Autologous bone has been the gold standard for grafting material in foot and ankle arthrodesis. While autograft use has been effective, the harvest procedure does present risks to the patient including readmission, infection, and persistent graft harvest site pain. Previous studies have examined graft harvest site pain, but most have focused on the iliac crest and none have long term follow-up. The purpose of this study was to examine long-term (7–10 year) harvest site pain in subjects undergoing autograft harvest from multiple sites for hindfoot and/or ankle arthrodesis.

Sixty (60) subjects underwent hindfoot or ankle arthrodesis supplemented with autograft as part of the control arm of a prospective, randomized trial. The mean subject age was 59.4 years (range, 24.7–76.8) and mean body mass index was 30.6 kg/m2 (range, 22.0–44.0). There were 29 males and 31 female subjects. Subjects had the tibiotalar (37.9%), subtalar (24.1%), talonavicular (10.3%), subtalar/talonavicular (5.1%), or subtalar/calcaneocuboid/talonavicular (22.4%) joints arthrodesed. Autograft was harvested from either the proximal tibia (51.7%), iliac crest (17.2%), calcaneous (15.5%), distal tibia (6.8%), or other location (8.6%). Graft harvest site pain was evaluated using a 100-point visual analog score (VAS), with clinically significant pain being any score greater than 20.

Subjects were followed a mean of 9.0 years (range, 7.8–10.5). The percentage of subjects who reported clinically significant pain was 35.7%, 21.4%, 18.2%, 10.5%, 8.9%, and 5.2% at 2, 6, 12, 24, 52 weeks, and final follow-up (7.8–10.5 years), respectively. The mean VAS autograft harvest site pain at final follow-up was 4.4 (range, 0.0–97.0), with 37.9% of subjects reporting at least some pain. For three subjects (5%) with clinically significant pain (VAS >20) at final follow-up, two had proximal tibial harvest sites and one had an iliac crest harvest site. There was no correlation between graft volume and harvest site pain.

This study is the first to examine long-term pain following autologous bone graft harvest for hindfoot and/or ankle arthrodesis. Over a third of patients reported having some pain at an average follow-up of nine years, with 5% experiencing clinically significant pain. The results of this study suggest that harvesting autograft bone carries a risk of persistent, long-term pain regardless of the volume of graft that is harvested. This potential for persistent pain should be considered when informing patients of procedure risks and when deciding to use autograft or a bone graft substitute material.

Anesthetic peripheral nerve blocks (PNB) have been shown to be more advantageous than general anesthesia in a variety of surgical operations. In comparison to conventional methods of general anesthesia, the choice of regional localized infiltration has been shown to shorten hospital stays, decrease hospital readmissions, allow early mobilization, and reduce narcotic use. Perioperative complications of PNBs have been reported at varying rates in literature. Thus, the purpose of this study was to provide a review on the clinical evidence of PNB complications associated with foot and ankle surgeries.

A systematic review of the literature was completed using PubMed search terms: “lower extremity”, “foot and ankle”, “nerve block”, and “complications”. All studies reporting minor and major complications were considered along with their acute management, treatments, and postoperative follow up timelines. The range of complications was reported for Sensory Abnormalities, Motor Deficits, Skin and systemic complications (local anesthetic systemic toxicity & intravascular injections). A designation of the scientific quality (Level I-IV) of all papers was assigned then a summary evidence grade was determined.

The search strategy extracted 378 studies of which 38 studies were included after criteria review. Block complications were reported in 20 studies while 18 studies had no complications to report. The quality of evidence reviewed ranged from Level I to Level IV studies with follow up ranging from twenty four hours to one-three year timelines. The range of complications for all studies reporting sensory abnormalities was 0.53 to 45.00%, motor deficits 0.05 to 16.22% and skin and systemic complications 0.05 to 6.67%. Sensory abnormalities that persisted at last follow up occurred in six studies with incidence ranging from 0.23 to 1.57%. Two studies reported motor complications of a foot drop with an incidence of 0.05% and 0.12%. When considering only the highest quality studies (Level 1) that had complications to report, the complications rate was 10.00% to 45.00% for sensory abnormalities, 7.81 to 16.22% for motor deficits, 6.67% for skin complications and 2.50% for systemic complications.

