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Patient-physician communication has the potential to improve outcomes and satisfaction through the shared decision-making process (SDM). This study aims to assess the relationship between perception of SDM and demographic, clinical, and patient-reported outcomes in patients undergoing Hallux Valgus (HV) correction. A prospective analysis of 306 patients scheduled for HV surgery was completed. The CollaboRATE score was used to measure SDM. Multivariable linear regression model was used to assess whether SDM scores were associated with preoperative characteristics or postoperative outcome scores. The mean CollaboRATE score was 2.9 (SD 0.9) and did not differ by age, socioeconomic status, or sex. Lower CollaboRATE scores were associated with more symptoms of depression, lower socioeconomic status, and lower general health scores (p-value

Category: Ankle Arthritis; Ankle Introduction/Purpose: Currently there are two major surgical options for the treatment of end-stage ankle arthritis (ESAA), namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA). Many patients inquire about what shoes they can expect to wear after surgery. Shoes should fit to the patient’s feet, help shielding pathological joints, be comfortable, but also fashionable, as they are part of personal style and fashion. The impact ESAA surgery has on choice of shoes and consecutively on quality of life, has not been studied. Potentially maintenance of ankle range of motion and improved gait mechanics with TAA could also improve the ability to comfortably wear different styles of shoes. The purpose of this study is to evaluate the effects of either AA and TAA on shoe-wear. Methods: This study is a retrospective analysis of a cohort of ESAA patients surgically treated with AA or TAA from the COFAS (Canadian Orthopaedic Foot and Ankle Society) database. Patient’s shoe wear comfort was obtained from the Musculoskeletal Outcomes Data Evaluation and Management Scale questionnaire, completed pre-operatively and post-operatively two and five years following surgery. The relationship between ankle-related quality of life and shoe-wear comfort, adjusting for patient factors was evaluated. A linear regression model adjusted for age, gender, BMI, smoking status, presence of inflammatory arthritis and baseline score was calculated. Additionally, differences within each pre-operative COFAS grades were analyzed. Results: 104 patients after AA and 106 following TAR have been included. The mean pre-operative baseline score did not differ between the cohorts (39.36 for AA and 38.94 for TAA, respectively; p= 0.74). Comparing AA patients with TAA patient scores over a 5-year period, there was no difference in shoe-wear comfort after 2 years, but after 5 years scores significantly improved for TAA patients (p= 0.02). Subgroup analysis showed that COFAS 4 patients improved the most with significant changes already after 2 years (mean difference 5.4, p=0.05), which further improved after 5 years of follow-up (mean difference 10.7, p=0.001). Conclusion: This study is the first study to elucidate patient experience after ankle arthrodesis and total ankle arthroplasty with regards to their shoe-wear. Patients undergoing TAR have better shoe-wear scores by five years post-operatively than those undergoing AA. Especially patients with a COFAS 4 grade, which represents a patient population with adjacent joint arthritis, show significant improvement already 2 years after surgery. This data is useful when counselling patients preoperatively, and further provides support for TAA over AA after appropriate patient selection.

