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Background: This retrospective cohort study compared short-term complication rates following total ankle arthroplasty (TAA), alone or with concomitant procedures. Secondary independent risk factors were also examined as they related to postoperative outcomes. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology ( CPT ) codes to identify patients who underwent TAA (27702) between 2010 to 2021. Patients were divided into cohorts based on the presence or absence of ancillary procedures. Propensity score matching was employed to account for demographic differences, and statistical analyses were performed to compare short-term complication rates between matched cohorts. Results: A total of 2225 patients were identified, with 1432 (64.4%) receiving TAA alone and 793 (35.6%) with ancillary procedure(s). After matching, 793 patients were included in each cohort. The ancillary cohort had longer operative times ( P

Background: The incidence of primary total ankle arthroplasty (TAA) is rising, with a corresponding increase in revision surgeries. Despite this, research on risk factors for revision TAA following primary TAA remains limited. Radiographic soft tissue thickness has been explored as a potential predictor for outcomes in hip, knee, and shoulder arthroplasty, but its role in TAA has not been assessed. This study aimed to assess the predictive value of radiographic soft tissue thickness for identifying patients at risk of requiring revision surgery following primary TAA. Methods: A retrospective study was conducted on 323 patients who underwent primary TAA between 2003 and 2019. Radiographic measurements of soft tissue thickness were obtained from preoperative radiographs. Two novel radiographic measures of soft tissue thickness were developed and assessed (tibial tissue thickness and talus tissue thickness). Clinical variables including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, diabetes, smoking status, primary diagnosis, and implant type were recorded. Logistic regression analysis was used to assess the predictive value of soft tissue thickness and BMI for revision TAA. Results: The rate of revision surgery was 4.3% (14 of 323 patients). Patients requiring revision had significantly greater tibial tissue (3.54 vs 2.48 cm; P = .02) and talus tissue (2.79 vs 2.42 cm; P = .02) thickness compared with those not requiring revision. Both the tibial tissue thickness (odds ratio 1.16 [1.12-1.20]; P

Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. They require a strong plan. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment required to achieve a satisfactory result. In general, operative treatment is reserved for patients with displaced OLTs or for patients who have failed nonoperative treatment for 3 to 6 months. Operative treatments can be broken down into cartilage repair, replacement, and regenerative strategies. There are many promising treatment options, and research is needed to elucidate which are superior to minimize the morbidity from OLTs.

Category: Midfoot/Forefoot Introduction/Purpose: Functional hallux rigidus is characterized by limited first metatarsophalangeal (MTP) dorsiflexion during weight bearing conditions, but normal motion when the metatarsal is allowed to plantarflex. This phenomenon alters the mechanics of the foot, potentially leading to lateral column overloading and dynamic cavovarus. Furthermore, it is suspected that the abnormal forces across the first MTP alters its biomechanics, leading to cartilage destruction and eventual structural hallux rigidus. The purpose of this study is to assess the role of the flexor hallucis longus (FHL) and plantar fascia in functional hallux rigidus and to determine the best surgical treatment. Methods: Six cadaveric lower limbs disarticulated at the hip were analyzed. The feet were positioned manually in the same manner that would be used in a clinical exam of patients. The examiner's thumb was used to stabilize the first metatarsal head and prevent plantarflexion to simulate the closed-chain kinetics of weight bearing. The same hand was used to hold the ankle neutrally aligned to the leg. The other hand was used to maximally dorsiflex the great toe. X-ray was used to obtain images of the feet. The plantar fascia was transected with a Z cut, shortened approximately 5 mm, then repaired. The fiberosseous tunnel was released. The FHL was transected with a Z cut then shortened approximately 5 mm. Great toe dorsiflexion was assessed and X-rays taken after each of the manipulations. Range of motion of the first MTP was measured on Xrays and analyzed using Student's T-test. Results: Average passive dorsiflexion of the first MTP is 29.8° (range 17-46°) prior to manipulation. Shortening the plantar fascia and FHL did not decrease the MTP dorsiflexion significantly beyond baseline (P = 0.08, 0.09 respectively). Transecting the plantar fascia increased the dorsiflexion by 14° (standard deviation (SD) 9.5) and transecting the FHL increased dorsiflexion by 13.7° (SD 4.0). Dorsiflexion increased significantly beyond baseline with both these methods (P = 0.02 and P < 0.001 respectively), but the difference between the two methods was not significant (P = 0.93). Releasing the fiberosseous tunnel alone increased the dorsiflexion 8.8° (SD 5.7). Increased dorsiflexion beyond baseline was significant (P = 0.03). The increase in dorsiflexion with fiberosseous tunnel release was not significantly different than transecting the plantar fascia or the FHL (P = 0.40 and 0.42 respectively). Conclusion: By definition, functional hallux rigidus is diagnosed when first MTP dorsiflexion cannot reach 60°. Its prevalence may be more widespread than previously identified. Both the FHL and plantar fascia are implicated in functional hallux rigidus, as transection of either improves the dorsiflexion of the great toe. However, accessing the plantar fascia comes with significant risks and complete transection of the FHL is not feasible. As an alternative, releasing the fiberosseous tunnel is a simple, minimally morbid procedure that can also significantly improve functional hallux rigidus to a similar degree.

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Kim et al.'s simulated weight-bearing CT (WBCT) investigation classifying first metatarsal (M1) pronation and its relationship to the metatarso-sesamoid complex suggested a high prevalence (87.3%) of M1 hyper-pronation in hallux valgus (HV). These authors' conclusions have prompted a marked increase in M1 derotation (supination) in HV surgical correction. No subsequent study confirms their M1 pronation values, and two recent WBCT investigations suggest lower normative M1 pronation values. The objectives of our WBCT study were to (1) determine M1 pronation distribution in HV, (2) define the hyperpronation prevalence compared to preexisting normative values, and (3) assess the relationship of M1 pronation to the metatarso-sesamoid complex. We hypothesized identifying a high HV M1 head pronation distribution, but not as high as suggested by Kim et al. Methods: We retrospectively identified 88 consecutive feet with HV in our WBCT dataset and measured M1 pronation with two previously validated methods, the Metatarsal Pronation (MPA) and α angles. Similarly, using two previously published methods defining the pathologic pronation threshold, we assessed our cohort's M1 hyper-pronation prevalence, specifically (1) the upper value of the 95% confidence interval (CI95) and (2) adding 2 standard deviations at the mean normative value (2SD).The position of the sesamoids relative to the crista on the axial plane (sesamoid grading) was assessed according to Talbot et al. classification secondarily adapted by Yildirim et al. on CT scan (Figure).Normality of different variables was assessed using the Shapiro-Wilk test and distribution histogram. Two groups were compared using Student's t-test for normal, and Mann-Whitney U test for non- normal variables. P values less than .05 were considered significant. Results: The mean MPA was 11.4+/-7.4 degrees (IC95%:9.9-13.0; Range: -2.3-37.1) in our HV population and the α angle was 16.2+/-7.4 degrees (IC95%:14.7-17.7; Range: 2.8-43.2). A strong positive correlation was found between these two variables (ρ=0.82;r2=0.79;P

