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Category: Ankle Arthritis Introduction/Purpose: There is much interest in the surgical treatment of end-stage ankle arthritis. Our team has previously reported comparisons between ankle fusion and replacement outcomes for 321 ankles at 5.5 years from a prospective cohort. This research extends the observational period for another six years, ending in 2013. Our primary hypothesis is that patient-reported clinical outcomes for ankle fusion and replacements would be similar at last follow up. Methods: Patients in the Canadian Orthopaedic Foot and Ankle Society (COFAS) Prospective Ankle Reconstructive Database were treated with total ankle replacement (involving Agilty, Star, Mobilty, Hintegra, or Inbone) or fusion (open or arthroscopic). Patient characteristics collected included demographics, comorbidities, smoking status and body mass index. Patient-reported outcomes (PROs) completed by patients were the Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36). Pre-operative and most recent patient data, with at least four years follow-up, were analyzed. Sensitivity analyses excluded ankles that had undergone revision. A linear mixed-effects regression model compared scores between total ankle replacement and fusion groups, adjusting for patient characteristics, baseline data and surgeon. Results: The sample included 844 ankles (556 ankle replacements and 284 arthrodesis). The mean follow up period was 8.0 years (standard deviation 3.1 years), with minimum and maximum of 4 and 14 years, respectively. Patients treated with arthrodesis were younger, more likely to be diabetic and smokers, and somewhat less likely to have inflammatory arthritis. Overall, 19.4% of ankle fusion and 30.8% of ankle replacements underwent all-cause re-operation. The mean AOS total score improved from 58.6 points pre-operatively to 31.4 post-operatively (delta 27.2), and from 57.0 to 26.9 points (delta 30.1) in the ankle replacement group. Differences in the change in AOS and SF-36 scores between the arthrodesis and ankle replacement groups were minimal after adjustment for baseline characteristics and surgeon. Conclusion: Clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort of patients whose follow up period ranged between 4 and 14 years post-operatively.

Category: Ankle Arthritis Introduction/Purpose: Numerous studies have demonstrated that concomitant lower back pain (LBP) results in worse functional outcomes in patients undergoing surgical treatment for the management of end stage hip and knee arthritis. However, no equivalent studies have analysed the impact of back pain on the outcomes of patients with end stage ankle arthritis. Furthermore, given that two widely accepted surgical options exist in the treatment of ankle arthritis, namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA), it is possible that one surgical technique may be superior in patients with LBP. The aim of this study was to determine the incidence of LBP in people with ankle arthritis, analyse its effect on functional outcomes, and explore whether there was a treatment advantage from either TAA or AA. Methods: Prospectively collected data from the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was analysed in this study. All patients with ankle arthritis who underwent surgery performed by three fellowship-trained foot and ankle surgeons at a single institution between January 2003 and July 2012 were studied. Patient demographics were collected pre-operatively, including the absence or presence of back pain, and post-operative follow up was performed at 2 and 5 years, evaluating patient-reported functional outcome measures including the Ankle Arthritis Score (AAS) and the 36-item short form survey (SF-36). Using a linear regression model, a multivariate analysis was performed to examine the relationship between back pain, TAAs and AAs. Results: In total, 451 patients were studied. 164 patients (36.4%) presented with concomitant LBP. At presentation, the LBP group had worse AAS scores (54.8 vs 57.8 p < 0.04), SF-36 PCS (32.5 vs 28.9 p 0.05) in any of the functional outcome scores at 2 or 5 years post-operatively. Conclusion: The results of this study suggest there is no advantage of TAA over AA in the treatment of ankle arthritis in patients with concomitant lower back pain. Although pre-operative back pain resulted in worse SF-36 outcomes at 2 and 5 years post-operatively, this was not the case for AAS scores.

