA prosthesis. The overall mean follow-up duration was 66 (range, 24-161) months. The patients were allocated into 2 groups according to the presence of periprosthetic osteolysis: the osteolysis group (64 patients, 65 ankles) and nonosteolysis group (145 patients, 153 ankles). Between the 2 groups, we investigated and compared the radiographic outcomes, including the Hounsfield unit (HU) value around the ankle joint and the coronal plane alignment. Results: HU values of the tibia and talus measured at 5 mm from the reference points were higher than those at 10 mm in each group. However, comparing the osteolysis and nonosteolysis groups, we found no significant intergroup difference in HU value at every measured level in the tibia and talus (P >.05). Concerning the coronal plane alignment, there were no significant between-group differences in the tibiotalar and talar tilt angles (P >.05). Conclusion: Patients with osteolysis showed similar preoperative bone density of the distal tibia and talus compared with patients without osteolysis. Our results suggest that low bone density around the ankle joint may not be associated with increased development of osteolysis. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Background: In patients with end-stage varus ankle osteoarthritis (OA), hindfoot varus malalignment resulting from the varus deformity of the ankle joint is common. Although total ankle arthroplasty (TAA) performed to correct varus deformity of the ankle joint has the effect of correcting hindfoot alignment, no reports to date have described how much hindfoot alignment correction can be achieved. The purpose of this study was to identify correlation between ankle deformity correction and hindfoot alignment change after performing TAA in patients with end-stage varus ankle OA. Methods: A total of 61 cases that underwent TAA for end-stage varus ankle OA and followed up for at least 1 year were enrolled for this study. Correlation between changes of tibial-ankle surface angle (TAS), talar tilt (TT), and tibiotalar surface angle (TTS) and changes of hindfoot alignment angle (HA), hindfoot alignment ratio (HR), and hindfoot alignment distance (HD) measured preoperatively and at postoperative year 1 was analyzed. Results: TAS, TT, and TTS changed from 83.9 ± 4.1 degrees, 5.8 ± 5.0 degrees, and 78.1 ± 5.9 degrees, respectively, before operation to 89.2 ± 2.1 degrees, 0.4 ± 0.5 degrees, and 88.7 ± 2.3 degrees, respectively, after operation. HA, HR, and HD also changed from −9.2 ± 4.6 degrees, 0.66 ± 0.18, and −11.2 ± 6.9 mm to −3.7 ± 4.1 degrees, 0.48 ± 0.14, and −5.0 ± 5.3 mm. All the changes were statistically significant (P <.001, respectively). The regression slope of correlation was 0.390 (R 2 = 0.654) between TTS and HA; 0.017 (R 2 = 0.617) between TTS and HR; and 0.560 (R 2 = 0.703) between TTS and HD. Conclusion: In patients with end-stage varus ankle OA, changes of hindfoot alignment could be predicted based on degree of ankle deformity corrected with TAA. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Background: Ankle arthrodesis has historically been the standard of care for end-stage ankle arthritis; however, total ankle arthroplasty (TAA) is considered a reliable alternative. Our objective was to compare 3-dimensional foot and ankle kinetics and kinematics and determine the ankle power that is generated during level walking and stair ascent between TAA and ankle arthrodesis patients. Methods: Ten patients who underwent TAA with a modern fixed-bearing ankle prosthesis and 10 patients who previously underwent ankle arthrodesis were recruited. Patients were matched for age, sex, body mass index, time from surgery, and preoperative diagnosis. A minimum of 2-year follow-up was required. Patients completed instrumented 3D motion analysis while walking over level ground and during stair ascent. Between-group differences were assessed with a 2-tailed Mann-Whitney exact test for 2 independent samples. Results: Sagittal ankle range of motion (ROM) was significantly higher in the TAA group (21.1 vs 14.7 degrees, P =.003) during level walking. In addition, forefoot-tibia motion (25.3±5.9 degrees vs 18.6±5.1 degrees, P =.015) and hindfoot-tibia motion (15.4±3.2 degrees vs 12.2±2.5 degrees, P =.022) were significantly greater in the TAA group. During stair ascent, sagittal ankle ROM (25 vs 17.1 degrees, P =.026), forefoot-tibia motion (27.6 vs 19.6 degrees, P =.017), and hindfoot-tibia motion (16.8 vs 12 degrees, P =.012) was greater. Conclusion: There were significant differences during level walking and stair ascent between patients with TAA and ankle arthrodesis. TAA patients generated greater peak plantarflexion power and sagittal motion within the foot and ankle compared to patients with an ankle arthrodesis. Further investigation should continue to assess biomechanical differences in the foot and ankle during additional activities of daily living. Level of Evidence: Level III, comparative study. [ABSTRACT FROM AUTHOR]