High quality studies (Level I providing Summary Grade A Evidence) reporting all complications with a range of incidence from 0 to 45%. While most of these complications were not serious and permanent, some were significant including sensory abnormalities, foot drop and CRPS. Based on this systematic review of the current literature, the authors emphasize a significant rate of complications with PNB and recommend that patients are appropriately informed prior to consenting to these procedures.

Ankle arthrodesis and replacement are the widely accepted options in managing end-stage ankle arthritis. Ankle replacement as an alternate treatment option for ankle arthritis is relatively new and this is in large part to the successes observed with hip and knee arthroplasty for arthritis. Relative benefits of ankle replacement and arthrodesis remains a contentious topic. We conducted a multicenter pilot randomized controlled trial, first of its kind, comparing the clinical outcomes of ankle arthrodesis and ankle replacement in managing ankle arthritis. We hypothesized that clinical outcomes would be similar for both.

Patients recruited for this study were part of Canadian Orthopaedic Foot and Ankle Society (COFAS) Database. Canadian orthopaedic surgeons with fellowship training in foot and ankle surgery or extensive experience in the surgical treatment of end stage ankle arthritis determined whether the patient met the criteria for randomization, skeletal maturity, symptomatic ankle arthritis no longer amenable to non-operative management, and ability to give informed consent. Data was collected on patient demographics, follow-up time period, complication rates, and Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) scores. Our analysis of clinical outcomes was divided into two parts: (1) comparison of pre and postoperative data for each cohort separately, and (2) comparison of outcome scores, and revision rates between both cohorts. We employed the Student's t-test and calculated effect sizes in assessing improvements in AOS and SF-36 scores from baseline to latest follow-up within and between the two groups. We also examined postoperative complication and reoperation rates in the study population using the standardized coding system for reoperations following ankle replacement and arthrodesis.

Thirty-nine ankles were enrolled in the study with a mean follow-up of 5.1 ± 2.8 years. Ankle osteoarthritis scale scores improved significantly from baseline and last follow-up in both groups. The average baseline AOS total score for ankle replacement improved from 59.4 ±15.9 to 38 ±20 at last follow-up (p-value 19.7 to 31.8 ±16.5 at last follow-up (p-value 25.4 compared to ankle replacement's 20.3 ±23. Two major complications (10.5%) were observed in the ankle replacement cohort while the ankle arthrodesis cohort saw four major complications (20%).

Clinical outcomes of ankle replacement and arthrodesis were comparable. The ankle arthrodesis cohort held a slight advantage over ankle replacement in improvement of AOS scores, though not statistically significant. Rates of major complications and reoperations were higher with ankle arthrodesis.

Introduction

Studies have compared outcomes of first metatarsophalangeal joint (MTPJ1) implant hemiarthroplasty and arthrodesis, but there is a paucity of data on the influence of patient factors on outcomes. We evaluated data from a prospective, RCT of MTPJ1 implant hemiarthroplasty (Cartiva) and arthrodesis to determine the association between patient factors and clinical outcomes.

Introduction

A randomized clinical trial of first metatarsophalangeal (MTP) joint hemiarthroplasty with a synthetic cartilage implant demonstrated equivalent pain, function and safety outcomes to first MTP joint arthrodesis at 2 years. The implant cohort continues to be followed under an extension of the original study and we report on prospectively determined 5+ year outcomes for subjects assessed to date.

Reoperations may be a better way of tracking adverse outcomes than complications. Repeat surgery causes cost to the system, and often indicate failure of the primary procedure resulting in the patient not achieving the expected improvement in pain and function. Understanding the cause of repeat surgery at the primary site may result in design improvements to implants or improvements to fusion techniques resulting in better outcomes in the future. The COFAS group have designed a reoperation classification system. The purpose of this study was to outline the inter and intra observer reliability of this classification scheme.