Category: Ankle Arthritis; Hindfoot Introduction/Purpose: Ankle arthrodesis (AA) has, for many years, been considered the gold standard procedure for the surgical treatment of end stage ankle arthritis. Non-union following AA surgery is a devastating complication which subsequently requires revision surgery. However, data on outcomes including patient reported outcome measures (PROMs) following revision ankle arthrodesis (RAA) after failed AA is lacking. The aim of this study is to assess the outcome of RAA for symptomatic non-union after AA including PROMs. Methods: Prospectively collected data from a multicenter database of ankle arthritis surgery was analyzed. Demographic data and PROMs including Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) health survey were collected at regular intervals. Surgeries were performed by six fellowship-trained foot and ankle surgeons between January 2003 and July 2015. 336 primary AA cases were identified, of which 27 (8%) underwent revision for symptomatic AA non-union. Results: Mean follow-up of 27 AA non-union cases was 5.3 years (2-10). There were 16 (59%) males and 11 (41%) females, with a mean age of 62 years (44 - 81) and a mean BMI of 32 (26.5 – 45), respectively. At index AA, 12 (44%) cases were performed arthroscopically. Twenty-three (84%) AA non-union patients were actively smoking pre- and post-operatively, and 15 (56%) were diabetic. Overall union-rate following RAA was 85% (23/27). For RAA the pre-operative mean AOS score of 64.9 (38.8-81.5) improved to 49.1 (24.1-73) at latest follow-up. SF-36 PCS score improved from 27.2 (21.3 – 38.3) to 33.3 (19.1-54.2) and SF-36 MCS score improved from 41.2 (17.5-60.9) to 46.2 (29.3-65.9). Overall complication rate of RAA was 22%, with a re-operation rate of 15%. Conclusion: Revision ankle arthrodesis (RAA) for ankle fusion non-union resulted in a successful fusion of the ankle in 85% of patients with modest improvement in AOS and SF-36 scores. Indeed, even after successful RAA, patients report pain and disability levels comparable to that reported by primary AA patients pre-operatively. Additionally, complication and re-operation rates of RAA are high. This data emphasizes on the importance of achieving a primary fusion in AA. The presented patient reported outcomes may help the treating surgeon to counsel patients prior to RAA surgery to better set their expectations.

Category: Ankle Arthritis; Ankle Introduction/Purpose: End-stage ankle arthritis causes severe pain and disability. The most common treatment has been ankle arthrodesis (AA) with proven long-term results. However, total ankle arthroplasty (TAA) has become a viable option to preserve ankle joint motion, relieve pain and shield adjacent joints. And with the evolution of TAA prostheses over the past 2 decades, the use of TAA has been steadily increasing. Nevertheless, long term outcome data on the latest generation of TAA prostheses is scarce. The primary purpose of this study is to evaluate long-term PROMs after Infinity™ TAA and to compare the outcome to a patient cohort of ankle arthrodesis (AA) performed during the same time period. Methods: Patients with end-stage ankle arthritis who received surgical treatment with a primary Infinity TAA or AA performed between 2013-2015 were included in this study. All surgeries were performed by four fellowship trained foot and ankle surgeons. Patient reported outcomes (PROMs) comprising the AOS and SF-36 PCS score were prospectively collected for patients who were willing to enroll into the Canadian Orthopaedic Foot and Ankle Society (COFAS) database. PROM data was compared between the TAA and AA patient cohorts. Implant survivorship as well as revision and reoperation rates were also analyzed. Results: 33 patients/ankles underwent primary Infinity™ TAA and 59 patients/ankles underwent AA. Of these, 25 TAA and 46 AA were enrolled in the prospective database, 20 and 46 had PROMs available for follow-up, respectively. Mean TAA PROM follow- up was 6.8 years (3-9) and for AA 6.4 years (2-9). Mean TAA age at surgery was 67 years (54-85) and 58 years for AA (27-84). TAA total AOS score pre-operatively was 52.9, which improved significantly to 23.9. SF-36 PCS scores improved from 33.1 to 43.3. Pre- and post-operative PROMs were similar to the AA cohort. At clinical follow up of 8-10 years, TAA implant survival was 97% with one metal component exchange. Two TAA patients had two reoperations each. In the AA cohort, the reoperation rate was 10.8%. Conclusion: This is the first report on patient reported outcomes and implant survival at 8 or more years after primary Infinity™ TAA. PROMs remain significantly improved at long term follow-up and are comparable to a cohort of long-term AA patients. Revision rates were low with a single component revision in 33 patients resulting in an implant survivorship of 97%. Long-term outcome of the Infinity™ total ankle arthroplasty is promising.