Category: Bunion Introduction/Purpose: To evaluate the outcomes of 1st MTP motion preserving hallux valgus surgery using Patient Reported Outcomes (PROMs) in the literature since 2001. This paper also tries to eliminate some of the heterogeneity in reporting by using the effect size of the treatment using Minimally Important Clinical Differences (MCIDs). Methods: For this systematic review, we searched for peer-reviewed English-language articles published in 2001 or later, using the electronic databases Medline, Embase, SCOPUS, PEDro, CINAHL, Global Index Medicus, Web of Science, and World Wide Science. There were a total of 5,544 articles published on bunions. We reviewed all the abstracts and 1,200 papers were selected for full text evaluation. Finally, we analyzed 310 of the articles for this review. In total, there were 21,109 patients in 401 cohorts that underwent surgery on a total of 24,231 feet. Results: Our primary endpoint was patient reported outcomes measures (PROMs) and was stratified based on location of the osteotomy on the metatarsal shaft as well as follow up time. AOFAS was the most common PROM used and was included in 83.5% of the articles. We found that double osteotomies had the greatest overall change score in PROMs with an overall mean improvement of 1.69 MCIDs (CI +/- 0.7), compared to 1.23 (CI +/-0.46) for distal osteotomies; shaft and proximal osteotomies were similar to the distal subgroup. Although it had the highest positive change, double osteotomies were associated with the highest complication rates of recurrence (11.2%), malunion (4.8%), and avascular necrosis (3.2%). Minimally invasive vs open techniques had similar changes in HVA, IMA, and PROMs. There was a slightly higher satisfaction rate in the Open group at 91.6% vs 89.6% in the MIS group. Conclusion: Bony correction of bunions demonstrated a clinically significant improvement in patient reported outcomes with an aggregate MCID between 1.26-1.69. They performed significantly better than soft tissue procedures +/- proximal phalanx osteotomy. Although double osteotomy did perform better than the other bony osteotomies it did have a higher complication rate and the group was a much smaller cohort which makes it more susceptible to bias. MIS vs Open bunion correction demonstrated similar correction and AOFAS scores, the satisfaction rate was about 2% higher in open which was statistically significant but may not have clinical significance

Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: The utilization of total ankle arthroplasty (TAA) has increased over the past decade to include bilateral TAAs. The risk-benefit profiles of simultaneous versus staged joint arthroplasty continues to be debated in the literature. There are limited case series reporting outcomes after bilateral TAA with no previous comparison of simultaneous versus staged TAA. It is important to study patients with bilateral pathology as they represent a unique population often with a differing arthritis etiology and an overall more debilitating condition. Thus, we aim to compare bilateral simultaneous versus staged TAAs including perioperative complications and patient reported outcome measures (PROMs). Methods: We performed a comparative cohort study of patients who underwent primary TAA from 2007 to 2019 at a single academic center. Inclusion criteria were primary bilateral TAA performed in simultaneous or staged fashion in patients over 18 years of age. Exclusion criteria were patients with less than two-years follow-up and those with previous tibiotalar arthrodesis or infection. Patient demographics, comorbidities, perioperative complications, and PROMs were collected. PROMs included preoperative and postoperative visual analog scale (VAS) for pain, the Short Form-36 (SF-36) Health Survey, the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Short Musculoskeletal Function Assessment (SMFA) bother and function sub-scores. Bivariate tests of significance were used to compare variables between the two cohorts. Results: Fifty patients were included with an average clinical follow-up was 52.2 (+-27.3; range 24-109) months. The mean time between staged TAA surgeries was 17.5 months (+-20.1, range 3-74). The mean age was 64.3 (+-10.6, range 21-76) years with 32 (64.0%) men. Many patients had primary osteoarthritis (n=28, 56.0%). Both cohorts experienced improvement in all PROMs at one year, which were maintained at final follow-up with no significant between-group differences (p >0.05). There were no differences in perioperative complication rates with similar overall complications (22.0% vs. 24.0%; p=0.7788) and reoperations (6.0% vs 5.0%; p=0.7354) between the simultaneous and staged cohorts, respectively. The two-year and five-year reoperation-free survival were 96.0% and 90.0% for the staged cohort and 94.0% and 88.0% for the simultaneous cohort, respectively (p=0.4612) Both cohorts had 100% failure-free survival up to eight-years postoperative. One patient in the simultaneous cohort required metal component revision at eight years postoperative. Conclusion: The results of bilateral simultaneous TAA, including patient reported outcomes, perioperative complications, and component survival are comparable to patients undergoing staged TAA. When performed under surgeon expertise in appropriately selected patients, we advocate that simultaneous bilateral TAA is a safe and effective method for the treatment of bilateral end-stage ankle osteoarthritis. Potential benefits of simultaneous TAA warranting further investigation include decreased anesthesia events, surgery time, tourniquet time, length of hospitalization, recovery and rehabilitation time, and overall cost. Future investigations will include dedicated analyses of radiographic outcomes and cost comparisons between these two cohorts.

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Hallux valgus (HV) is recognized as a triplanar deformity comprising axial abduction, sagittal hypermobility, and coronal pronation of the first metatarsal. A first tarsometatarsal (TMT) arthrodesis may be used to address all three planes of deformity. The Lapiplasty system (Treace Medical Concepts, Inc., Ponte Vedra, FL) was developed to reproducibly address triplanar deformity. However, the Lapiplasty system is costlier than other fixation constructs. Because healthcare is increasingly value-focused, we sought to determine if the more expensive Lapiplasty system improved radiographic outcomes or decreased complication rates over standard cross-screw fixation. We hypothesized that HV patients undergoing first TMT arthrodesis with the Lapiplasty system would have equivalent radiographic correction and similar complication rates when compared to patients treated with cross-screw fixation. Methods: In this multi-center, IRB-approved retrospective study, consecutive series of patients who underwent 1st TMT arthrodesis for HV, either with cross-screw fixation at Institution A, or Lapiplasty at Institution B, were identified by registry search. Inclusion criteria included age over 18 and preoperative and minimum 6-month postoperative weight-bearing AP and lateral radiographs. Exclusion criteria included primary conditions other than hallux valgus and previous first ray surgeries or ipsilateral arthrodeses. Hallux valgus angle (HVA), intermetatarsal angle (IMA), and tibial sesamoid position (TSP) were measured preoperatively and at final follow-up, and clinic notes were reviewed to identify complications and reoperations. To compare cohorts, Mann-Whitney U tests and Fisher's Exact tests were applied for continuous and discrete variables, respectively. To examine preoperative-postoperative changes, Wilcoxon signed rank tests were used. Multivariable regressions tested the effect of fixation constructs on postoperative radiographic parameters, adjusted for preoperative radiographic measurements, age, sex, and BMI. Results: 65 patients were included in each group, with 121 (93.8%) female patients, mean (SD) age 54.7 (14.8), BMI 25.8 (5.2), and radiographic follow-up time 8.9 (6.7) months. The Lapiplasty cohort had greater BMI (26.8 vs. 24.7, P = .048), and there were no significant differences between groups in age, sex distribution, and radiographic follow-up time. Radiographic measurement data is displayed in Table 1. After adjusting for age, sex, BMI, preoperative HVA, and preoperative IMA, fixation with Lapiplasty was significantly associated with lower postoperative IMA (b=-2.03, 95% CI = [-2.78, -1.37], P < .001) and lower postoperative HVA (b= -7.48; 95% CI = [-9.69, -5.26]; P < .001), but not postoperative sesamoid position. There were no significant differences between cohorts in the incidence of complications or reoperations. Conclusion: We found that use of the Lapiplasty system was associated with better radiographic hallux valgus correction, as evidenced by lower postoperative HVAs and IMAs, compared to standard technique with crossing screws. The clinical significance of these findings is unclear, as complication and reoperation rates were similar between groups. Future research assessing longer- term outcomes, patient-reported outcome data, and cost-benefit analysis will be necessary to further compare techniques and fixation systems.