Periprosthetic osteolysis is a common occurrence after total ankle arthroplasty (TAA) and poses many challenges for the foot and ankle surgeon. Osteolysis may be asymptomatic and remain benign, or it may lead to component instability and require revision or arthrodesis. In this article, we present a current and comprehensive review of osteolysis in TAA with illustrative cases. We examine the basic science principles behind the etiology of osteolysis, discuss the workup of a patient with suspected osteolysis, and present a review of the evidence of various management strategies, including grafting of cysts, revision TAA, and arthrodesis. Level of Evidence: Level V, expert opinion. [ABSTRACT FROM AUTHOR]

The article discusses total ankle arthroplasty continues to grow in popularity and has expanding indications. Topics include particulate wear stimulates osteoblasts to produce proinflammatory mediators, attracting macrophages and cells that ultimately activate osteoclasts; and polyethylene wear debris phagocytized by macrophages, subsequently release receptor activator or nucleic factor K ligand.

Background: Although surgeons have argued that preserving motion at the level of the ankle joint may be crucial for the long-term success in the treatment of end-stage ankle osteoarthritis, there is little evidence regarding the potential of total ankle arthroplasty (TAA) to increase ankle range of motion (ROM). In addition, the effect of a percutaneous heel cord lengthening (HCL) during TAA on ankle motion is poorly understood. Methods: A total of 357 primary TAAs treated with a 3-component device (336 patients, mean age 62.6 [24-85] years) performed between May 2003 and November 2017 were retrospectively analyzed. Sagittal ankle ROM was assessed according to a previously published protocol preoperatively (PreOP), 1 year postoperatively (PostOP), and at the last available follow-up (LastFU). Pain assessed on a visual analog scale (VAS) was assessed at the same time points. The effect of a percutaneous HCL on ankle ROM and VAS for pain was also evaluated. Results: Preoperative ankle ROM increased from mean 31.3 (0-69) to 33.9 (5-65) degrees 1 year postoperatively (P =.0002) and decreased to 31.9 (5-70) degrees at the LastFU (P =.007). Percutaneous HCL showed no effect on ankle ROM development after TAA (P =.141). Ankle ROM improvement after TAA (PreOP to LastFU) was higher in ankles with lower preoperative ankle motion (P <.0001). A lower ankle ROM at the last follow-up tended to be associated with a higher pain level (P =.056). Conclusion: Although ankles with a lower preoperative sagittal ROM gained motion, the current data suggest that TAA has little potential to increase the preoperative available ankle motion. In some patients with a high preoperative ankle ROM, a slight decrease of ankle motion was observed postoperatively. Patients with limited ankle motion at long-term follow-up tended toward experiencing higher pain levels. The short- and long-term effect of a percutaneous HCL on ankle ROM following TAA was minimal. Level of Evidence: Level III, retrospective comparative series. [ABSTRACT FROM AUTHOR]