The deltoid ligament is the primary stabilizer of the medial side of the ankle joint. It is a complex structure with an origin at the medial malleolus from where it spreads fan shaped distally with an insertion into the medial side of the talus, calcaneus and navicular bone. This chapter gives an overview of the anatomy, function, and pathology of the deltoid ligament. The deltoid ligament can become insufficient as a result of an ankle injury or prolonged strain. In the acute setting, deltoid insufficiency often coincides with multi ligament injury the ankle joint; syndesmosis injury, or ankle fractures. Management in the acute phase remains a subject of debate. Some orthopedic surgeons have a tendency towards repair, whereas most trauma surgeons often treat the deltoid nonoperatively. In the chronic setting the ligament complex is often elongated as a result of prolonged strain. It often coexists with a hindfoot valgus, as is the case in planovalgus feet. In such a case a realignment procedure should be combined with the deltoid repair.

Background:. This multicenter prospective cohort study assessed the safety and performance of the Trabecular Metal Total Ankle System (TM Ankle; Zimmer) for primary total ankle arthroplasty (TAA). Methods:. One hundred and twenty-one consecutive patients qualifying for primary TAA were enrolled in the study. All patients received the TM Ankle implant. Clinical outcome examinations and radiographic evaluations were conducted at 6 weeks, 6 months, 1 year, 2 years, and 3 years. Patient-reported outcome measures (PROMs) were evaluated with use of the EuroQol-5 Dimensions questionnaire (EQ-5D), Ankle Osteoarthritis Scale (AOS), American Orthopaedic Foot & Ankle Society questionnaire (AOFAS), and patient satisfaction at each time point. Complications were classified according to the Canadian Orthopaedic Foot and Ankle Society (COFAS) system. Results:. The average AOFAS, EQ-5D, AOS pain, and AOS difficulty scores showed significant improvement at 6 weeks, 6 months, 1 year, 2 years, and 3 years as compared with the preoperative baseline (p < 0.001). The Kaplan-Meier survival estimate for revision when used in primary cases was 97.35% at 3 years. During the 3 years of follow-up, 9 patients showed abnormal radiographic findings. Two ankles had intraoperative complications, 38 had complications that were non-surgical or device-related, and 3 ankles underwent revision. Conclusions:. The results of the present study indicated that patient well-being significantly increased following TAA with use of the TM Ankle. Radiographic parameters also demonstrated a low incidence of abnormal findings. Level of Evidence:. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background:. A recent survey of orthopaedic surgeons asking about risk factors for nonunion following foot and ankle arthrodesis revealed that patient age is considered to be a relatively low risk factor, despite the potential for autologous graft quality to deteriorate with increasing age. The purpose of the current study was to evaluate the impact of patient age and graft type on fusion rates following hindfoot and ankle arthrodesis. Methods:. In this study, we analyzed data from a previously published clinical trial, comparing fusion success in 397 subjects who underwent hindfoot or ankle arthrodesis (597 joints) supplemented with either autograft or an osteoinductive autograft alternative, recombinant human platelet-derived growth factor-BB homodimer carried in beta-tricalcium phosphate (rhPDGF-BB/β-TCP). The odds of fusion success were compared among subjects older or younger than age thresholds of 55, 60, 65, 70, and 75 years. The odds of fusion success were also compared between autograft and rhPDGF-BB/β-TCP among subjects older than each age threshold. Results:. In the autograft group, the joints of subjects who were younger than the age thresholds of 60 and 65 years had >2 times the odds of successful fusion compared with those of older subjects. There was no significant difference in the odds of fusion success between the older and younger subjects at the age threshold of 55 years. In the rhPDGF-BB/β-TCP group, there was no significant difference in the odds of successful fusion between older and younger subjects at any age threshold. When the odds of fusion success were compared between the 2 graft materials in subjects who were older than each age threshold, rhPDGF-BB/β-TCP had approximately 2 times the odds of fusion success compared with autograft for all thresholds, except 55 years. Conclusions:. The presented evidence suggests that age is an identifiable and concerning risk factor for hindfoot and ankle arthrodesis nonunion, a finding in contrast to the wider perception in the surgeon community. Notably, patients ≥60 years of age had significantly lower odds of fusion success with the use of autograft. The data reveal that use of rhPDGF-BB/β-TCP as an alternative bone-healing adjunct may help mitigate the risk of nonunion when these procedures are performed in the elderly population. Level of Evidence:. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Ankle arthritis is a major source of morbidity impacting a younger working age population than hip and knee arthritis. Unlike the hip and knee, more than 70% of ankle arthritis cases are post-traumatic, with the remainder being inflammatory or primary arthritis. Nonoperative treatment begins with lifestyle and shoe-wear modifications and progresses to bracing, physical therapy, anti-inflammatory medications, and intra-articular injections. Ankle arthrodesis and total ankle arthroplasty are the 2 main surgical options for end-stage ankle arthritis, with debridement, realignment osteotomy, and distraction arthroplasty being appropriate for limited indications. Level of Evidence: Level V, expert opinion.