Category: Ankle; Hindfoot Introduction/Purpose: End-stage ankle osteoarthritis is a debilitating condition that often results in limited tibiotalar range of motion. Total ankle replacement (TAR) preserves ankle range of motion and improves the patient's functionality. Tendo-Achilles lengthening (TAL) and gastrocnemius recession (GR) are concomitant procedures often performed with TAR to improve tibiotalar dorsiflexion. The purpose of this study is to determine the effect of a TAL and GR during TAR on radiographic range of motion compared to a control group without a lengthening procedure. Methods: A retrospective review of a prospectively maintained TAR database was conducted from November 2015 - June 2020 at a single academic institution. All surgeries were performed by fellowship-trained foot and ankle surgeons. Inclusion criteria included greater than18 years of age and a minimum of one-year radiographic follow-up with both preoperative and postoperative weight-bearing, range of motion radiographs. Exclusion criteria included concomitant 1) calcaneal osteotomies, 2) hindfoot or midfoot arthrodesis, 3) prior ankle arthrodesis, or 4) revision total ankle arthroplasty. A total of seventy-five patients (TAL, n = 40; GR, n = 35) were included with a control group of seventy-five consecutive patients who underwent TAR without a lengthening procedure. Demographic and clinical data were extracted from the TAR database. Preoperative and postoperative radiographic assessment included a measurement of dorsiflexion and plantarflexion. All measurements were performed by two members of the research team. Results: A total of 150 patients were included in this study: TAL: n = 35, GR: n = 40, Control: n = 75. Dorsiflexion significantly improved by 3.4° (p=0.0053) and by 6.7° (p < 0.0001) in the TAL and GR cohorts respectively with no significant difference in the control group (+1.3°, p=0.0857). Plantarflexion was significantly decreased by 3.6° (p=0.0378) and by 6.6° (p=0.0002) in the TAL and GR cohorts respectively with no significant difference in the control group (+0.3°, p=0.7863). The total arc of motion did not change significantly for any of the three groups postoperative (control 1.63°, GR 0.05°, TAL -0.20°; all p>0.05). There were no significant between-group differences in the change in overall arc of motion between the groups (p=0.3913). Compared to TAL group, GR resulted in a greater increase in dorsiflexion (6.7° versus 3.4°; p=0.0459) with a reciprocal, albeit non-significant, greater decrease in plantarflexion (6.8° versus 3.6°; p=0.1598). Conclusion: Both TAL and GR significantly increased postoperative dorsiflexion; however, this was accompanied by a reciprocal significant loss in plantarflexion. GR resulted in double the improvement in dorsiflexion and loss in plantarflexion compared to TAL. The total arc of motion did not significantly change for the control, GR, or TAL cohorts. Patients should be counselled that their preoperative range of motion (ROM) will dictate their postoperative ROM, and that concomitant procedures performed to achieve an increase in dorsiflexion will do so at the expense of plantarflexion.

Category: Ankle; Ankle Arthritis Introduction/Purpose: The indications for both total talus replacement (TTR) and total ankle replacement (TAR) are expanding. Combined total ankle-total talus (combined TAR) is a novel treatment option for patients with end-stage ankle arthritis and talar avascular necrosis (AVN) and patients with a prior TAR and talar component collapse. End-stage talar AVN with subchondral collapse is a challenging entity to treat. Historically, an alternative treatment option was tibiotalocalcaneal arthrodesis with structural allograft which results in fair outcomes including nonunion rates up to 40%. Combined TAR is a treatment option that theoretically maintains joint range of motion and restores anatomic alignment. The purpose of this study is to evaluate the short-term outcomes for combined TAR including pain, functional outcomes, radiographic outcomes, and complications. Methods: Consecutive patients who underwent combined TAR from 2016-2020 were retrospectively reviewed. All surgeries were performed by one of four fellowship-trained foot and ankle orthopaedic surgeons at a single academic institution. All talus implants were custom 3D printed total tali (Additive Orthopaedics, Little Silver, NJ), composed of an alloy primarily made of cobalt chrome. The implants were sized based on computed tomography scans of the contralateral talus and created to articulate with multiple TAR systems. Patient demographics, comorbidities, and surgical data were collected. Outcomes included the Visual Analog Scale (VAS) scores, radiographic alignment, range of motion, and complications. Data analysis was performed with paired t- tests and a significance level of p

Category: Ankle Introduction/Purpose: The management of large osteochondral lesions of the talar shoulder remains a clinical challenge. Their size, three-dimensional geometry, and subchondral cystic degeneration often preclude treatment with traditional measures such as microfracture and osteochondral autograft transplantation. Structural or bulk osteochondral allograft transplantation has demonstrated efficacy in several retrospective reviews. The purpose of this study was to prospectively evaluate patients who received fresh structural allograft transplantation to the talus. Methods: A prospective evaluation of consecutive patients who underwent fresh structural allograft transplantation for an OLT form 2010 to 2019 was performed under Institutional Review Board approval. All patients failed a minimum of 6 months of conservative management. Preoperative MRI and/or CT, as well as plain radiographs were obtained on all patients. The following patient reported outcomes questionnaires were administered preoperatively and yearly after surgery: 100mm VAS pain scale, AOFAS Ankle-Hindfoot Scale, SF-36, and the Short Musculoskeletal Functional Assessment (SMFA). Pre- and postoperative radiographs were assessed for allograft incorporation and the development of arthritis. Results: 27 patients underwent fresh osteochondral allograft transplantation and were followed for a minimum of 2 years. The mean follow-up was 5 years (range 2-11). The average size of the OLT was 2,269 mm 3 (range 813-8,366) based on CT imaging and 5,797 mm 3 (range 1,136-12,489) based on MRI imaging. There was significant improvement in the VAS pain score, AOFAS Ankle- Hindfoot Scale score, the SF-36 total score, and the SMFA functional and bother indices (Figure 1). Thirteen (48%) of the patients required subsequent surgery. Twelve underwent removal of hardware and joint debridement and one patient underwent isolated joint debridement. At the time of these surgeries, two grafts demonstrated cartilage delamination. One of these patients had continued pain and progression of arthritis without additional surgery and one was converted to an ankle replacement. Therefore, the failure rate was 7%. Conclusion: Significant improvement in pain and function can be achieved with structural allograft transplantation for large OLTs. However, it is important to council patients that painful hardware and stiffness can occur in approximately one-half of patients. An unstable graft and cartilage delamination are indicators of subsequent failure. The use of a structural allograft does not preclude subsequent ankle arthrodesis or arthroplasty.

