Search

Category: Ankle Arthritis; Ankle Introduction/Purpose: A relatively frequent need for secondary surgery is an important consideration when treating end-stage ankle arthritis with total ankle arthroplasty (TAA). Despite a significant reported rate of non-revision reoperation after TAA, it is uncertain if these subsequent procedures have an impact on the longer term outcomes. It is imperative to know whether patients undergoing reoperation after TAA would have comparable functional ability compared to those with uncomplicated TAA in order to optimize patient outcomes when faced with complications after TAA. This study aimed to compare minimum five-year functional outcomes of patients who had undergone reoperation after TAA to those who did not require reoperation. Methods: Seventy-six ankles (74 patients) who underwent TAA with the Salto Talaris fixed bearing system between 2007 to 2014 were allocated into two groups based on presence (n=16) or absence of reoperation (n=60). Reoperations included all secondary procedures after index TAA, excluding revision surgeries requiring removal or exchange of the original prosthesis. The foot and ankle outcome score (FAOS) at preoperative and minimum five-year follow-up was compared between the groups. Additionally, improvements in FAOS subscales were compared. Preoperative deformity, postoperative implant alignment, number of periprosthetic cysts, and subsidence between groups were compared using standard weightbearing radiographs. A subgroup analysis was performed to compare clinical and radiographic outcomes of gutter impingement patients to those of uncomplicated group. Results: The most common cause of reoperation was gutter impingement (n=11), followed by stress fracture of the medial malleolus (n=2), tarsal tunnel syndrome (n=1), periprosthetic cyst (n=1), and infection (n=1). In comparison to the non- reoperation group, all FAOS subscales except for the Sports and Recreational Activities subscale were significantly lower in the reoperation group at final follow-up. The reoperation group exhibited significantly less improvement in the Pain, Symptoms, and Quality of Life subscales at final follow-up (p

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle arthroplasty (TAA) has garnered significant interest and increased use over the past decade, with advancements made in both design and surgical technique. The main advantage of TAA for the surgical treatment of ankle arthritis is to preserve range of motion compared to ankle arthrodesis. Among the criteria guiding the choice between arthroplasty and arthrodesis, the long-term survival and postoperative outcomes are of crucial importance. The Salto Talaris is a fixed-bearing implant first approved in the US in 2006, and long-term survivorship data is limited. The purpose of this study is to determine minimum 5-year survivorship of the Salto Talaris prosthesis and causes of failure. In addition, we evaluate long-term radiographic and patient-reported outcomes. Methods: We retrospectively identified 86 prospectively followed patients from 2007 to 2014 who underwent TAA with the Salto Talaris prosthesis at our institution. Of these, 81 patients (84 feet) had a minimum follow-up of 5 years (mean, 7.1; range, 5 to 12). Mean age was 63.5 years (range, 42 to 82) and mean BMI was 28.1 (range, 17.9 to 41.2). Survivorship was determined by incidence of revision, defined as removal/exchange of a metal component. Chart review was performed to record incidences of revision and reoperation. Preoperative, immediate and minimum 5-year postoperative x-rays were reviewed; coronal tibiotalar alignment (TTA) was measured on standing AP radiographs to assess alignment of the prosthesis. A TTA of +-5° from 90° indicated neutral alignment, while 95° was considered varus and valgus alignment, respectively. Radiographic subsidence as well as presence and location of periprosthetic cysts were documented. Pre- and minimum 5-year FAOS domains were compared. Results: Survivorship was 97.6% with two revisions. One patient underwent tibial and talar component revision for varus malalignment of the ankle, another underwent talar component revision for aseptic loosening and subsidence. The rate of other reoperations was 19.5% (18) with the main reoperation being exostectomy with debridement for ankle impingement (12). Average preoperative TTA was 88.8° with 48 neutral (average TTA of 90.1°), 18 varus (82.3°) and 8 valgus (99.6°) ankles. Average postoperative TTA was 89.0° with 69 neutral (89.7°), 6 varus (83°), and 1 valgus ankle (99.3°). Radiographic subsidence was observed in one patient who underwent revision, and periprosthetic cysts were observed in 18 patients. There was significant improvement in all FAOS domains at final follow-up. Conclusion: This is the largest study to date dedicated to evaluating survivorship of the Salto Talaris prosthesis. Our data reflects a high survival rate and moderate reoperation rate with long-term follow-up of the Salto Talaris implant. We observed significant improvement in radiographic alignment as well as patient-reported clinical outcomes at minimum 5-year follow-up.