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.

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus is the most common arthritic condition of the foot. A prospective, randomized, non-inferiority clinical trial of first metatarsophalangeal joint (MTPJ) hemiarthroplasty with a synthetic polyvinyl alcohol hydrogel implant, for moderate to severe hallux rigidus, demonstrated maintenance of MTPJ active dorsiflexion motion and excellent pain relief; additionally, the trial showed functional outcomes and safety equivalent to first MTPJ arthrodesis at 24 months (Baumhauer et al. 2016; FAI:37(5):457-469). Recognizing that many hemiarthroplasty and total toe implants have initially good results that deteriorate over time, the purpose of this study was to prospectively assess the safety and efficacy outcomes for the synthetic cartilage implant population and to determine if the excellent outcomes were maintained at >5 years. Methods: One hundred and fifty-two patients underwent implant hemiarthroplasty in the original trial; 14 underwent implant removal and conversion to fusion and 3 were lost to follow-up during the first 24 months, leaving 135 eligible for this study. One hundred patients were evaluated at 5+ years; 5 could not be reached for follow-up. Thirty are pending consent, follow-up, and/or data entry; their status will be available for inclusion at the conference presentation. Patients completed a pain visual analogue scale (VAS) and Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) scores, preoperatively and at 2, 6, 12, 26, 52, 104 and 260 weeks postoperatively. Minimal clinically important differences are: =30% difference for pain VAS, 9 points for FAAM Sports, and 8 points for FAAM ADL. Great toe active dorsiflexion, weight-bearing radiographs, secondary procedures, and safety parameters were evaluated. Results: Of 100 synthetic cartilage implant hemiarthroplasty patients available at mean 5.8 years follow-up (SD ±0.7; range: 4.4- 7.4), 5 underwent implant removal and conversion to fusion in years 2-5 (Figure 1), and 2 underwent subsequent surgical interventions during the pivotal trial and were censored, leaving 93 patients for evaluation. Pain and function outcomes observed at 5.8 years were similar to those at 2 years (Figure 1). VAS Pain and FAAM Sports Scores were maintained or improved at 5.8 years follow-up, but these differences were not clinically significant. Joint motion was maintained at 5.8 years. No evidence of avascular necrosis, device migration or fragmentation was observed upon independent radiographic review. Eighty-six percent of patients agreed their overall well-being had improved, and 92% would have the procedure again. Conclusion: Clinical and safety outcomes of patients having undergone synthetic cartilage implant hemiarthroplasty for the surgical treatment of hallux rigidus were previously demonstrated to be non-inferior to the gold standard treatment, MTPJ fusion, at 2 years. Prospectively determined outcomes for 100/135 of these implant hemiarthroplasty patients at 5.8 years are similar to those reported at 2 years. Longer-term results demonstrate that clinical and safety outcomes for synthetic cartilage implant hemiarthroplasty are durable, and that the implant remains a viable treatment option to decrease pain, improve function and maintain motion for advanced hallux rigidus.

