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Background: Nonunion is a postoperative complication after ankle arthrodesis (AA), which leads to increased morbidity and revision rates. Previous studies have identified risk factors for nonunion following AA, but no meta-analysis has been performed to stratify risk factors based on strength of evidence., Methods: Abstracts and full-text articles were screened by 2 independent reviewers. Relevant data were extracted from the included studies. Random effects meta-analyses were summarized as forest plots of individual study and pooled random effect results., Results: Database search yielded 13 studies involving 987 patients were included, and 37 potential risk factors for nonunion. Meta-analysis found 5 significant risk factors for nonunion post-AA. Strong evidence supports male gender (OR: 1.96; 95% CI: 1.13-3.41), smoking (OR: 2.89; 95% CI: 1.23-6.76), and history of operative site infection prior to arthrodesis (OR: 2.40; 95% CI: 1.13-5.09) as predictors for nonunion following AA. There was moderate evidence supporting history of open injury (OR: 5.95; 95% CI: 2.31-15.38) and limited evidence for preoperative avascular necrosis (OR: 13.16; 95% CI: 2.17-79.61) as possible risk factors for nonunion., Conclusion: The results of our meta-analysis suggest that male gender, smoking, and history of operative site infection have strong evidence and that history of open injury and avascular necrosis also have evidence as risk factors for nonunion. Surgeons should be cognizant of these risks when performing AA and closely follow up with patients with the aforementioned risk factors to ensure postoperative success., Levels of Evidence: Level V: Systematic review of cohort and case-control studies.

Background: Total ankle replacement (TAR) represents an alternative to fusion for the treatment of end-stage ankle osteoarthritis. The aim of the present study was to retrospectively assess the frequency of infections between TARs with anterior and lateral transfibular approach at 12-months follow-up., Methods: 81 TARs through an anterior approach and 69 TARs through a lateral approach were performed between May 2011 and July 2015. We compared surgical time and tourniquet time, as well as superficial and deep infections frequency during the first 12 postoperative months., Results: In the anterior approach group, there were 3 (3.7%) deep infections and 4 (4.9%) superficial wound infections. In the lateral approach group, there were 1 (1.4%) deep infection and 2 superficial wound infections (2.9%). There were not statistically significant differences between the groups. There was a significant difference between anterior approach (115minutes) and lateral approach group (179minutes) in terms of surgical time (P<0.001)., Conclusions: The frequency of superficial and deep periprosthetic infections during the first postoperative year was not significantly different in the lateral approach group compared to the anterior approach group, despite the significantly longer surgical time in the lateral transfibular approach group., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Two main treatments for end-stage ankle arthritis are ankle arthrodesis and total ankle arthroplasty (TAA). While both procedures can be performed either by a foot and ankle orthopaedic surgeon or a podiatrist (when within a particular state's scope of practice), studies comparing the surgical outcomes of the 2 surgeon types are lacking. Therefore, in this study, we compared outcomes by surgeon type for TAA and for ankle arthrodesis., Methods: This retrospective cohort study utilized data from the nationwide Premier Healthcare claims database (2011 to 2016) regarding TAA (n = 3,674) and ankle arthrodesis (n = 4,980) procedures. Multivariable models estimated associations between surgeon type (podiatrist versus orthopaedic foot and ankle surgeon) and opioid utilization (in oral morphine equivalents [OMEs]), length of stay, and cost of hospitalization. We report percent change (compared with reference) and 95% confidence intervals (CIs)., Results: Overall, 76.5% (n = 2,812) and 18.8% (n = 690) of TAA procedures were performed by orthopaedic foot and ankle surgeons and podiatrists, respectively; surgeon type was unknown for 4.7% (n = 172). For ankle arthrodesis, 75.3% (n = 3,752) and 18.3% (n = 912) of the procedures were performed by orthopaedic foot and ankle surgeons and podiatrists, respectively; surgeon type was unknown for 6.3% (n = 316). The proportion of TAA and ankle arthrodesis procedures performed by podiatrists increased over time, from 12.8% and 13.6% in 2011 to 24.6% and 26.0% in 2016, respectively. When adjusting for relevant covariates, procedures performed by podiatrists (compared with orthopaedic foot and ankle surgeons) were associated with increased length of stay: for TAA, +16.7% (95% CI, 7.6% to 26.5%; median, 2 days in both groups) and for ankle arthrodesis, +14.2% (95% CI, 7.9% to 20.9%; median, 3 compared with 2 days) (p < 0.05 for both). In addition, ankle arthrodesis performed by podiatrists was associated with increased cost of hospitalization: +28.5% (95% CI, 22.1% to 35.2%; median, $19,236 compared with $13,433) (p < 0.05). Differences in opioid utilization were nonsignificant in the main analysis: +10.9% (95% CI, -3.1% to 26.8%; median, 345 compared with 250 OMEs) and +2.8% (95% CI, -5.9% to 12.4%; median, 351 compared with 315 OMEs) for TAA and ankle arthrodesis, respectively., Conclusions: An increasing trend in the proportion of procedures performed by podiatrists was coupled with apparent increases in length of stay and cost compared with procedures performed by orthopaedic foot and ankle surgeons. Given the increasing demand for these procedures, factors associated with resource utilization, such as type of surgeon, may be increasingly important on the population level., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The rate of total ankle arthroplasty (TAA) is increasing in the United States as its popularity and indications expand. There currently is no national joint registry available to monitor outcomes, and few studies have addressed the challenges faced with TAA. The purpose of this study was to evaluate the incidence, complications, and survival rates associated with TAA using a large statewide administrative discharge database. Individuals who underwent primary TAA from 1997 to 2010 were identified in the Statewide Planning and Research Cooperative System database from the New York State Department of Health. The age, sex, comorbidities, state of residence, primary diagnosis, and readmissions within 90 days were analyzed for patients with an ICD-9-CM procedure code of 81.56 (TAA). Failure of a TAA implant was defined as revision, tibiotalar arthrodesis, amputation, or implant removal. During the 14-year period, 420 patients underwent 444 TAAs (mean patient age of 61 years, 59% women, mean Charlson-Deyo comorbidity score of 0.45, and 86% New York State residents). The primary diagnosis was 37.4% osteoarthritis, 34.3% traumatic arthritis, and 15.5% rheumatoid arthritis. Surgery for failure was associated only with a younger age (56.5 vs 62 years, P=.005). The rate of subsequent failure procedures following TAAs performed in New York State was 13.8%. The incidence of TAAs is steadily increasing. The overall survival rate in New York State is better than rates reported in other national registries, but it is not yet comparable to those of hip and knee replacements. [Orthopedics. 2016; 39(3):170-176.]., (Copyright 2016, SLACK Incorporated.)

The foot and ankle outcome score (FAOS) has been evaluated for many conditions of the foot and ankle. We evaluated its construct validity in 136 patients with osteoarthritis of the ankle, its content validity in 37 patients and its responsiveness in 39. Data were collected prospectively from the registry of patients at our institution. All FAOS subscales were rated relevant by patients. The Pain, Activities of Daily Living, and Quality of Life subscales showed good correlation with the Physical Component score of the Short-Form-12v2. All subscales except Symptoms were responsive to change after surgery. We concluded that the FAOS is a weak instrument for evaluating osteoarthritis of the ankle. However, some of the FAOS subscales have relative strengths that allow for its limited use while we continue to seek other satisfactory outcome instruments., (©2015 The British Editorial Society of Bone & Joint Surgery.)