To verify the inter- and intra-observer reliability of this new coding system, six fellow ship trained practicing foot and ankle Orthopaedic surgeons were asked to classify 62 repeat surgeries from a single surgeons practice. The six surgeons read the operation reports in random order, and reread the reports 2 weeks later in a different order. Reliability was determined using intraclass correlation coefficients (ICC) and proportions of agreement. The agreement between pairs of readings (915 for inter observer for the first and second read – 61 readings with 15 comparisons, observer 1 with observer 2, observer 1 with observer 3, etc) was determined by seeing how often each observer agreed. This was repeated for the 366 ratings for intra observer readings (61 times 6).

The inter-observer reliability on the first read had a mean intra-class correlation coefficient (ICC) of 0.89. The range for the 15 comparisons was 0.81 to 1.0. Amongst all 1830 paired codings between two observers, 1605 (88%) were in agreement. Across the 61 cases, 45 (74%) were given the same code by all six observers. However, the difference when present was larger with more observers not agreeing. The inter-observer reliability test on the second read had a mean ICC of 0.94, with a range of 0.90. There were 43 (72%) observations that were the same across all six observers. Of all pairs (915 in total) there was agreement in 804 pairs for the first reading (88%) and disagreement in 111 (12%). For the second reading there was agreement in 801 pairs (86%) and disagreement in 114 (14%). The intra-observer reliability averaged an ICC value of 0.92, with a range of 0.86 to 0.98. The observers agreed with their own previous observations 324 times out of 366 paired readings (89% agreement of pairs).

The COFAS classification of reoperations for end stage ankle arthritis was reliable. This scheme potentially could be applied to other areas of Orthopaedic surgery and should replace the Claiden Dindo modifications that do not accurately reflect Orthopaedic outcomes. As complications are hard to define and lack consistent terminology reoperations and resource utilisation (extra clinic visits, extra days in hospital and extra hours of surgery) may be more reliable measures of the negative effects of surgery.

Patients often comment on swelling after foot and ankle surgery. However the relationship between swelling and outcome (pain and function) has not previously been outlined. A recent study by Pinsker and Daniels demonstrated that while swelling was rated as important by patients it was rarely included in outcome scores. The purpose of this paper was to determine the relationship between swelling and outcome after ankle fusion or replacement. A secondary purpose was to determine how this relationship changed in time, how swelling score changed before and after surgery, and determine differences in swelling score between total ankle replacement (TAR), open ankle arthrodesis (OAA) and arthroscopic ankle arthrodesis (AAA).

The COFAS prospective ankle arthritis database enrolls patients in 4 centers undergoing surgery by one of 6 surgeons since 2002. The MODEMS outcomes package from AAOS was used, with the validated ankle osteoarthritis score (AOS) score being used to assess outcomes in the pain and disability domains. The swelling score was indexed from 1 to 5, 1 being no swelling and 5 being severe swelling. Outcomes were recorded preoperatively and annually up to 2010. Statistical analysis was performed using 95% confidence intervals and correlations being determined using Pearson's correlation and r2 values.

The swelling score was correlated with AOS score with an r2 of 0.13 for postoperative patients. With the swelling score analysed categorically the difference of outcome was significant with a mean AOS score of 15.1 (CI 13.3 to 16.9) for a swelling score of 1, 23 (CI 21.7 to 24.9) for a swelling score of 2, 31 (CI 29.6 to 33.1) for 33.6 (CI 34.9 to 38.8) for 4, and 39 (CI 35.3 to 43.0) for 5. Swelling scores fell outside the 95% confidence intervals for all groups indicating that the AOS outcome of swelling score 5 patients was worse than the 4 group, 4 worse than 3, 3 worse than 2, and 2 worse than 1. Patients with swelling scores of 1 scored 24 points better than those with a swelling score of 5.

Swelling scores were the same preoperatively for total ankle arthroplasty, Arthroscopic and open fusions. However swelling scores were lower for arthroscopic fusions after surgery for all time periods at an average of 2.1 (CI 1.9 to 2.2), compared to total ankle arthroplasty (2.5, CI 2.4 to 2.6) and open ankle fusion (2.5, CI 2.4 to 2.6).