Category: Ankle, Ankle Arthritis Introduction/Purpose: Ankle arthritis is a leading cause of pain and disability. Total ankle replacement and Ankle fusion are two common surgical treatments with successful outcomes. Despite the effectiveness of those treatments, a subset of patients remains with persistent pain and functional limitations. This has prompted the search for predictive tools capable of identifying patients who are likely to benefit from surgery which allows surgeons to provide valuable prognostic information, implement, and direct appropriate treatment programs. The purpose of this study is to use preoperative patient-reported outcome measures (PROMs) to predict which patients with end-stage ankle arthritis undergoing surgical treatment are most likely to experience postoperative improvements (a clinically meaningful change) in functional outcomes at an average follow-up of five years after surgical treatment. Methods: A prospective cohort design used to evaluate 427 Patients with end-stage ankle arthritis at preoperative baseline and an average of five years after undergoing total ankle replacement or ankle fusion at a single academic institution. Data on demographics, comorbidities, Ankle Osteoarthritis Score (AOS), and Physical components (PCS) of SF-36 were collected. The Canadian Orthopaedic Foot and Ankle Society Ankle Arthritis Score (COFAS-AAS) was calculated from the AOS. The Minimal clinically important difference (MCID) was then determined using a distribution-based method. A multivariable logistic regression analysis examined the variables affecting the change in PROM scores. Receiver operating characteristic (ROC) analysis was used to calculate threshold values, defined as the levels at which substantial changes occurred, and their predictive ability to determine whether preoperative PROM scores were predictive of achieving MCID. Results: Patients who scored worst at preoperative baseline made the greatest gains in function and pain relief following surgical treatment. ROC curves demonstrated that preoperative AOS, COFAS-AAS, SF-36 PCS physical function scores were predictive of postoperative improvements in physical function. Patients with preoperative AOS score above 45.7 had an 83% probability of achieving a clinically meaningful improvement in function as defined by MCID (area under the curve [AUC] 0.67). Similarly, Patients with preoperative COFAS-AAS score above 25.70 had a 78% probability of achieving MCID (area under the curve [AUC] 0.63). Patients with preoperative SF-36 PCS score below 31 had a 62% probability of achieving MCID (area under the curve [AUC] 0.64). MCIDs for AOS, COFAS-AAS and SF3-36 PCS score changes were 12.35, 9.99 and 6.43, respectively. Conclusion: In the present study, we identified PROM threshold values that predict clinically meaningful improvements in functional outcome in patients with end-stage ankle OA. Patients with a higher level of preoperative function are less likely to obtain meaningful improvement after surgical treatment. The results of this study may be used to facilitate discussion between physicians and patients regarding the expected functional benefit after surgery and to support the development of patient-based informed decision-making tools.

