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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: 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: We aimed to perform an economic analysis and compare the clinical outcomes between inpatient and short-stay designation total ankle replacement (TAR). Methods: We performed a retrospective study on 178 consecutive patients undergoing primary inpatient versus short-stay designation TAR during the 2016 and 2017 fiscal years. Patient demographics, concomitant procedures, perioperative complications, patient-reported outcomes, and perioperative costs were collected. Results: The mean age of our cohort was 62.5 ± 9.6 years (range, 30-88 years), with a significant difference in age (64.1 vs 58.5 years) (P =.005) and Charlson Comorbidity Index (3.3 ± 1.9 vs 2.3 ± 1.4; P =.002) for the inpatient and short-stay designation groups, respectively. At a mean follow-up of 29.6 ± 11.8 months (range, 12-52.3 months), there was no difference in complications between groups (P =.97). The inpatient designation TAR group had a worse baseline Short Musculoskeletal Functional Assessment (SMFA) function score (76.1; 95% CI, 70.5-81.6) than the short-stay designation TAR group (63.9; 95% CI, 52.5-75.3) while achieving similar final postoperative SMFA function scores for the inpatient (55.2; 95% CI, 51.1-59.2) and short-stay (56.2; 95% CI, 48.2-64.2) designation TAR groups (P >.05). However, the inpatient designation TAR group showed a significantly greater mean improvement in SMFA function score (20.9; 95% CI, 19.4-22.4) compared with the short-stay designation TAR group (7.7; 95% CI, 3.7-11.1) (P =.0442). The total direct cost was significantly higher for the inpatient designation group ($15 340) than the short-stay designation group ($13 002) (P <.001). Conclusion: While inpatient designation TARs were more comorbid, short-stay designation TARs were associated with a 15.5% reduction in perioperative costs, comparable complication rates, and similar final postoperative patient-reported outcome scores compared with inpatient TARs. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Background: As the popularity of total ankle arthroplasty (TAA) increases and indications expand, surgeons require a better understanding of which patient factors are associated with implant failure. In this study, we aimed to use a large total ankle database to identify independent risk factors for implant failure at mid- to long-term follow-up. Methods: A prospectively collected database was used to identify all patients who underwent primary TAA with a minimum 5 years' follow-up. The primary outcome was revision, defined as removal of one or both metal components; failures due to infection were excluded. Patient and clinical factors analyzed included age, sex, body mass index (BMI), smoking status, presence of diabetes, indication for TAA, implant, tourniquet time, and presence of ipsilateral hindfoot fusion. Preoperative coronal deformity and sagittal talar translation were assessed, as were postoperative coronal and sagittal tibial component alignment. Univariable and multivariable analyses were performed to identify predictors of implant failure. After excluding 5 ankles that failed because of deep infection, 533 ankles with a mean 7 (range, 5-11) years of follow-up met the inclusion criteria. Four implants were used: INBONE I, INBONE II, STAR, and Salto-Talaris. Results: Thirty-four ankles (6.4%) were revised or removed a mean 4 (range, 1-9) years postoperatively. The only independent predictors of failure were the INBONE I prosthesis and ipsilateral hindfoot fusion (P = .006 and P = .023, respectively). Conclusions: This is among the largest studies to analyze the relationship between TAA failure rates and multiple different patient, operative, and radiographic factors. Of note, age, BMI, and amount of deformity were not associated with higher failure rates. Only patients with ipsilateral hindfoot fusion or who received the INBONE I prosthesis were at significantly higher risk of implant failure. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Background: The effect of bone mineral density (BMD) on outcomes from total ankle arthroplasty (TAA) has not been studied. BMD can be estimated by measuring Hounsfield units (HU) on standard computed tomography (CT), which is frequently performed prior to TAA. We aimed to identify whether tibial and talar HU measured from preoperative CT scans were associated with periprosthetic fracture or revision risk in patients undergoing TAA. Methods: A prospectively collected database was used to retrospectively screen all patients undergoing primary TAA. Only patients with a preoperative CT within 1 year of surgery were included. Primary outcomes were periprosthetic fracture and prosthetic revision. HU were measured on axial CT cuts in the distal tibia and talus. Additional patient factors analyzed included age, sex, weight, body mass index (BMI), tobacco use, presence of rheumatoid arthritis, and preoperative deformity. A total of 198 ankles were included, with a mean 2.4 years of follow-up. Results: There were 7 intraoperative and 9 postoperative periprosthetic fractures (3.5% and 4.5%, respectively). Seven patients (3.5%) underwent prosthetic removal or revision. Lower tibial and talar HU, lower weight, and lower BMI were associated with periprosthetic fractures (P < .05). After controlling for age, sex, and weight, only tibial HU was significantly associated with periprosthetic fracture (P = .018). All intraoperative fractures occurred in patients with tibial HU less than 200. None of the patient factors analyzed were associated with revision. Conclusions: Lower tibial HU on preoperative CT was strongly associated with periprosthetic fracture risk with TAA. In patients with tibial HU less than 200, surgeons may consider prophylactic internal fixation of the medial malleolus. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Background: A number of new 2-component total ankle arthroplasty systems that emphasize minimal bone resection have been introduced for which few clinical outcomes reports are available. Our aim was to identify the rate of early revision among patients receiving the 2-component INFINITY prosthesis. Methods: Patients from 2 prospectively collected databases at the authors' institution were screened for inclusion in the present study. All patients who underwent a primary total ankle arthroplasty (TAA) with the INFINITY prosthesis and who were at least 1 year postoperative were included. A total of 159 ankles with a mean 20 months of follow up (range, 12-37) met these criteria. All surgeries were performed by 1 of 2 orthopedic foot and ankle surgeons with extensive experience in TAA. The primary outcome was the need for revision surgery, defined as removal of 1 or both metal components. Peri-implant lucency at most recent follow-up was a secondary outcome. Weightbearing radiographs at most recent follow-up were graded for lucency independently by 2 reviewers. Results: Sixteen ankles (10%) underwent revision at a mean 13 months postoperatively. The most common reasons for revision were symptomatic tibial component loosening and deep infection (6 patients each, 3.8%). Of the 108 ankles with retained components and at least 1 year of radiographic follow-up, 8 (7.4%) had global lucency around the tibial component suggestive of loosening at most recent follow-up. Conclusions: Our initial review of patients undergoing TAA with this new 2-component prosthesis demonstrates an elevated early revision rate due to tibial component loosening compared to other implant systems. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to assess the radiographic progression of subtalar and talonavicular degenerative joint disease in a series of patients who had undergone TAA (total ankle arthroplasty) with minimum follow-up of 5 years. Methods: TAA patient radiographs from a single institution were analyzed for peritalar arthritic changes by extrapolating the modified Kellgren Lawrence (KL) grades of the knee to the subtalar and talonavicular joints. Patients were included if they had a minimum of 5 years of follow-up. Patients who had undergone prior arthrodesis of the talonavicular or subtalar joints were excluded. A total of 140 patients with average follow-up of 6.5 years (range, 5.0-8.9 years) were included. Results: Overall, 27% of patients advanced 1 KL grade at the subtalar joint and 31% of patients increased 1 KL grade at the talonavicular joint. Furthermore, 60% and 66% of patients showed no progression in the subtalar and talonavicular joints, respectively. Two patients progressed greater than 2 KL subtalar arthritis grades and only 2 patients with talonavicular arthritis progressed to the same extent. Sixteen patients went on to require a subtalar arthrodesis compared to 2 requiring a talonavicular fusion (P < .05). Conclusion: This study suggests a moderate but nominal radiographic increase in adjacent subtalar and talonavicular arthritis over a minimum of 5 years after TAA. Future studies require a comparative control group of ankle fusion, but these data may suggest the motion preserved with an arthroplasty diminishes the stresses and compensatory motion incurred during tibiotalar arthrodesis. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