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: The utilization of total ankle replacement (TAR) for end-stage ankle osteoarthritis continues to increase in the United States. From 2011-2012, 47.5% of all TAR were covered by Medicare insurance, which represents a large insurance market share for inpatient ankle surgeries. However, there is a growing trend in orthopedics toward performing outpatient surgery. There have been studies that demonstrate the cost benefits and safety of outpatient TAR surgery. However, previous cost studies involve a single implant, small sample size, and lack clinical outcomes. Thus, we aim to compare the costs and clinical outcomes associated with TAR in the outpatient versus inpatient settings. 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 yo. The implant types were: Infinity (39.3%), Salto (38.2%), INBONE (15.2%), Vantage (7.3%), and STAR (3.4%). 47.8% of patients were covered under managed care and 42.1% under Medicare. There were no significant differences in medical comorbidities (p > 0.05) or concomitant surgeries (p=0.4574) between inpatient and outpatient groups. There was no difference in complications between inpatient and outpatient groups (p= 0.9652). Inpatients had a greater improvement in their SMFA function score compared to outpatients (p=0.0442). Both inpatient and outpatient cohorts significantly improved in all other reported patient reported outcomes at final follow-up (0.05). The total direct cost was higher for the inpatient group ($15,340.1) versus outpatient group ($13,002.6) (p

Category: Ankle; Ankle Arthritis Introduction/Purpose: The utilization of total ankle arthroplasty has increased over the past decade, including bilateral TARs. The risk-benefit profiles of staged versus simultaneous joint arthroplasty continues to be debated in the literature. Previous studies of the hip and knee have demonstrated simultaneous bilateral surgery is associated with shorter hospitalization, shorter recovery and rehabilitation time, and decreased cost without increasing perioperative morbidity or mortality. There are limited case series reporting outcomes after bilateral TAR with no previous comparison of simultaneous versus staged TAR. Thus, we aim to compare our experience with bilateral simultaneous versus staged TARs including perioperative complications and patient reported outcomes. Methods: We performed a retrospective study on 62 patients (124 ankles) undergoing primary TAA (CPT 27702) from 2008 at a single academic center. Inclusion criteria were primary bilateral TAA performed in staged or simultaneous fashion in patients over the age of 18 years-old. Exclusion criteria were patients with less than one-year follow-up. Patient demographics, comorbidities, concomitant procedures, perioperative complications, and patient reported outcomes were also collected. Patient reported outcomes included preoperative and postoperative visual analog scale (VAS) for pain, the Short Form-36 (SF-36) Health Survey, the American Orthopaedic Foot & Ankle Society (AOFAS) score, the Foot and Ankle disability Index (FADI) score, and the Short Musculoskeletal Function Assessment (SMFA) bother and function sub-scores. Every patient had separate outcome scores available for each ankle. Univariate and multivariable tests of significance were used to relate patient and operative characteristics to outcomes. Separate subgroup analyses were performed comparing stages versus simultaneous surgeries. Results: The mean age was 63.7 years-old with a mean duration of 40.5 months of clinical follow-up. There were no significant pre-operative differences between simultaneous and staged groups in terms of age, gender, BMI, ASA classification, or arthritis etiology (p>0.05). The majority (54.5%) of patients had primary or secondary arthritis. Comorbidities were similar between the two groups with the exception of the simultaneous cohort having a higher proportion of previous smokers (56.3 vs 26.1, p=0.0020) and coronary artery disease (19.8 vs 6.5, 0.0447). There was no difference in perioperative complications between the groups(p= 0.4652). Both cohorts significantly improved in all reported patient reported outcomes at final follow-up (0.05) (Table 1). Conclusion: The prevalence of osteoarthritis (primary arthritis) and inflammatory arthritis (secondary arthritis) was higher in patients with bilateral end-stage arthritis necessitating a TAR than previous reports of unilateral TAR. The results of bilateral simultaneous TAA, including perioperative complications and patient reported outcomes, are comparable to patients undergoing staged TAA. We advocate that simultaneous bilateral TAA is a safe and effective method the treatment of bilateral end-stage ankle osteoarthritis in a setting where experienced surgeons are available. Potential benefits of simultaneous TAR for further investigation include decreased: anesthesia events, surgery time, length of hospitalization, recovery and rehabilitation time, and overall cost.

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) use has increased with newer generation implants. Current reports in the literature regarding complications use data extracted from high-volume centers. The types of complications experienced by less experienced centers may not be reflected in these reports. The purpose of this study was to determine a comprehensive TAA adverse event profile from a mandatory-reporting regulatory database. Methods: The US Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2015-2018 to determine reported adverse events for approved implants. We recorded the type of adverse event and excluded duplicate reports and those extracted from already published literature. We categorized the adverse events into infection, intraoperative guide/jig error, component loosening (tibia or talus), cyst formation, component fracture, gutter impingement/heterotopic ossification, iatrogenic fracture, polyethylene wear, component dissociation, malalignment, malalignment recurrence, direct surgeon error, and miscellaneous. The overall percentage distribution of each of the adverse events failure causes was calculated as was the percentage distribution for each total ankle device. Results: Among 408 unique TAA device failures, the modes of failure listed by commonality were component loosening (17.9% [9.6% tibia, 8.3% talus]), intraoperative guide or jig error (15.4%), infection (13.7%), cyst formation (12.7%), gutter impingement/heterotopic ossification (10.3%), component fracture (9.6%), iatrogenic fracture (5.4%), poly wear (3.7%), component dissociation (3.2%), malalignment (2.5%), miscellaneous (2.9%), malalignment recurrence (2.2%), and direct surgeon error (0.5%). These were consistent with some systematic reviews of the literature but in disagreement with others which found high rates of iatrogenic fracture. In addition, the percentage distribution of adverse event failure types differed among implants. Conclusion: The MAUDE database is a publicly available method which requires mandatory reporting of approved device adverse events. Using this report, we found general agreement in types of complications reported in the literature, although there were some differences. In addition, intraoperative guide or jig errors were very common and may not have been previously appreciated. This data may more accurately reflect a comprehensive profile of TAA complications as data was taken from a database of all device users rather than only high-volume centers.

Category: Ankle Arthritis; Ankle Introduction/Purpose: The purpose of this study was to report on the radiographic outcomes, clinical outcomes, and implant survivorship following extramedullary-referenced (EMr) versus intramedullary-referenced (IMr) total ankle replacement (TAR). Methods: From May 2007 to February 2018, a consecutive series of patients with end-stage tibiotalar osteoarthritis undergoing TAR for primary arthritis, post-traumatic arthritis, and inflammatory arthritis was enrolled in this study. Analyses were performed comparing IMr versus EMr components for patient-reported outcomes data, pre and postoperative radiographic ankle alignment, concomitant procedures, and complications. Kaplan-Meier survivorship analyses served to determine implant reoperation and revision surgery. Data was prospectively collected and retrospectively analyzed. A p-value of < 0.05 was considered significant for all statistical analyses. Results: A total of 340 TARs were included with 105 IMr TAR and 235 EMr TAR. The mean follow-up was 5.3 years ( +- 2.5, range 2-12). The absolute value for preoperative coronal alignment was significantly greater for IMr compared to EMr TAR (13.0 vs 6.4 degrees; p < 0.0001), but both groups achieved near neutral alignment postoperatively (1.4 vs 1.5 degrees; p=0.6655). The odds of having a concomitant procedure was 2.7 times higher in patients with an IMr TAR (OR 2.7, CI 1.7-4.4; p-value 0.05). The 5-year implant survivorship was 98.6.% for IMr versus 97.5% for EMr at final follow-up. Conclusion: Despite the IMr TAR group having more severe preoperative coronal and sagittal malalignment, both IMr and EMr TAR components had comparable postoperative alignment, patient-reported outcome scores, and complications. Among the patients with preoperative varus, valgus, or anterior distal tibial slope, the IMr patients achieved greater correction than the EMr patients. Although the 5-year implant survivorship was similar between the two cohorts with 98.6% survival for IMr TAR and 97.5% for EMr TAR, impending failures were greater for the mobile-bearing EMr TAR.