Category: Ankle Arthritis Introduction/Purpose: Early ankle arthritis can result in disabling symptoms and loss of function. However the degree of arthritis may not be severe enough or the symptoms severe enough to merit a fusion or replacement. For other patients they may wish to delay surgery to avoid financial issues with recovery time. Many of these patients have also been treated with NSAIDs, physiotherapy and bracing with variable effect. Stabilized long chain Hyaluronic acid (NASHA) has been used successfully in the knee, and has given a longer duration of effect compared to steroid injection. The purpose of this study was to determine the effect of hyaluronic acid in the ankle for sustainable symptom relief. Methods: A power analysis determined that a minimum of 29 patients would be required to appropriately power the study. A total of 37 adult patients with KL grade II and III ankle arthritis were enrolled in the study at a single institution. Patients recruited via a newspaper advertisement and from the surgical clinics and and screened for standard inclusion and exclusion criteria. The VAS pain preoperatively had to be greater than 30 / 100 mm. Outcomes were recorded at baseline, weeks 6, 12 and 26. The injection was performed after the baseline assessment using 1 ml of Hyaluronic acid NASHA (Q-Med AB, Uppsala, Sweden; DUROLANE 10 mg / mL) with or without local anesthetic to the skin. Outcomes included a VAS from the AOS scale for pain and disability, review of adverse events, physical exam, and use of rescue medication. Results: 35 of 37 patients completed the study. At baseline the VAS pain was 7.2 (SD +/-1.8). At 6 weeks the pain score was 5.4 (+/-2.5) improving by 1.8 points with a 26% improvement. At 12 weeks the pain score was 5.3 (+/-2.7) for a 29% improvement. At week 26 the pain score was 5 (+/- 2.7) for a 32% improvement. 4 adverse events were recorded – one patient reported increased pain after injection. One reported pain and swelling, one reported inflammation, and one pain after injection. Conclusion: This prospective cohort study shows promise for the use of Hyaluronic acid for the treatment of ankle arthritis with relief of symptoms up to 26 weeks after injection. The injection was safe for all 37 patients, although one patient reported pain and dropped out of the study. We would support the use of Hyaluronic acid for the treatment for moderate ankle arthritis. An RCT would be merited based on this study to compare results with placebo or cortisone injection.

Category: Ankle Arthritis Introduction/Purpose: Wait lists for consultation and surgery for ankle arthritis are often over three years in our Province. While waiting for surgery patients may become unemployed and lose income. Earlier consultation and earlier treatment may allow these patients to return to work. The purpose of this paper is to calculate the lost wages annually and over the remaining working lifetime of a cohort of patients, and use this to extrapolate the lost wages for patients undergoing ankle arthritis surgery in the Province of British Columbia. Methods: Using data from an ankle outcome database, patients under the age of 60 were studied. Employment was recorded at the time of surgery, at 2 years, and an average 6.7 years follow up. Using the MODEMS instrument, patients self classified as (1) working, (2) on leave of absence, (3) unemployed, (4) homemaker, (5) student, (6) Retired (not due to ill health), (7) disabled or retired due to ill health. Items 2,3,7 were considered unemployed and items 1,4,5,6 employed. Using annual rates of ankle arthritis surgery from our Province of 4.6 million people, the cumulative lost income was determined using the statistics Canada website (http://www12.statcan.gc.ca/nhs-enm/2011). Lost wages were calculated from the time of surgery until 75. All figures are quoted in Canadian dollars. Results: 127 of 276 database patients (46%) were under the age of 60 at the time of surgery. The average age was 51 years. 61 (48%) were unemployed. 2 years after surgery the unemployment rate was 42% and remained a similar rate at mean 6.7 years after surgery. There were 140 ankle arthritis operations in 2013 in our Province. Using the database rates the lost wages the working lifetime of these patients is $ 22.8 million. Using prior statistics (FAI 2015) the total surgical cost of ankle arthritis surgery in the Province is $ 1.1 million (1/20th the lost income). The cumulative lost wages per million population per year for ankle arthritis is 4.9 million dollars, and the money spent on surgery is 0.24 million dollars. Conclusion: The lost wages within the ankle arthritis population is of concern with regards to productivity, as well as the mental health and financial stability of these patients and their families. Earlier access to care may maintain the employment status in this patient group. Once patients are out of the work force it is very hard for them to return. The money spent on surgery is 1/20th of the lost wages.