Background:Little is known about the efficacy and durability of total ankle arthroplasty (TAA) in younger patients. The purpose of this study was to determine the effect of age on the clinical, radiographic, and patient-reported outcomes of patients with end-stage ankle arthritis treated with TAA using modern prostheses.Methods:Patients who underwent primary TAA from June 2007 to July 2011 were prospectively enrolled in the study. Three hundred and ninety-five consecutive patients were reviewed with a mean follow-up of 3.5 years (range, 2-5.4 years). Patients were divided into 3 groups based on age at the time of surgery (<55, 55-70, and >70 years). Patient-reported outcome scores, physical performance scores, and weight-bearing radiographs were used to assess patients preoperatively and at yearly postoperative office visits. Revision was defined as failure of either the tibial or talar components requiring removal of the metallic implants. A repeated-measures analysis of variance with post hoc testing and the Pearson chi-square test were used to assess differences between the 3 groups. Statistical significance was set at an alpha level of .05.Results:Patients under the age of 55 had a greater improvement in Short-Form 36 (SF-36) Vitality (P = .026) and American Orthopaedic Foot & Ankle Society (AOFAS) Function scores (P < .001) compared with patients over the age of 70 at most recent follow-up. There were no differences in the Visual Analog Scale (VAS) pain score or the physical performance outcomes between the age groups. The incidence of wound complications, need for reoperation, and revision were not different between groups.Conclusions:Outcomes of TAA in younger patients were similar to outcomes in older patients at early follow-up. This study establishes a cohort of patients that will be followed to determine the effect of age on the long-term outcomes of TAA with an emphasis on the need for reoperation and revision.Level of Evidence:Level II, prospective comparative study. [ABSTRACT FROM AUTHOR]

Background:This series reviews the clinical and radiographic outcomes of patients who underwent total ankle replacement (TAR) using first- and second-generations of a modern fixed-bearing prosthesis utilizing a modular intramedullary stem.Methods:A consecutive series of first- and second-generation primary TARs with modular intramedullary stems were identified. Clinical outcome data were collected prospectively—including visual analog scale for pain, American Orthopaedic Foot & Ankle Society hindfoot-ankle, Short Musculoskeletal Function Assessment, and Short Form–36 scores. Preoperative coronal plane deformity and correction of deformity after TAR were assessed. Complications, subsequent procedures, and failure rates were compared. A total of 193 first- and 56 second-generation patients were identified with a mean follow-up of 3.7 and 2.1 years, respectively.Results:Clinical outcome data reflected significant improvements at 1 year postoperatively, and improvements were maintained at 2-year follow-up for each group. Improvement in visual analog scale scores were significantly better in the second-generation group at 1 year postoperatively, but this was not maintained at 2 years. Mean coronal tibiotalar angles for ankles with preoperative varus or valgus deformities were significantly improved. Correction was maintained until final follow-up, with no significant differences in deformity improvement between groups. The rate of reoperation at 2 years postoperatively on the affected foot or ankle subsequent to the index ankle replacement for patients in the first-generation group (18.5%) was higher compared to the second-generation group (15.9%), but the time until reoperation was not statistically significant (P = .376). The implant failure rate was higher in the first-generation group (6.0%) compared to the second-generation group (2.6%) at 2 years postoperatively, but the time until failure was not significantly different (P = .295).Conclusion:Patients who underwent TAR with a first- or second-generation fixed-bearing prosthesis with an intramedullary tibial component demonstrated significant improvements in all measures of pain and function with sustained improvements in coronal plane alignment. The second-generation prosthesis demonstrated slightly better improvements at 1 year and was associated with lower reoperation and implant failure rates.Level of Evidence:Level II, comparative series. [ABSTRACT FROM AUTHOR]