Category: Other Introduction/Purpose: Cases of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus (COVID-19) first emerged in Wuhan, China, in December 2019. Since then, the virus has spread globally at a rapid pace. The first case in New York City was reported on March 1, 2020, and the World Health Organization (WHO) declared a pandemic on March 11, 2020. New York City rapidly became the epicenter of the pandemic, with hospitals across the city making a number of changes to accommodate the influx of COVID-19 patients. Here, we describe our experience in adapting to the COVID-19 pandemic as a department consisting of 10 foot and ankle fellowship-trained surgeons with up to 28 years of individual experience in an academic orthopedic hospital. Methods: Information was obtained from direct interviews with surgeons in the Foot and Ankle Service and from our institution’s intranet. Additional information was obtained by viewing twice-weekly livestreams from March 27th, 2020 to May 1st, 2020 held by the Surgeon-In-Chief, which detailed hospital-wide policies and initiatives being implemented in the wake of the COVID-19 pandemic. Results: On March 17, 2020, all elective surgeries were suspended at our institution, and a list of essential procedures was established. In-person clinical visits were limited to new patients being evaluated for essential procedures and first postoperative visits for returning patients, with all patients receiving pre-visit and on-site screening for COVID-19. All other new patient and follow-up appointments were conducted via telehealth visits. Much of our main hospital was repurposed to accept transfers of both COVID-negative and COVID-positive patients. A postanesthesia care unit and a floor of 9 operating rooms were repurposed as negative-pressure rooms for the care of critical COVID-positive patients on ventilators. An Orthopedic Triage Center (OTC) was established to relieve the patient load in the emergency departments of other hospitals in the city. Conclusion: By changing the way we delivered foot and ankle care and repurposing the roles of our employees and our institution, we have adapted strategies to continue delivering care to our patients. As we transition toward a ‘new normal,’ our goals are to gradually progress toward normal operations while keeping our patients and employees safe. With these gradual steps, we hope to emerge from this pandemic stronger and ready to adapt to the ever-changing needs of our community.

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus is a common arthritic condition seen by foot and ankle specialists. Historically, surgical treatment options have varied from an isolated cheilectomy to first metatarsophalangeal joint fusion. More recently, first metatarsophalangeal (MTP) joint hemiarthroplasty with a polyvinyl alcohol (PVA) hydrogel implant (Cartiva) has become a popular surgical option. A randomized clinical trial sponsored by the manufacturers of the implant showed equivalent pain relief and functional outcome scores at 2 year follow-up when compared to patients undergoing first MTP fusion. In addition, the study reported no bone loss, implant wear or loosening. We retrospectively reviewed 1 year PROMIS score outcomes, clinical outcomes and implant survivorship of patients treated with first MTP hemiarthroplasty with the Cartiva implant at an academic, multi-surgeon center. Methods: We retrospectively reviewed 54 consecutive patients that underwent first MTP hemiarthroplasty with Cartiva for hallux rigidus between January 1, 2017 and December 1, 2017. Minimum follow-up criteria was 1 year, with the average being 1.37 years and maximum follow-up of 1.9 years. The Coughlin radiographic grading of disease severity averaged 2.18 at the time of implantation on a scale of 0 to 4. Surgery was performed by 8 fellowship-trained orthopedic foot and ankle surgeons at an academic institution. Baseline PROMIS scores (physical function, pain interference, global function, global mental, depression) and PROMIS scores acquired at 1 year postoperative were compared and evaluated using the Wilcoxon signed t-test. Clinical outcomes and postoperative complications/events were documented through review of electronic medical records. At the time of the study, 49 patients had reached 1 year follow-up with an average age of 56 (range, 33 - 74) years at the time of implantation. Results: Physical function, pain interference, global function and depression scores all demonstrated clinically and statistically significant improvement at 1 year postoperative. Global mental score did not show significant improvement at the one year follow-up. One patient underwent revision surgery to a 1st MTP fusion for persistent pain. Three patients had postoperative soft tissue swelling requiring prolonged retained sutures. Five patients underwent therapeutic injection with steroid between 2 - 11 months postoperative for persistent discomfort which improved. Five patients were prescribed orthotics between 3 - 6 months follow-up. One patient sustained a metatarsal fracture during the application of the implant requiring ORIF but retained the implant. Implant retention at 1 year was 98% (48/49). No correlation between preoperative radiographic grading and the incidence of poor clinical outcomes. Conclusion: To our knowledge, this is the first study that demonstrates the outcomes of synthetic cartilage implants using a large series of surgeons without affiliation or consultation for the implant company. One year following first MTP hemiarthroplasty with PVA hydrogel implant (Cartiva), functional and pain scores improved significantly, but did not show significant improvement with global mental scores. The implant displayed excellent survivorship at the 1 year time point, with only one patient undergoing surgical revision. Treatment of hallux rigidus with the PVA hydrogel implant - Cartiva, shows improved patient outcomes and has reassuring results at one year.