Swelling has a major relationship with outcome. Swelling may be the cause of poorer outcomes for open ankle fusion compared to arthroscopic. Swelling is an independent factor as swelling scores for TAA were higher compared to AAA despite similar outcomes. Arthroscopic surgery reduces the postoperative swelling. Methods to reduce swelling such as compression stockings, elevation, controlling bleeding may result in better outcomes. Minimising the invasiveness of surgery achieves this goal. Patient education about swelling, elevation and compression stockings would assist in these goals.

Patients with advanced stage hallux rigidus from 12 centers in Canada and the UK were randomized (2:1) to treatment with a small (8/10 mm) hydrogel implant (Cartiva) or 1^st MTP arthrodesis. VAS pain scale, validated outcome measures (FAAM sport scale), great toe active dorsiflexion motion, secondary procedures, radiographic assessment and safety parameters were evaluated.

236 patients were initially enrolled, 17 patients withdrew prior to randomization, 17 patients withdrew after randomization and 22 were non-randomized training patients, leaving 152 implant and 50 arthrodesis patients. Standard demographics and baseline outcomes were similar for both groups.

Mean VAS pain scores decreased from 6.8 and 6.9 respectively for the implant and arthrodesis groups from baseline to 1.4 and 0.7 at 24 months. Similarly, the FAAM sports score improved significantly from baseline levels of 37 and 36 to 24 months level of 77 and 82 respectively for the implant and arthrodesis groups. First MTP active dorsiflexion motion improved an average of 4° at 3 months after implant placement and was maintained at 24 months.

Secondary surgeries occurred in 17 (11.2%) implant patients and 6 (12.0%) arthrodesis patients. Fourteen (9.2%) implants were removed and converted to arthrodesis and 6 (12.0%) arthrodesis patients had painful hardware requiring removal. There was no case of implant fragmentation, wear, or bone loss. Analysis of a single composite endpoint utilizing the three primary study outcomes (pain, function, and safety) showed statistical equivalence between the2groups.

Introduction:

The treatment of acute rupture of the tendo-achilles remains controversial. There is good evidence to suggest that outcomes are the same for both operative and non-operative treatment when a functional rehabilitation program is utilised. However, debate continues as to whether the radiological gap-size between the proximal and distal remnants of the tendon has an influence on the suitability for non-operative management.

Purpose

The failure rate of total ankle arthroplasty (TAA) in rheumatoid patients may be higher than in osteoarthritis patients due to the medications used to treat rheumatoid arthritis and the comorbidities associated with this disease. The purpose of this study was to prospectively look at the intermediate-term outcomes of TAA in patients with rheumatoid arthritis and to compare the results to a matched cohort of patients with ankle osteoarthritis undergoing TAA.

Purpose

The purpose of this study was to assess the clinical outcomes over two years for total ankle arthroplasty (TAA) using Short Form-36, Foot Function Index and Ankle Osteoarthritis Scores, and to compare these with radiostereometric analysis longitudinal migration and inducible displacement results.

Purpose

The purpose of this study was to assess the biomechanical stability of the a total ankle arthroplasty system using longitudinal migration (LM) and inducible displacement (ID) measures. This study is the first study of its kind to assess total ankle arthroplasty (TAA) implant micromotion using model-based radiostereometric analysis (MBRSA).

Purpose

Surgical repair is the preferred method of treatment of acute Achilles ruptures in North America because, despite a higher risk of overall complications, it offers a reduced risk of re-rupture. However, more recent trials, particularly those using functional bracing with early range of motion (ROM) have challenged this statement. This meta-analysis aims to compare surgical to conservative treatment in respect to re-rupture, overall complications, return to work, calf circumference and functional outcomes, as well as to examine the effects of early ROM on re-rupture rate.