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) and ankle arthrodesis (AA) are standard treatment modalities for end-stage ankle osteoarthritis. The total ankle arthroplasty (TAA) anatomical alignment is critical for the longevity of total ankle components. Coronal and sagittal malalignment results in altered joint mechanics and reactive forces that result in implant failure. Also, to our knowledge, tibial component sizing in the sagittal plane has been addressed in knee arthroplasty literature, but not in ankle arthroplasty literature. Based on these parameters, we developed a novel radiographic predictive score for failure in TAA (RPSFT). Methods: A retrospective review performed on the COFAS database, selecting for all total ankle replacements done at a single institution between September 2004 and June 2015. Those with complete series of anteroposterior and lateral standing ankle radiographs, both preoperative and postoperative and a minimum of 1 year of follow-up, were included. We performed a multivariate logistic regression, using the medial distal tibial component angle, lateral talar station, talar tilt angle, and the absence of posterior under= or overhang of the tibial component in the first post-operative radiographs. These parameters were used to develop a RPSFT. Binomial regression was used to determine each variable’s weight in the RPSFT and assigned a corresponding score value. A univariate logistic regression was estimated, using the RPSFT as the independent variable and mechanical failure as the dependent variable. Then a Receiver-Operating Characteristic curve was constructed and the probability of failure for each possible score was estimated. Results: Of a total of 296 TAAs, 146 were included, and 8 TAAs required revision (5%). TAA revision was defined as a reoperation to remove one or both metal components, or amputation. According to our predictive score, if all the parameters are within established normal ranges (17 points) the TAA failure probability (TFP) is 2% [0-0.1] p

Category: Bunion Introduction/Purpose: Little is known about the effect of delayed access to bunion correction (Hallux Valgus) surgery on patient-reported outcomes. The objective of this study is to measure the association between delayed access to bunion correction surgery and post-operative patient-reported outcomes. Methods: This study prospectively recruited patients to complete pre-operative patient-reported outcomes measuring pain, depression and foot and ankle health. Patients complete the same patient-reported outcomes six months post-operatively. Linear regression models measured outcomes, adjusting for baseline health, age category, sex, comorbidities and socio-economic status. Results: This study included 74 participants, a response rate of 53% among eligible patients. Among participants, 58.9% underwent a Lapidus procedure, the remainder underwent a corrective osteotomy. There was no relationship between post-operative depression and pain scores with duration of wait time, adjusting for patient characteristics. Longer waits for bunion correction surgery, adjusting for other factors, were associated with smaller gains in health in four of the five domains of measurement of foot and ankle health. Conclusion: At the six-month post-operative time point, prolonged wait times were detrimental to foot and ankle outcomes in four of the five domains of the foot and ankle specific PRO. Policies for expediting access for symptomatic hallux valgus are warranted to mitigate poorer long-term outcomes.

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacements (TAR) are an increasingly common treatment for end-stage ankle arthritis but evidence on optimal alignment is not as well-established as in the hip and knee arthroplasty literature. Many believe that restoration of coronal and sagittal alignment is critical, while others suggest malalignment within a certain range has no impact on failure (Braito et al. 2015). There is controversy on the ideal TAR component positioning to minimize failure and requiring revision surgery. In this study we examine 9 radiographic measures of TARs, 6 of which have previously been described for TARs, 1 commonly used on preoperative ankles, and 2 novel measures on a database of 146 TARs to identify predictors of TAR re-operation. Methods: A retrospective review was performed on the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis, selecting for all total ankle replacements done at a single institution by one of three fellowship-trained foot and ankle surgeons between September 2004 and June 2015. Those with complete series of anteroposterior and lateral standing ankle radiographs both preoperative and postoperative, and minimum of 1 year of follow-up were included. Measurements were performed on the postoperative radiographs and included: coronal and sagittal distal tibial component angles, talar center migration, talar tilt angle, lateral talar station, tibial axis-talus ratio, talar component gamma angle, anterior and posterior tibial component overhang and underhang. Standard descriptive statistical methods were used to analyze the data. Results: Of a total of 296 TARs, 146 were included and 14 TARs failed (9.6%), defined as requiring re-operation, 8 of which were metal-component revisions (5%). The TARs were stratified into those with measurements within previously published normal values and those that fall outside that range. Time to failure ranged from 1.4 to 9.6 years. Our preliminary data analysis showed that TARs with coronal distal tibial component angles between 87-93 degrees demonstrated an odds ratio of 0.11 for re-operation compared with those beyond that range, p=0.003. TARs with talar tilt angles of 0 degrees demonstrated an odds ratio of 0.24 for re-operation compared with those whose talar tilt was not zero, p=0.02. Conclusion: Post-operative coronal alignment of TARs, namely distal tibial component angle and talar tilt, appear to be associated with TAR-reoperation. Specifically, if the measurements are within previously described normal limits, the odds ratio for re-operation is low and statistically significant. Further data analysis is underway and may demonstrate more parameters of significance in predicting TAR failure.