Background: Treatment of failed total ankle arthroplasty (TAA) is challenging. Limited literature is available on options and outcomes of revision arthroplasty despite failure rates ranging from 10% to 23% within 10 years after primary TAA. This study reports the clinical and radiographic outcomes of revision TAA using a fixed-bearing, intramedullary-referencing implant. Methods: A retrospective review was performed of 18 consecutive revision TAA cases between 2008-2015 using an intramedullary-referencing, fixed-bearing, 2-component total ankle system. Demographic and radiographic data were collected preoperatively, immediately postoperatively, and at the most recent follow-up. Functional outcome data were collected immediately postoperatively and at mean follow-up 47.5 months. Results: Eighteen patients underwent revision TAA, with 77.8% (14/18) implant survival. Index revision was performed most commonly for aseptic talar subsidence (55.6%) or implant loosening (tibia, 29.4%; talus, 58.9%). Following revision, 22.2% (4/18) patients required reoperation at a mean 57.3 (39-86) months. Osteolysis of the tibia, talus, and fibula was present preoperatively in 66.7% (12/18), 38.9% (7/18), and 38.9% (7/18) of patients, respectively, with progression of osteolysis in 27.8% (5/18), 11.1% (2/18) and 11.1% (2/18) of patients, respectively. Subsidence of the tibial and talar revision components was observed in 38.9% (7/18) and 55.6% (10/18) of patients, respectively. The median American Orthopaedic Foot & Ankle Society (AOFAS) score was 74.5 (26-100) and Foot Function Index (FFI) score 10.2 (0-50.4). Conclusion: Early results of intramedullary-referencing revision TAA demonstrated good patient-reported outcomes with maintenance of radiographic parameters at mean follow-up of 47.5 months. Aseptic talar subsidence or loosening were the main postoperative causes of reoperation. Revision arthroplasty utilizing an intramedullary-referencing implant was a viable option for the failed TAA. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Background: The Salto Talaris is a fixed-bearing implant first approved in the US in 2006. While early surgical outcomes have been promising, mid- to long-term survivorship data are limited. The aim of this study was to present the survivorship and causes of failure of the Salto Talaris implant, with functional and radiographic outcomes. Methods: Eighty-seven prospectively followed patients who underwent total ankle arthroplasty with the Salto Talaris between 2007 and 2015 at our institution were retrospectively identified. Of these, 82 patients (85 ankles) had a minimum follow-up of 5 (mean, 7.1; range, 5-12) years. The mean age was 63.5 (range, 42-82) years and the mean body mass index was 28.1 (range, 17.9-41.2) kg/m2. Survivorship was determined by incidence of revision, defined as removal/exchange of a metal component. Preoperative, immediate, and minimum 5-year postoperative AP and lateral weightbearing radiographs were reviewed; tibiotalar alignment (TTA) and the medial distal tibial angle (MDTA) were measured to assess coronal talar and tibial alignment, respectively. The sagittal tibial angle (STA) was measured; the talar inclination angle (TIA) was measured to evaluate for radiographic subsidence of the implant, defined as a change in TIA of 5 degrees or more from the immediately to the latest postoperative lateral radiograph. The locations of periprosthetic cysts were documented. Preoperative and minimum 5-year postoperative Foot and Ankle Outcome Score (FAOS) subscales were compared. Results: Survivorship was 97.6% with 2 revisions. One patient underwent tibial and talar component revision for varus malalignment of the ankle; another underwent talar component revision for aseptic loosening and subsidence. The rate of other reoperations was 21.2% (n = 18), with the main reoperation being exostectomy with debridement for ankle impingement (n = 12). At final follow-up, the average TTA improved 4.4 (± 3.8) degrees, the average MDTA improved 3.4 (± 2.6) degrees, and the average STA improved 5.3 (± 4.5) degrees. Periprosthetic cysts were observed in 18 patients, and there was no radiographic subsidence. All FAOS subscales demonstrated significant improvement at final follow-up. Conclusions: We found the Salto Talaris implant to be durable, consistent with previous studies of shorter follow-up lengths. We observed significant improvement in radiographic alignment as well as patient-reported clinical outcomes at a minimum 5-year follow-up. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

Background: The overall health and the importance of physical therapy for people following total ankle arthroplasty (TAA) have been understudied. Our purpose was to characterize the overall health of patients following TAA, and explore the frequency, influence, and patient-perceived value of physical therapy. Methods: People who received a TAA participated in this retrospective cohort online survey study. The survey included medical history questions and items from the Patient-Reported Outcomes Measurement Information System (PROMIS) Short Forms. Seven PROMIS domains, reflecting the biopsychosocial model of care (physical, mental, social), were included to examine participant overall health status in comparison to the general population. Items regarding physical therapy participation (yes/no), number of visits, and perceived value (scale 0-10; 10 = extremely helpful) were also included. Descriptive statistics were generated for participant characteristics, PROMIS domain T scores, and physical therapy questions. The influence of participant characteristics or physical therapy visits on PROMIS domain T scores that scored below the population mean were examined with multiple linear regression or ordinal regression. Results: The response rate was 61% (n=95). Average postoperative time was approximately 3 years (mean [SD]: 40.0 [35.3] months). Physical function and ability to participate in social roles and activities domain T scores were at least 1 SD below the population mean. Most patients received physical therapy (86%; 17.1 [11.0] visits) and found it helpful (7.2 [3.0]). Participant characteristics were minimally predictive of physical function and social participation T scores. Number of physical therapy visits predicted physical function T scores (P =.03). Conclusions: Most health domain scores approached the population mean. Physical therapy was perceived to have a high value, and greater visits were related to greater physical function. However, lower physical function and social participation scores suggest that postoperative care directed toward these domains could improve the value of TAA and promote overall health. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]