Category: Ankle, Ankle Arthritis, Basic Sciences/Biologics, Hindfoot Introduction/Purpose: Ankle arthrodesis has traditionally been the treatment of choice for ankle arthritis. However, loss of range of motion, chronic pain, risk of nonunion, and potential risk of adjacent arthritis are ongoing concerns after this procedure. Most of surgeons state that subtalar fusion is an alternative to treat a painful and dysfunctional ankle fusion, but successful ankle arthrodesis take down using Total Ankle Arthroplasty (TAA) has been reported in the literature. The paucity of literature comparing these two treatment methods hinders the ability to make an informed decision on the best therapy. The purpose of the study was to compare patient-reported outcomes; gait mechanics and complications in patients with ankle arthrodesis take down using TAA to those who underwent subtalar fusion in a previously fused ankle. Methods: This is a comparative study of patients who underwent tibiotalar arthrodesis take down with total ankle arthroplasty and subtalar arthrodesis in previously arthrodesed ankles. Patients who were willing to take the gait mechanics test were included. They were distributed in two groups according to the undergone procedure. Postoperative outcomes consisted of patient- reported functional measures, and complications rate. Patient-reported functional measures included the American Orthopaedic Foot & Ankle Society Score (AOFAS) hindfoot scale, Visual Analogue Scale (VAS) for pain, and the Short Form 36 Health Survey (SF-36). Three-dimensional joint mechanics and ground reaction forces were measured during level walking at least one-year post surgery. Gait mechanics included spatiotemporal parameters, and the peak plantar and dorsiflexion moment. Data were analyzed using analysis of variance (ANOVA) to determine significant differences between the two groups. (a = 0.05). Results: Ten patients were included in the ankle arthrodesis taken down (AATD) group, and seven patients were included in the subtalar fusion (STF) group. The average follow-up time in the AATD and SFT group was 70.4 and 46 months, respectively P=0.14. There were no statistically significant differences in the demographics of both groups. The peak plantar flexion was 4.6 degrees and 1.3 degrees in the AATD and STF group, respectively; P=0.04. The range of motion in the sagittal plane was 11.5 degrees and 7.8 degrees in patients with AATD and STF groups, respectively; P=0.13. The complication rate was higher in the AATD group (7 patients, 70% vs 1 patient, 14%; P=0.02). There were no statistically significant differences in the patient-reported outcomes between the two groups. Conclusion: Patients with ankle arthrodesis taken down using total ankle arthroplasty as compared with patients with tibiotalocalcaneal arthrodesis have better range of motion of the hindfoot and improved gait mechanics. The improved cadence and mobility decreased the imbalance in the midfoot and forefoot during the gait. Nevertheless, due to the complexity of the procedure the complication rate is considerably higher. Further research with a larger sample of both groups may demonstrate greater differences in patient-reported outcomes.

Category: Ankle, Ankle Arthritis Introduction/Purpose: The literature for total ankle arthroplasty (TAA) demonstrates significant improvements in patient- reported outcomes. While these reports focus on the overall study population, it is clear that some patients do not have a successful outcome. In regards to total hip and knee arthroplasty there is literature helping to define responders, or those who achieve a clinical improvement above the level of a minimally clinically important difference. However, characteristics of responders versus non-responders to TAA have not been defined. The purpose of this study was to determine patient comorbidities and characteristics that help distinguish responders from non-responders after TAA. Methods: Patients undergoing TAA between 1/2007 and 12/2016 were enrolled into a prospective study at a single academic center. Patients completed multiple patient reported outcome measures before surgery and in follow-up including the Short Musculoskeletal Function Assessment (SMFA). Patients were characterized as responders if their 2-year follow-up SMFA function score increased by 50% or more compared to preoperatively and were characterized as non-responders if their SMFA score increased by less than 50% at 2-year follow-up, consistent with OMERACT–OARSI responder criteria. Patient and operative factors along with prevalent pre-operative comorbidities were then associated with responder or non-responder status. Comorbidities that met a significance threshold of p

Category: Ankle Arthritis Introduction/Purpose: The Scandinavian Total Ankle Replacement(STAR) system and Salto Talaris(ST) total ankle system are two of the more commonly studied total ankle implants. As the STAR is one of the oldest total ankle arthroplasty (TAA) implants still in use today, most studies focus on longevity and survivorship. Reported rates of cyst formation for these two prosthesis in most series vary from 11-22% but no large study has focused on surgical management of these cysts or included patient reported outcomes after surgery. In this series, we aimed to investigate rates of cyst formation between mobile(MB) and fixed-bearing(FB) TAA and examine clinical and patient reported outcomes of bone grafting or cementing of large cysts surrounding the STAR and ST implants. Methods: A prospectively collected database at a high volume total ankle replacement center was retrospectively reviewed to identify patients who underwent TAA with either the STAR or the ST total ankle system between 2007 and 2015. Cysts were identified and measured on standard weight bearing radiographs and confirmed on computed tomography(CT) when available. Visual analog scale (VAS) score, Short Form-36 (SF-36) physical and mental component scores, Short Musculoskeletal Function Assessment(SMFA), and AOFAS hindfoot scores were collected from all patients preoperatively and then at 6 months, 1 year and annually postoperatively. Patients with a minimum 2 years follow-up who underwent revision TAA secondary to catastrophic bone cysts or who were managed with either curettage and bone grafting or curettage and cementing of bone cysts surrounding the TAA prosthesis were included in the patient reported outcomes (PRO) analysis Results: Excluding 53 patients for inadequate follow-up, 232 patients (29% female, 71% male; follow-up 6.7 years) who underwent STAR-TAA and 147 patients (26.6% female, 73.5% male; follow-up 7 years) who underwent ST-TAA were identified. Cysts 10 mm were identified in 95/232 (41%) STAR and 24/147 (16%) ST ankles. In the STAR group, 24 patients underwent cyst bone grafting (13), cementing (6) or both (8) at a mean 4.8 years. In the ST group, 14 patients underwent cyst bone grafting (6), cementing (4), or both (4) at a mean of 2.7 years. PRO data improved significantly for both the STAR and ST group in all questionnaires (p10mm 95(41%) 24 (16%) Patients Requiring Cyst Surgery 24/95 (25%) 14/24 (58%) Age (years) 61.8 63.3 Sex Male 165(71%) 107(73%) Female 67(29%) 40(27%) Time Until Cysts Visible (years) 1.82 1.63 Cysts 20mm Diameter Tibia 28 patients 4 patients Talus 4 patients 2 patients Both 0 Patients 2 patients Reoperation for Cyst n=24 n=14 Management mean 4.8 years post-op mean 2.7 years post-op Bone Grafting 13 6 Cementing 6 4 Both 8 4 SF-36 Before Cyst Surgery Physical Function 23.8 19.9 Mental Health 75.1 77.9 SF-36 After Cyst Surgery Physical Function 68.3 67.6 Mental Health 89.4 88.8 VAS Before Cyst Surgery 62.7 59.4 VAS After Cyst Surgery 4.1 3.7