Category: Ankle, Ankle Arthritis Introduction/Purpose: Patients living with end stage ankle arthritis suffer significant disability. They are two standard deviations below population scores for all symptom and function SF-36 sub-scales. In addition, they tend to be younger and still active in the workforce. The economic impact of disability attributable to end0stage ankle arthritis has not been quantified. In the era of cost- effectiveness, policy makers want to see tangible evidence to justify the cost of treatment. One common metric has been quality adjusted life years (QALYs). The purpose of this study is to determine the gain in QALYs attributable to surgical treatment of end- stage arthritis. Methods: This study is based on an existing longitudinal cohort of end stage ankle arthritis patients. The study cohort included 180 subjects (45% female, 55% male) with an average age of 61 years, treated with either ankle arthrodesis or arthroplasty. Patients responses to the SF-36 questionnaire were transformed to SF-6D using SF-6D preference based algorithm licensed software (University of Sheffield, UK) to calculate the health utility value at time of surgical consent and at one year postoperatively. The difference in health utility value was assumed to be the gain in health attributable to end-stage ankle arthritis surgery. Using three theoretical valuations per QALY; $20000, $50000, and $100000, based on previously published cost per QUALY for other orthopedic conditions, we calculated the valuation per QALY for treating ankle arthritis at one year post surgery. Results: The mean pre-surgical health utility value was 0.603, and post-surgically it was 0.690, an average gain in health in one year of 0.087 QALY. This is greater than what is considered the minimally important difference threshold. We then calculated the economic gain at QALY valuations of $20000, $50000, and $100000; at $20000/QALY the cost per QALY is $1740. At $50000 the gain is $4350 cost per QALY, and at $100000 it is $8700 per QALY. Conclusion: From this study cohort, surgically treating end-stage ankle arthritis has a meaningful health benefit for a range of cost per QALYs. Moreover, spending on surgical treatment of end-stage ankle arthritis is cost-effective. These results from this cohort provide valuable empirical insights into treating end-stage ankle arthritis - these findings are meaningful for policy makers faced with resource allocation demands.

Category: Midfoot/Forefoot Introduction/Purpose: Hallux metatarsophalangeal (MTP) arthrodesis is a common procedure for painful conditions of the great toe. Dorsal plate fixation for MTP arthrodesis using locked plates produces good clinical outcomes and superior biomechanical strength to other techniques. However, arthroscopic fusion with new generation full thread compression screws is emerging as an alternative to open fusion. This method has been utilized clinically with good outcomes, but the biomechanical strength of arthroscopic MTP fusion fixation techniques is unknown. The purpose of this study was to compare low profile contoured locked plates to new generation full thread compression screws for first MTP fusion, in a biomechanical cadaver model. We hypothesize that there will be no significant difference in plantar gapping during cyclic loading, stiffness, or load-to-failure between the two groups, Methods: The first rays of eight matched pairs of fresh frozen cadaveric feet underwent dissection and DEXA scanning to measure bone mineral density (BMD). The “plate” group was prepared with cup-and-cone reamers, and fixation of the MTP joint with one compression screw and low profile dorsal locked plate. The matched pair “screws” group was prepared through a simulated arthroscopic technique, achieving fixation with two new generation full-thread compression screws, while preserving capsular attachments. Each specimen was loaded on the proximal phalanx in a cantilever fashion to 90 N at 3 Hz for a total of 250,000 cycles. Plantar MTP gap was recorded using a calibrated extensometer; Load-to-failure testing was performed for all specimens that endured cyclical loading; and stiffness was calculated from the final load-to-failure. Data was analyzed with a Student’s T-Test, with significance set at p 0.7). Conclusion: Arthroscopic hallux MTP arthrodesis utilizing full thread compression screws has similar mean stiffness and load-to- failure compared to a low-profile locking plate, with significantly less plantar gapping. These data, combined with advantages of the arthroscopic preparation technique, support an increased role of arthroscopic fusion in lieu of more invasive open plating techniques. The two preload failures of the screws-only cohort occurred in specimens with the lowest BMD, potentially indicating a clinical contraindication with this technique. BMD and metatarsal width may aid in predicting early failure such that appropriate fixation construct and more conservative post-operative protocols might improve results for these patients.