Background

Ankle arthrodesis results in significantly improved pain and function for patients with end-stage ankle arthritis. Arthroscopic ankle arthrodesis has gained increasing popularity with reports of shorter hospital stays, time to union and equivalent union rates to open arthrodesis. However, there remains a lack of good quality prospective data.

Purpose

Total Ankle Replacement (TAR) is increasingly being offered to patients as an alternative to arthrodesis for the operative management of debilitating end-stage ankle arthritis. The Mobility Total Ankle System is a third-generation design consisting of a three component, cementless, unconstrained, mobile-bearing prosthesis. This study reports the early results of a multi-centre prospective study of the Mobility prosthesis. This is the first such report by independent researchers.

Purpose

To compare Radiostereometric Analysis (RSA) and subjective outcomes of Total Knee Arthroplasty (TKA) and Total Ankle Arthroplasty (TAA).

Purpose: To compare the clinical outcomes of patients surgically treated for end stage ankle arthritis using total ankle arthroplasty or ankle arthrodesis.

Method: This is a single center clinical outcome study of the surgical treatment of patients with end stage ankle arthritis (n=81) using an ankle arthrodesis or total ankle arthroplasty. Clinical outcome was assessed using health related quality of life (SF36v2) and joint specific (Ankle Osteoarthritis Scale, American Orthopedic Foot and Ankle Hindfoot Scale and the AAOS Foot and Ankle Baseline Questionnaire(version 2000)) outcome scores. Complications were recorded as well.

Results: Preoperatively, all patients had significant physical and psychological morbidity. There was a significant improvement in the health related quality of life and the joint specific clinical outcome scores at 1, 2 and 3 years follow up (p-value.05) Complications included 5 (10%) non union, in the ankle arthrodesis cohort and 2 (6.7%) revisions for aseptic loosening in the total ankle arthroplasty cohort.

Conclusion: The results of this study indicate that surgical treatment of end stage ankle arthritis with ankle arthrodesis or total ankle arthroplasty equally improve clinical outcome in the short term with acceptable and similar complication rates.

Purpose: To describe the pre- and one-year post-operative preference-based, health related quality of life (health state values) among a cohort of subjects with end-stage ankle arthritis treated with total ankle arthroplasty or ankle arthrodesis. This short-term study is not intended to compare the efficacy of arthoplasty and arthrodesis.

Method: The Short-Form 36 (SF-36) was prospectively completed by subjects enrolled in the Canadian Orthopaedic Foot and Ankle Society Multicentered Ankle Arthritis Outcome Study between 2003 and 2005. Preference-based quality of life was assessed pre-operatively and at one-year post-procedure using health state values (HSVs) derived from the SF-36 transformation described by Brazier (SF-6D). The SF-6D scores are anchored at 1.0 (full health) and at 0 (death). Basic patient demographic and treatment information was also collected. The decision to perform arthroplasty or arthrodesis was made by the attending surgeon.

Results: Two hundred four of the 214 eligible subjects had complete preoperative SF-36 data to allow transformation to SF-6D values. One-year follow-up was available for 114 of the participants. The mean age at surgery of the included subjects was 58.9 +/− 13.3 years. Of the patients with one-year follow-up, 56% were male and 59% had received total ankle arthroplasty. These demographics did not differ from the original preoperative cohort. The mean SF-6D score among all subjects with end-stage ankle arthrosis was 0.66 (95% CI 0.65 – 0.68). At one-year, the mean HSVs of the total ankle arthroplasty and ankle arthrodesis groups were 0.73 (95% CI 0.71 – 0.76) and 0.73 (95% CI 0.70 – 0.75), respectively. The reported pre-operative scores describe health states below normative data for the US population (0.76 +/− 0.01 for females, ages 55–64).

Conclusion: These are the first available HSVs for a cohort of patients with end-stage ankle arthritis treated with total ankle arthroplasty or ankle arthrodesis. These data demonstrate an improvement in preference-based quality of life following ankle arthroplasty or arthrodesis. At one-year follow-up, patient reported HSVs approach age-matched US norms.