Background: Metal component failure in total ankle arthroplasty (TAA) is difficult to treat. Traditionally, conversion to an arthrodesis has been advocated. Revision TAA surgery has become more common with availability of revision implants and refinement of bone-conserving primary implants. The goal of this study was to analyze the clinical results and patient-reported outcomes for patients undergoing revision total ankle arthroplasty. Methods: We retrospectively reviewed prospectively collected data on 52 patients with a mean age of 63.5 ± 9.6 years who had developed loosening or collapse of major metal components following primary TAA. These patients were compared to a case-matched control group of 52 primary TAAs performed at the host institution with a minimum of 2 years’ follow-up. Cases of isolated polyethylene exchange, infection, or extra-articular realignment procedures were excluded. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), and pain scores were prospectively collected. Clinical data was collected through review of the electronic medical record to identify reasons for clinical failure, where clinical failure was defined as second revision or conversion to arthrodesis or amputation. Results: The identified causes of failure of primary TAA were aseptic loosening of both components (42%), talar component subsidence/loosening (36%), coronal talar subluxation (12%), tibial loosening (8%), and talar malrotation (2%). Thirty-one patients (59.5%) underwent revision of all components, 20 (38.5%) just the talar and polyethylene components, and one (2%) the tibial and polyethylene components. The average time to revision was 5.5 years ± 5.4 with a follow-up of 3.1 years ± 1.5 after revision. Eleven (21.2%) revision arthroplasties required further surgery: 6 required conversion to arthrodesis and 5 required second revision TAA. Pain scores, SF-36 scores, SMFA scores, and AOFAS Hindfoot scores all improved after revision surgery but never reached the same degree of improvement seen after primary TAA. Conclusions: Clinical and patient-reported outcomes of revision ankle arthroplasty after metal component failure significantly improved after surgery, although the recovery time was longer. In this series, 21.2% of revision TAAs required a second revision TAA or arthrodesis surgery. Various prostheses performed similarly when used for revision surgery. Revision TAA can offer significant improvements postoperatively. Level of Evidence: Level III, therapeutic.

Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. They require a strong plan. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment required to achieve a satisfactory result. In general, operative treatment is reserved for patients with displaced OLTs or for patients who have failed nonoperative treatment for 3 to 6 months. Operative treatments can be broken down into cartilage repair, replacement, and regenerative strategies. There are many promising treatment options, and research is needed to elucidate which are superior to minimize the morbidity from OLTs.

Category: Ankle. Introduction/Purpose: The management of large osteochondral lesions of the talar shoulder remains a clinical challenge. Their size, three-dimensional geometry, and subchondral cystic degeneration often preclude treatment with traditional measures such as microfracture and osteochondral autograft transplantation. Structural or bulk osteochondral allograft transplantation has demonstrated efficacy in several retrospective reviews. The purpose of this study was to prospectively evaluate patients who received fresh structural allograft transplantation to the talus. Methods: A prospective evaluation of consecutive patients who underwent fresh structural allograft transplantation for an OLT form 2010 to 2013 was performed under Institutional Review Board approval. All patients failed a minimum of 6 months of conservative management. Preoperative MRI and/or CT, as well as plain radiographs were obtained on all patients. The following patient reported outcomes questionnaires were administered preoperatively and yearly after surgery: 100 mm VAS pain scale, AOFAS Ankle-Hindfoot Scale, SF-36, and the Short Musculoskeletal Functional Assessment (SMFA). Pre- and postoperative radiographs were assessed for allograft incorporation and the development of arthritis. Results: Fourteen patients underwent fresh osteochondral allograft transplantation. The mean follow-up was 47 months (range 24-73). The average size of the OLT was 2,269 mm3 (range 813-8,366) based on CT imaging and 5,797 mm3 (range 1,136-12,489) based on MRI imaging. There was significant improvement in the VAS pain score, AOFAS Ankle-Hindfoot Scale score, the SF-36 total score, and the SMFA functional and bother indices. Five (36%) of the patients required subsequent arthroscopy and removal of the screw(s) used to secure the graft. Three of these second-look patients had stable grafts without chondral damage. Two grafts demonstrated cartilage delamination. One of these patients had continued pain and progression of arthritis without additional surgery and one was converted to an ankle replacement. Therefore, the failure rate was 14%. Conclusion: Significant improvement in pain and function can be achieved with structural allograft transplantation for large OLTs. However, it is important to council patients that painful hardware and stiffness can occur in approximately one-third of patients. An unstable graft and cartilage delamination are indicators of subsequent failure. The use of a structural allograft does not preclude subsequent ankle arthrodesis or arthroplasty.

Category: Ankle Arthritis Introduction/Purpose: While it is thought that stresses through the subtalar and talonavicular joints will be decreased in total ankle replacement (TAR) relative to ankle fusion, progressive arthritis or deformity of these joints may require a fusion after a successful TAR. However, after ankle replacement, it is unknown how hindfoot biomechanics and blood supply may have been affected. Consequently, subsequent hindfoot joint fusion may be adversely affected. We hypothesize that fusion rates are not significantly affected following a TAR. Methods: We retrospectively identified a consecutive series of 1001 primary TARs performed between January 1998 and December 2014. We identified patients who underwent a secondary triple, subtalar or talonavicular arthrodesis to treat progressive arthritis or pes planus deformity. Clinical outcomes including pain and functional outcome scores, revision procedures, delayed union, nonunion, complications, and failure rates were recorded. We then compared these patients to patients who had a subtalar fusion after an ankle arthrodesis (13). Results: 26 patients required a subtalar (18), talonavicular (3), talonavicular and subtalar (3), or triple arthrodesis (2) with a mean 70.9 months follow-up. The mean time between TAR and secondary fusion was 37.5 months. 92.7% of the patients went successfully fused. Two patients (7.7%) had a delayed union. Two patients had a nonunion who had one revision talonavicular and one revision subtalar fusion. The mean time to radiographic and clinical fusion was 26.5 weeks. Pain and functional outcome scores improved significantly. There were no differences in the rates of subsequent fusions among implant choices. Compared to thirteen patients with prior ipsilateral ankle arthrodeses and subtalar fusions, patients who had TAR had a higher fusion rate (p=0.03), but did not have a longer time to fusion. Conclusion: Hindfoot arthrodesis following a TAR is safe and effective in improving function and pain. Additionally, arthrodesis following a TAR is more successful than a subtalar fusion following an ankle arthrodesis. While the time to healing is relatively long, various hindfoot fusions can be used to treat progressive arthritis and deformity with high fusion rates.