Category: Ankle Arthritis Introduction/Purpose: Accepted surgical treatment options for end-stage ankle arthritis include total ankle arthroplasty (TAA) and ankle arthrodesis (AA). Although they have comparable clinical outcomes, TAA is growing in popularity and one reason for this is that TAA, compared to AA, better preserves range of motion and function at the ankle, and results in a gait pattern that more closely replicates normal controls. This has the theoretical benefit of protecting adjacent articulations and thereby limiting degenerative changes from occurring in other joints. Although multiple studies have analysed the impact of both TAA and AA on adjacent joint disease in the foot, little data exists on their impact on the knee. This study explored the relationships between knee pain, TAA and AA in patients with end-stage ankle arthritis. Methods: Prospectively collected data was used from the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis at a single institution by three fellowship-trained foot and ankle surgeons between January 2003 and July 2012. In total, 342 patients were studied, with patient demographics collected pre-operatively, and post-operative follow up performed at the 5 year mark. All patients were examined for the development or resolution of knee pain, as well as patient-reported outcome measures including the Ankle Osteoarthritis Scale (AOS). Using a linear regression model, a multivariate analysis was performed to examine the relationship between knee pain, TAAs and AAs. Results: In the 233 patients that presented without knee pain pre-operatively, 22% who underwent TAA developed knee pain at 5 years, compared to 16% of AA patients (p>0.05). In this group, patients who underwent TAA had statistically significant better outcomes in terms of AOS Pain (p0.05) between patients who underwent TAA and AA. Compared with patients who did not have knee pain pre-operatively, the presence of pre-operative knee pain resulted in worse AOS (p

Category: Ankle Arthritis Introduction/Purpose: Ankle arthrodesis is the most favored surgical treatment for several tibiotalar pathologies. Nonunion requiring revision occurs in 5.7% - 6.5% of patients. Nonunion is a challenging surgical complication and bone graft substitutes are costly. This study aimed to summarize all institutional expenditures related to ankle fusion nonunion needing revision, presuming that cost and skin-to-skin time would exceed that of the index surgery. Methods: Reviewing electronic charts from a foot and ankle center, a patient list with two or more entries for tibiocalcaneal, pantalar and tibiotalar fusions was generated. Out of 44 cases found, 21 patients had bilateral surgery and were excluded. Three had TAR or surgery in the periphery as index surgery; four had revision not for nonunion.Demographic factors and skin-to-skin time of the 16 remaining patients were compiled. Supplemental clinic visits and investigations were included either after CT to assess union, or 365 days post-index procedure in the absence of CT. Total cost of the revision was calculated from surgical billing codes, length of operation, and period of hospitalization. Post-revision outpatient fees were all included. This cohort included 16 patients (6F: 10 M) with an average age of 60 years (52 - 67) and BMI of 33 (29 - 38). 14 revisions were performed open; 13 patients received bone graft. Results: Average hospitalization post-operatively was 5.5 days (1.87 - 9.28). The additional cost associated with nonunion were $1,538 (CAD) for imaging, $737 for pre-revision visits, $12,483 for the revision and hospital stay, and $1,990 for post-revision follow-up. The total average amount was $14,982, equivalent to 10 nights of acute inpatient stay. Index average skin to skin time was 2:00:50 and for revisions 2:18:20, for a p-value of 0.26. The cost of nonunion per 100 primary procedures is therefore $85,397 to $97,383. If an intervention reduces the incidence of nonunion by 50% the cost saved would be $486 per procedure. As grafting or bone graft substitutes cost over $1,000, grafting should be limited to at risk patients. Conclusion: Additional care related to ankle fusion nonunion represents a financial burden equivalent to 10 nights of acute inpatient stay. Revision surgery is not significantly longer intraoperatively than index surgery. Bone graft and/or substitute should only be considered if it’s cost is less than $486 CAD at our institution.