Background: Concomitant procedures are being performed with total ankle replacement (TAR) to improve alignment, function, and mobility. The purpose of this study was to examine the differences in outcomes between patients who had a concomitant triceps surae lengthening (gastrocnemius recession [GSR] or triple hemisection [TAL]) versus a group that underwent TAR alone preoperatively and 1 year after TAR. Methods: For this prospective, nonrandomized study, 229 patients (37 GSR, 22 TAL, and 170 TAR alone) were examined. Patient-reported outcomes, physical performance, and lower extremity gait mechanics were completed preoperatively and 1 year postoperatively. A series of repeated measures ANOVAs were used to determine significant differences (P < .05), and Tukey’s post hoc testing was used to follow any significant ANOVA results. Results: No difference existed in BMI, age, gender, or dorsiflexion (DF) angle at heel strike between the triceps surae lengthening groups or between preoperative and 1 year following TAR. Walking speed, the physical performance measures, the AOFAS Hindfoot Score, SF-36, peak plantar flexion angle, and the peak plantar flexion moment were significantly improved (P < .001) postoperatively with no differences between the triceps surae lengthening groups. The peak DF angle (P = .006) and the ankle range of motion (P = .014) demonstrated a greater improvement from preoperative to 1 year postoperatively in the triceps surae lengthening groups in comparison to the TAR alone group. Conclusion: Significant improvements existed between preoperative and 1 year postoperatively for most of the variables of interest independent of the triceps surae lengthening group. This study demonstrated that the use of a concomitant triceps surae lengthening procedure (GSR or TAL) resulted in equivalent outcomes when compared with a group undergoing TAR alone. Level of Evidence: Level II, prospective comparative study. [ABSTRACT FROM AUTHOR]

Background: Ipsilateral hindfoot arthrodesis in combination with total ankle replacement (TAR) may diminish functional outcome and prosthesis survivorship compared to isolated TAR. We compared the outcome of isolated TAR to outcomes of TAR with ipsilateral hindfoot arthrodesis. Methods: In a consecutive series of 404 primary TARs in 396 patients, 70 patients (17.3%) had a hindfoot fusion before, after, or at the time of TAR; the majority had either an isolated subtalar arthrodesis (n = 43, 62%) or triple arthrodesis (n = 15, 21%). The remaining 334 isolated TARs served as the control group. Mean patient follow-up was 3.2 years (range, 24-72 months). Results: The SF-36 total, AOFAS Hindfoot-Ankle pain subscale. Foot and Ankle Disability Index, and Short Musculoskeletal Function Assessment scores were significantly improved from preoperative measures, with no significant differences between the hindfoot arthrodesis and control groups. The AOFAS Hindfoot-Ankle total, function, and alignment scores were significantly improved for both groups, albeit the control group demonstrated significantly higher scores in all 3 scales. Furthermore, the control group demonstrated a significantly greater improvement in VAS pain score compared to the hindfoot arthrodesis group. Walking speed, sit-to-stand time, and 4-square step test time were significantly improved for both groups at each postoperative time point; however, the hindfoot arthrodesis group completed these tests significantly slower than the control group. There was no significant difference in terms of talar component subsidence between the fusion (2.6 mm) and control groups (2.0 mm). The failure rate in the hindfoot fusion group (10.0%) was significantly higher than that in the control group (2.4%; p < 0.05). Conclusion: To our knowledge, this study represents the first series evaluating the clinical outcome of TARs performed with and without hindfoot fusion using implants available in the United States. At follow-up of 3.2 years, TAR performed with ipsilateral hindfoot arthrodesis resulted in significant improvements in pain and functional outcome; in contrast to prior studies, however, overall outcome was inferior to that of isolated TAR. Level of Evidence: Level II, prospective comparative series. [ABSTRACT FROM AUTHOR]

The article discusses research which was conducted to investigate changes in gait mechanics from before surgery to one and two years after surgery in patients who received a fixed-bearing total ankle replacement (TAR). Researchers evaluated 51 patients. They found that there was improved or maintained functioning in patients who received a TAR and that the greatest improvement occurred within the first year following surgery.