Category: Sports. Introduction/Purpose: Irreparable peroneal tendon tears are rare and there is scant evidence to guide surgeons on the appropriate treatment. In general, if more than 50% of the tendon is affected, segmental resection of the tendon and tenodesis to the remaining healthy tendon is recommended. We hypothesized that normal tension at the insertions of the peroneal tendons after an irreparable tear cannot be reestablished by tenodesis to the remaining tendon and can only be restored by allograft reconstruction. Methods: To assess tendon loading at their insertions, custom-made strain gage-based tension transducers were implanted into the peroneus longus (PL) and brevis (PB) tendons adjacent to their insertions on the 1st and 5th metatarsal bases in 12 fresh- frozen cadaver feet. Axial load was applied to the foot, and the peroneal tendons, tibialis anterior and posterior tendons were tensioned to 50% and 100% of physiologic load. Transducer outputs were recorded in this normal tendon condition and after sequential PB to PL tenodesis and peroneus brevis allograft reconstruction. The tendon force transmission was quantified in five different foot inversion/eversion and plantarflexion/dorsiflexion positions. The distal peroneal tendons and 1st and 5th metatarsals were then excised along with the implanted transducers, and calibration was performed by applying incremental tendon loads in a materials testing machine. Insertion site tensile loading in each surgical condition was then expressed as a percentage of normal. Results of the allograft and tenodesis procedures were compared using paired t tests. Results: Under 50% of physiologic load, tendon tension at the PB insertion ranged from 3% to 28% of normal after tenodesis. After allograft reconstruction, PB insertion tension increased to 73% to 101% of normal. Tension at the PL insertion site was 102% to 117% of normal after tenodesis, and 84% to 93% of normal after allograft reconstruction. The treatment outcomes differed significantly, with p-values < 0.02. Under the 100% loading condition, tension at the PB site ranged from 6% to 43% of normal after tenodesis and 88% to 99% of normal after repair with allograft. Tension at the PL insertion site was 101% to 120% and 94% to 101% after tenodesis and PB allograft reconstruction, respectively. The treatments differed significantly, with p-values < 0.02, in all comparisons except for PL tension in inverted and neutral foot positions. Conclusion: Allograft reconstruction of a peroneus brevis tendon tear substantially restored tension at both the PB and PL insertion sites when the tendons and their antagonists were loaded to 50% and 100% of physiologic load. In comparison, peroneus brevis tenodesis to PL did not effectively restore tendon tension under most of the tested conditions, suggesting that this procedure may result in an imbalanced foot when applied clinically. Clinical comparative studies are necessary to determine if the results of this cadaveric, biomechanical study have similar in-vivo consequences.

Category: Ankle Introduction/Purpose: Tibiotalocalcaneal(TTC) arthrodesis is a salvage procedure for patients with complex disease of the ankle and subtalar joints. Despite the clinical efficacy and mechanical advantage of intramedullary nails, complications, such as nonunion, are not uncommon. It may be possible to sustain compression in the face of bone resorption and implant loosening over the course of healing using a novel pseudoelastic intramedullary nail. Methods: We identified 15 patients (age+54.7+/-20.0 years) who had undergone a tibiotalocalcaneal arthrodesis using a pseudoelastic intramedullary nai. Serial radiographs were used to determine the amount and rate of Nitinol element migration over time. Results: Three months after surgery, there was at least 2.38mm of Nitinol element migration proximally with mean of 5.58mm(range: 2.38 to 8.11mm). Average follow up time was 195 days (range: 89 to 490 days). Conclusion: The Nitinol element recovers distance when stretched intra-operatively and maintains moderate compression in response to bone resorption. Further studies are needed to assess if this increased compression lends itself to higher fusion rates than traditional IMN’s.

Category: Ankle Introduction/Purpose: Tobacco use is a known risk factor for increased perioperative complications rates and having worse functional outcomes in many orthopaedic procedures. To date, no study has elucidated the effect of cigarette smoking on complications or functional outcomes scores after total ankle arthroplasty (TAA). The purpose of this study is to compare the rate of perioperative complications and outcome scores in nonsmokers, former smokers, and current smokers. Methods: We retrospectively reviewed the records of 642 patients who had TAA between June 2007 and February 2014 with a known smoking status. These patients were separated into three groups based on their smoking status: 34 current smokers, 249 former smokers, and 359 nonsmokers. Outcome scores and perioperative complications which included wound complications, talar component subsidence, periprosthetic infection, and periprosthetic bone cyst were compared between the groups. Results: When compared to nonsmokers, active smokers had a statistically significant increased risk of wound complications (Hazard ratio [HR] 3.5; p=0.03). Although the active smokers had an increased rate of talar component subsidence (HR 1.6; p=0.66) and persistent pain (HR 1.4; p=0.35), these findings were not statistically significant. Although all groups demonstrated improvement in outcome scores at 1 year and 2 year follow up compared to their preoperative scores, the active smokers showed statistically significant less improvement in their outcome scores than the nonsmokers and former smokers at 1 and 2 year follow up. Furthermore, there was no significant difference in the outcome scores or complications when comparing the nonsmokers to the former smokers. Conclusion: Patients with tobacco use undergoing TAA have a higher rate of perioperative complications and worse outcome scores compared to nonsmokers and former smokers. Furthermore, tobacco cessation appears to reverse the effects of smoking which allows TAA to be an effective and safe procedure for providing pain relief and improving function in former smokers as they have perioperative complication rates and outcomes similar to nonsmokers.

Category: Ankle Arthritis Introduction/Purpose: Patients with ankle arthrodesis exhibit hypermobility of adjacent joints that is hypothesized to result in accelerated arthritis. One theoretical advantage of total ankle replacement (TAR) over arthrodesis is preserved ankle motion and reduced stress on adjacent joints. We hypothesized that sagittal plane radiographic assessment will demonstrate “true” ankle motion of the prosthesis is less than the total arc of hindfoot motion secondary to contributions from adjacent joints. We aimed to compare fixed versus mobile-bearing prostheses for: (1) true ankle motion after TAR, (2) contribution of adjacent joint and midfoot motion that can lead to artificially inflated observed ankle motion (3) progression of subtalar and talonavicular joint arthritis. Previously described radiographic parameters were measured to allow for comparison of TAR motion to published ankle arthrodesis values. Methods: Patients underwent standardized weightbearing maximum dorsiflexion and plantar flexion sagittal radiographs. Previously described ankle and foot measurements were performed on each dorsiflexion and plantar flexion radiograph to determine the maximum observed ankle motion, true ankle motion through the prosthesis, motion through the subtalar joint, motion through the talonavicular joint, and talo-first metatarsal (midfoot) motion. Pre- and post-operative modified Kellgren- Lawrence grades of subtalar and talonavicular osteoarthritis were assigned to each patient preoperatively and latest follow-up. A minimum of two years of follow-up was needed. Results: Three prostheses were evaluated and 197 patients met inclusion criteria (75 INBONE, 52 Salto-Talaris, 70 STAR). Mean time to final ROM radiographs was 42.9 months. Mean true ankle motion through the prosthesis (25.9°) was less than the mean hindfoot motion arc (37.4°) that would be observed during clinical assessment. Mean subtalar motion was 8.6° and mean change in Meary’s angle was 16.5°. No significant difference was identified between prosthesis or fixed versus mobile-bearing design for the above parameters. The mobile-bearing STAR demonstrated more talonavicular joint motion (7.2°) than both fixed-bearing prostheses (INBONE 5.0°, p=0.02; Salto-Talaris 4.8°, p=0.02). There was no identifiable progression of modified Kellgren- Lawrence grade of subtalar or talonavicular arthritis when stratified by prosthesis or bearing type and adjusted for time to final follow-up. Conclusion: This study demonstrated that true ankle motion after TAR is approximately 10 degrees less than the total arc of clinical hindfoot motion—a difference that can be attributed to adjacent joint and midfoot motion. Additionally, no difference in true ankle motion or total arc of hindfoot motion was identified between fixed versus mobile-bearing designs. Counterintuitively, the mobile-bearing STAR prosthesis demonstrated significantly more adjacent joint talonavicular motion than its fixed-bearing counterparts. Progression of subtalar or talonavicular arthritis was not correlated with prosthesis or bearing type in this study and subtalar motion (8.6°) appears similar between TAR and historical arthrodesis controls (9.3°).