Category: Other Introduction/Purpose: Individuals with inadequate health literacy and limited comprehension may lack the skills needed to make informed decisions about their health. They are also at risk for inferior treatment outcomes and are more likely to express dissatisfaction with their care. Unfortunately, the Institute of Medicine has declared low health literacy a “silent epidemic”, as approximately 50% of Americans are afflicted. Because foot and ankle disorders are common, often disabling, and at times utilize a variety of diagnostic and therapeutic modalities unfamiliar to patients, it is critical that we gain insight into patients’ foot and ankle comprehension. As such, we developed a novel questionnaire, the Foot and Ankle Literacy Survey (FALS), to evaluate this and the relationship between demographic factors and foot and ankle specific comprehension. Methods: The 14 question FALS (Figure 1A) was developed by our study group and was distributed to a consecutive series of 206 English-speaking adults presenting for first visits, immediate pre-operative evaluations, or one of a number of post-operative or follow-up visits in the foot and ankle practices of our senior authors and the ambulatory care clinic of an academic, urban medical center. The questionnaire’s content was based on the following four categories: 1) terminology, 2) anatomy, 3) conditions and treatment, and 4) perioperative considerations. These categories were chosen following our group’s review of the most commonly emphasized themes within the American Orthopaedic Foot and Ankle Society’s internet-based patient education website, FootCareMD.org. Participants completed the FALS and a demographic survey. Both overall and categorical performance were evaluated as a function of demographic characteristics via Wilcox Rank Sum, Kruskal-Wallis and McNemar’s testing. The level of significance for all tests was set at P < 0.05. Results: Participants’ demographic characteristics are presented in Figure 1B. The mean FALS score was 9.88 ± 2.67 out of a possible 14 points. Participants performed significantly worse on the conditions and treatment subsection as compared to the others (P < 0.05). Significantly better FALS performance correlated with race (Caucasian, P < 0.001), higher levels of education (College degree or higher, P < 0.001), visit type (Pre-operative evaluation, P < 0.002), and a current or previous healthcare occupation (P=0.008) (Figure 1B). Additionally, of those patients who had previously seen a provider (orthopaedic surgeon, podiatrist, orthopaedic surgeon and podiatrist, other provider) for a foot and ankle complaint, a significantly higher score was observed in patients who saw an orthopaedic surgeon versus other types of providers. Age, gender and anatomic region did not correlate with FALS scores. Conclusion: Patient comprehension of foot and ankle related terminology, anatomy, conditions, treatment, and perioperative issues is critical for successful encounters between orthopaedic foot and ankle surgeons and patients. This study has identified race, education, occupation, prior evaluation by an orthopaedic surgeon, and visit type as factors that significantly correlate with comprehension. With such knowledge, patient education can be focused on those most in need, an approach that we hope will improve health literacy and optimize outcomes. Admittedly, future research is pivotal and must identify the most effective means of educating patients and objectively evaluate the relationship between outcomes and patient comprehension.