Category: Sports, Trauma Introduction/Purpose: The need for repair of the ruptured achilles tendon has been discussed extensively in recent literature. A landmark paper in 2010 (Willits JBJS) outlined that the re-rupture rates were similar in surgical and non surgically treated Achilles tendon ruptures. However concern has to be raised as to the strength of the muscle tendon complex if the tendon is too long, potentially increasing the rate of late repair. This paper analyses the rate of acute achilles tendon repair and delayed repair before and after the 2010 publication of the Willits paper. Methods: Using the published billings from the Province of British Columbia, the rates per year of surgical repair of achilles tendon and delayed repair were determined. The population of British Columbia has increased over the years from 3.9 million in 1997 to 4.7 million in 2016. The rates of acute and chronic surgery were plotted prior to 2010, and since 2010. The rates were fitted against time using a linear and binomial plot. The rates in the years before and after 2010 were compared with ANOVA and the change of rate in time compared with Pearson’s correlation. Results: The rate of acute repair increased from 271 repairs in 1997 to over 400 repairs per year in 2009. The rate of acute repair has since dropped to just over 300 repairs per year. This is reflected in the enclosed binomial plot. There was a significant increase until 2010 (p

Category: Midfoot/Forefoot Introduction/Purpose: Many studies have compared the outcomes of MTPJ1 hemiarthroplasty and arthrodesis, but there is a paucity of data on the influence of patient factors on clinical outcomes. A prior prospective, randomized, clinical trial compared the efficacy and safety of first metatarsophalangeal joint (MTPJ1) hemiarthroplasty with a synthetic polyvinyl alcohol hydrogel implant (Cartiva®) and MTPJ1 arthrodesis for moderate to severe hallux rigidus. The current study evaluated the data from this clinical trial to determine the impact of numerous patient variables, including osteoarthritis grade, hallux valgus angle, preoperative range of motion (ROM), gender, body mass index (BMI), preoperative duration of symptoms, and preoperative pain level, on the success or failure of MTPJ1 hemiarthroplasty and arthrodesis. Methods: Patients =18 years diagnosed with hallux rigidus grade 2, 3, or 4 were randomized and treated with synthetic cartilage implant MTPJ1 hemiarthroplasty (n=129) or arthrodesis (n=47). Outcome measures included a pain visual analogue scale (VAS), Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) scores, and Short Form-36 Physical Functioning (SF-36 PF) subscore, obtained preoperatively and at 2, 6, 12, 24, 52 and 104 weeks postoperatively. Great toe active dorsiflexion motion, secondary procedures, radiographs and safety parameters were evaluated. A patient’s outcome was deemed successful if composite primary endpoint criteria for clinical success (pain, function and safety) were met at 24 months. Predictor variables included: osteoarthritis grade; hallux valgus angle; preoperative ROM; gender; body mass index (BMI); preoperative symptom duration; prior surgery; and preoperative pain level. Two-sided Fisher’s Exact test was used to assess the impact of these variables on success of surgery (p0.05) in success rates (i.e., VAS pain reduction ≥ 30%, maintenance/improvement in function, freedom from radiographic complications, and no secondary surgical intervention) between synthetic cartilage implant MTPJ1 hemiarthroplasty and arthrodesis when stratified by osteoarthritis grade, degree of preoperative hallux valgus, extent of preoperative ROM, gender, BMI, duration of symptoms, prior MTPJ1 surgery status, and preoperative pain VAS score (Table 1). Notably, patients with minimal ROM and mild hallux valgus had equivalent success rates for both procedures. Males tended to have greater clinical success with implant hemiarthroplasty versus arthrodesis, but this difference was not statistically significant. 1Baumhauer et al., FAI, 2016;37(5):457-69. Conclusion: Synthetic cartilage implant hemiarthroplasty is an appropriate treatment for patients with hallux rigidus of Coughlin grade 2, 3 or 4. Its results in those with associated mild hallux valgus (