Category: Hindfoot Introduction/Purpose: Avascular necrosis (AVN) of the talus can lead to subtalar arthritis, pain, and decreased function. Isolated subtalar arthrodesis has been attempted in these patients, potentially allowing re-vascularization of the talus from calcaneal bone ingrowth while preserving the tibiotalar joint. The purpose of this study is to determine the union rate and complications of subtalar arthrodesis in patients with AVN of the talus. Methods: After obtaining IRB approval, a retrospective review of subtalar arthrodeses performed at a single academic institution, from 2000 to 2014, was conducted. Patients were included if they had a preoperative diagnosis of avascular necrosis of the talus, underwent subtalar arthrodesis and had a minimum follow up of 12 months. Exclusion criteria include: age younger of 18 years, incomplete clinical and radiological data or those whom underwent a concomitant tibiotalar arthrodesis. Results: Twelve patients with a mean age of 46.6 ± 13.9 years were included in the study. The fusion rate was 58% with a mean time to fuse of 35 weeks (range, 14-146). Seventeen percent of the patients had diabetes or vascular disease and an additional 17% had a positive history for tobacco use. The overall complication rate was 67% (8 patients). Five patients progressed to non-union (42%) and three of them underwent revision to tibiotalocalcaneal arthrodesis. Two patients (17%) had progression of AVN, one of which necessitated a tibiotalocalcaneal arthrodesis. Two patients (17%) developed a wound dehiscence that healed uneventfully with local wound care and oral antibiotics administration. One patient (8%) underwent hardware removal. Conclusion: With a fusion rate as low as 58% and a 67% complication rate, caution should be exhibited when considering an isolated subtalar arthrodesis in the setting of AVN of the talus. In selected cases, consideration should be given to extending the arthrodesis site to include the tibiotalar or talonavicular joint or revascularization procedures such as concomitant vascularized bone grafts.

Category: Ankle Arthritis. Introduction/Purpose: Wound complications following total ankle replacement (TAR) potentially lead to devastating consequences. The aim of this study is to compare the surgical and demographic differences in those with and without wounds which require operative management. We hypothesize that increased tourniquet and surgical time negatively influences wound healing. Methods: We retrospectively identified a consecutive series of 760 primary TARs performed between January 1998 and December 2014 whose data was prospectively collected. We then identified patients who required a secondary surgery to treat wound complications (ie operative debridement, split-thickness skin grafting, soft tissue reconstruction). All patients had operative wound debridement. We then compared demographics, surgical characteristics, and functional scores to see if there were any differences between the two groups. Clinical outcomes including secondary procedures and implant failure rate were recorded. Results: Twenty-seven patients (3.6%) had a total of 50 procedures to treat wound issues. 18 patients had flaps and 13 had split- thickness skin grafts. The mean time to operatively treating the wound was 12.6 weeks after the index TAR. The follow-up time from wound procedure was 28 months. Compared to the control group, patients with major wounds had a significantly longer surgery (215.6 vs. 189.2 min, p=.028) and tourniquet time (150.9 vs. 140 min, p=.0037). The control patients were more likely to have post-traumatic arthritis, whereas those with wound complications were more likely to have osteoarthritis (p=.002). Post- operatively, only the FAOS pain score was worse in patients with wounds (p=.047). There were seven failures in the major wound complication cohort (25.9%), including 2 BKAs. Conclusion: Ankle wounds which require operative management have high failure rates and may result in devastating outcomes. Given our data, we recommend limiting tourniquet time.

Category: Midfoot/Forefoot Introduction/Purpose: Combined arthrodesis of the talonavicular (TN) and 1st tarsometatarsal (TMT) joints is a treatment option for the patient with both a rigid flatfoot and hallux valgus deformity or 1st TMT joint arthritis. In these cases, the naviculocuneiform (NC) joint is spared, as long as no evidence of joint collapse or instability is present. The purpose of this study was to assess the effect of this medial column stabilization construct on the spared NC joint over time and its ability to improve the radiographic parameters in the flatfoot deformity. Methods: Patients who underwent concomitant TN and 1st TMT joint arthrodesis, while sparing the NC joint, in the setting of a rigid flatfoot deformity, between January 2006 and December 2014, were identified. The medical records, including preoperative and postoperative radiographs were retrospectively reviewed. Outcomes included radiographic correction gained by surgery (AP and lateral talo-first metatarsal angles), union rate, complications, and need for subsequent surgery. Specific radiographic attention was paid to development of subsequent collapse and/or arthritis at the NC joint at the time of final follow-up. Results: 21 consecutive combined TN and 1st TMT joint arthrodeses were performed. Average age at time of surgery was 61 (range, 23-82) years. 17 patients had a mean follow-up of 35 (range, 12-88) months. Union was achieved at both arthrodesis sites in 16/17 patients (94.1%). One patient (5.9%) had a nonunion at the TN joint, requiring revision arthrodesis. The mean lateral talo- first metatarsal angle correction was 24.5 (range, 12-36) degrees. The mean AP talo-first metatarsal angle correction was 11.6 (range, 0-33) degrees. One patient (5.9%) developed NC joint collapse and underwent subsequent arthrodesis at that level. There was radiographic evidence of NC joint arthritis to varying degrees in all cases by the time of final follow-up, however, none were symptomatic to warrant arthrodesis. Conclusion: Simultaneous arthrodesis of the TN and 1st TMT joints, while sparing the NC joint, is a reliable treatment in the carefully selected patient who presents with both a rigid flatfoot and hallux valgus deformity or 1st TMT joint arthritis. Good results in terms of union rate and radiographic correction, as well as a low complication rate were found in this study. Subsequent joint collapse and symptomatic arthritis at the spared NC joint was rare. Longer term follow-up and inclusion of functional outcomes are warranted in future studies on this topic.

Category: Ankle Arthritis Introduction/Purpose: As surgeons have become more comfortable with performing more complex total ankle replacements (TAR) with larger amounts of deformity, it is unclear whether or not to address additional pathology at the time of surgery. Currently, we address all foot and ankle pathology at time of the index arthroplasty. It is unclear however, how often and for what reasons secondary surgery is performed after TAR. We hypothesize that there were no differences in the type or rate of secondary surgeries performed. Methods: We identified a consecutive series of 761 primary TARs performed between January 1998 and December 2014. We identified patients who required a secondary surgery to treat foot and ankle pathology following a STAR, INBONE I/II, or Salto- Talaris. We then analyzed if there were differences between the implants in terms of time to secondary surgery or types of procedures performed. Results: 193 patients (25.3%) required a secondary procedure with an average time to a secondary procedure of 24.5 months. The rate of second surgery in both the Salto (25/113, HR=0.64 with 95%CI=0.408-0.996; p=0.048) and STAR (81/333, HR=0.694 with 95%CI=0.507-0.949; p=0.022) is less when compared to the INBONE group (87/315). The STAR had a significantly longer time to secondary procedure (33.8 months) versus a Salto-Talaris (12.8 months) or an INBONE (19.2 months, p=001). The number of secondary procedures (p< .001), polyethylene exchanges (p< .001), cyst grafting (p=.036) were similar in INBONE and STAR, but significantly more than the Salto. The INBONE prosthesis had a significantly higher talar component failure rate (p=.038), but similar rate of subtalar, ankle, and TTC fusion. Conclusion: Knowledge of the rates and types of secondary surgeries is useful information on the natural history of third generation ankle implants. While there are differences in the rate of failure or revisions between implants, no implant has proven superior to one another.