Purpose: Radiostereometric Analysis (RSA) is used to measure migration and inducible displacement (ID) of orthopedic implant devices to allow early prediction of implant failure (eg. Aseptic loosening). Total Ankle Arthroplasty (TAA) is used for the treatment of end-stage ankle arthritis. First generation TAA implant have meet with widespread failures while some second generation TAA implants are showing improved results. In this study RSA is used to evaluate the biomechanical properties of a new third generation TAA implant in an attempt to set a standard for the biomechanical evaluation on TAA implants in-vivo.

Method: Patients undergoing TAA were enrolled consecutively (n=12; 7 males; mean age=59 years; mean BMI=29) and had 8 markers (0.08mm) inserted in both the tibia and talus during surgery. Standing, weight-bearing RSA exams were performed at 3 and 6 months and compared to concurrent supine exams to determine component ID.

Results: For tibial components: at six months the components had translated posteriorly (0.3mm±0.5) and proximally (0.5mm±0.2), tilted into varus (0.5°±1.3), and tilted posteriorly (0.4°±0.8). The magnitudes of ID for the tibial components were moderate (mean < 0.2mm and 0.5°, standard deviation < 0.3mm and 2.2° in each direction). For talar components: at six months the components had translated distally (0.28mm±0.35), rotated internally (0.21°±1.32) and tilted posteriorly (0.15°±0.90). There was varus/valgus tilt measured in the talar components but there was no consistent direction of migration (0.03°±1.4). At six months the magnitudes of ID for the talar components were small (mean < 0.1mm and 0.25°, standard deviation < 0.2mm and 0.6° in each direction).

Conclusion: An RSA methodology has been established to predict stability.

Purpose: For patients with moderate to severe hallux valgus with increased intermetatarsal angle, correction with a proximal first metatarsal osteotomy is indicated. The purpose of this study is to compare the opening-wedge osteotomy of the proximal first metatarsal the proximal chevron osteotomy in the treatment of moderate to severe hallux valgus with increased intermetatarsal angle.

Method: This prospective, randomized, multi-centered study is being conducted at three centers in Canada. Approximately 75 adult patients with hallux valgus are being randomized to either the proximal metatarsal opening-wedge osteotomy with plate fixation or the proximal chevron osteotomy. Patient functional scores using the SF-36, American Orthopaedic Foot and Ankle Society (AOFAS) forefoot metatarsophalangeal inter-phalangeal score and Visual Analogue Scale (VAS) for pain, activity & patient satisfaction, are assessed prior to surgery and 3, 6, 12 and 24 months. Surgeon preference is being evaluated based on a questionnaire and actual surgical times. Radiologic measurements (inter-metatarsal angle correction, hallux valgus angle correction, sagital talus-first metatarsal (Meary’s) angle, metatarsal length and union) will also be assessed.

Results: Preliminary results demonstrate that patients who undergo the opening-wedge osteotomy have less pain at 3 months (ave. VAS pain reduction 2.9, SE±1.0) than those with the chevron (ave. VAS pain reduction 2.4, SE±1.2). VAS for activity demonstrates greater improvements with the chevron osteotomy at 3 months (0.8, SE±0.8) versus the opening-wedge (0.1, SE±1.0). AOFAS scores improve on average 18.3 (SE±8.6) with the opening wedge compared to 20.8 (SE±7.4) with the chevron at 3 months. Average hallux valgus angle correction for opening-wedge and chevron osteotomies are 11.0 degrees (SE±2.5) and 19.0 degrees (SE±3.1) respectfully. Average intermetatarsal angle correction for opening-wedge and chevron osteotomies are 6.5 (SE±1.3) and 4.3 (SE±1.7) respectfully. Both procedures are effective at maintaining metatarsal length. The opening-wedge osteotomy takes on average 60.9 minutes (SE±3.9) to complete compared to 69.1 minutes (SE±5.1) for the chevron ostetotomy. Surgeon response to the new opening-wedge osteotomy is favorable.

Conclusion: Opening-wedge and proximal chevron osteotomies have comparable pain, function and radiographic outcomes. Opening wedge osteotomy is technically less demanding and requires less surgical time.