Introduction

Despite the increasing numbers of ankle replacements that are being performed there are still limited studies on the survival of ankle replacements and comparisons between different implants. The primary aim of this study is to link NJR data with NHS digital data to determine the true failure rates of ankle replacements. Secondary outcomes include analysis risk factors for failure, patient demographics and outcomes of individual prosthesis.

Introduction

This is a multi-centre, prospective, observational study of 503 INFINITY fixed bearing total ankle arthroplasties. We report the minimum two-year results of this prosthesis which was introduced to the UK Market in 2014 and is now the most used ankle arthroplasty in the National Joint Registry of England and Wales.

Revision options for a failed Total ankle arthroplasty (TAA) have historically been limited to complex hindfoot fusions, bespoke ankle arthroplasty revision or amputation. The patient outcomes of these procedures has been felt to be poor. The introduction of the INBONE-II and INVISION ankle arthroplasty revision systems has created a range of revision arthroplasty options, with the possibility of improved patient outcomes. We aim to report on the early results of 20 sequential revision TAA. All patients undergoing revision TAA with INBONE-II or INVISION had prospective collection of pre-operative and post-operative MOx-FQ and EQ-5D scores. Between September 2013 and June 2019 23 patients underwent revision TAA with mean time from implantation of 35 months (6 to 74). Those with greater than 1 year follow-up had scores included. Other outcomes included radiographic assessment for loosening and revision. 13 patients had INBONE-II and 10 INVISION. None required revision at the time of review. Pre-operative MOx-FQ averaged 40.6 (13.4 pain, 21 walking, 6.2 social). Post-operative MOx-FQ averaged 17.4 (6.2 pain, 8.1 walking, 3.1 social). Average EQ-5D improved from 8 to 6.6 and average EQ-VAS from 60 to 80. On radiograph review one patient had radiolucent lines around their INBONE-II stem evident at 1 year. This had not progressed by 4 years total follow-up. Another patient had uncoupling of part of the stem of her INBONE-II but had not required revision. This was attributed to surgeon error. Revision TAA using the INBONE-II and INVISION systems shows promising early results relating to loosening and revision and good maintained improvement in MOx-FQ and EQ-5D scores. This provides further evidence that patients with a failed TAA can safely have revision rather than having to commit to complex ankle/hindfoot fusion. This provides surgeons with flexibility particularly in those patients with other hindfoot arthritis or arthrodesis.

Aims

Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty (TAA) fails, it can either undergo revision to another ankle replacement, revision of the TAA to ankle arthrodesis (fusion), or amputation. Currently there is a paucity of literature on the outcomes of these revisions. The aim of this meta-analysis is to assess the outcomes of revision TAA with respect to surgery type, functional outcomes, and reoperations.

Introduction

Active patients may benefit from surgical repair of the achilles tendon with the aim of preserving functional length and optimising push-off power. A mini-open device assisted technique has the potential to reduce wound complications, but risks nerve injury. We present the largest published series of midsubstance achilles tendon repairs using the Achillon® device.

The global economy has been facing a financial crisis. Healthcare costs are spiraling, and there is a projected £30 billion health funding gap by 2020 in the UK.¹ This has prompted a drive for efficiency in healthcare provision in the UK, and in 2012, the Health and Social Care Act was introduced, heralding a fundamental change to the structure of the National Health Service, especially in the way that healthcare is funded in England.²

What is happening in the UK is a reflection of a global problem. Rationing of healthcare is a topic of much discussion; as unless spending is capped, providing healthcare will become unsustainable. Who decides how money is spent, and which services should be rationed?

In this article we aim to discuss the impact that rationing may have on orthopaedic surgery, and we will discuss our own experiences of attempts to ration local services.³ We also seek to inform and educate the general orthopaedic community on this topic.

There are longstanding debates regarding surgical versus conservative management of Achilles tendon ruptures, however there is limited focus on rehabilitation. A specific rehabilitation programme was initiated in 2008 to unify management and improve patient outcomes. We present the results at three and a half years.

In October 2008 management was streamlined under the foot and ankle surgeons and a dedicated physiotherapy service. Operative management used mainly the Achillon device (Integra) and VACOped boot with a specific rehabilitation protocol.

We prospectively collected data on all patients with Achilles tendon ruptures from October 2008 to March 2012. There were 246 patients in total with four lost to follow up. 80 were treated with the Achillon system, 18 had an open repair and 144 were treated conservatively (of which 56 were partial or musculocutaneous junction tears).

Three patients sustained re-rupture (1.2%), all initially treated conservatively. There were two operative complications (2%), both wound breakdowns. Two patients suffered PE's (0.8%), confirmed on VQ scan or CTPA (one operative, one conservative). One non-compliant patient healed functionally long and required a shortening procedure.

The authors experience has been that using the VACOped boot with our custom rehabilitation programme in dedicated physiotherapy clinics has produced excellent results.

Achilles tendinopathy is chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. It involves a triad of pain, swelling and impaired function. Primary treatment is rest, analgesia, corticosteroid injections and physiotherapy (eccentric training and heel pads to correct gait). Some patients remain symptomatic and further treatment options need considering.

NICE produced a document from the Interventional Procedures Advisory Committee in 2009 which reviewed the literature and evidence for extracorporeal shockwave treatment (ESWT). Low energy shock wave treatment (SWT) is thought to stimulate soft tissue healing, inhibit pain receptors and promote angiogenesis. NICE guidance was that ESWT could be used in refractory Achilles tendinopathy if used for clinical governance, audit or research.

Patients with refractory Achilles tendinopathy were enrolled between October 2010 and 2011. They received three sessions of ESWT over three week. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale (six points, high is worsening) were reassessed at 6 and 16 weeks post treatment.

51 patients completed follow up. The mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. There was a significant improvement (p<0.05) in VAS scores observed from baseline and 16 weeks post treatment. This was also the case in the VISA-A scores. The mean Likert score was 3 (somewhat improved) at 16 weeks but there was no statistical significance.

This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy. Patients over 60 possibly have a worse outcome along with patient who had symptoms for over 25 months. Follow up scores at one year are due to be collected and the data will be submitted to NICE.

Background

Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems including combined arthritis of the ankle and subtalar joints, complex hindfoot deformities and failed total ankle arthroplasty. The aim of this study was to report the elective results of combined subtalar and ankle arthrodesis using one design of dynamic retrograde intramedullary compression nail-the T2 Ankle Arthrodesis Nail(Stryker)

Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems including combined arthritis of the ankle and subtalar joints, complex hindfoot deformities and failed total ankle arthroplasty. The aim of this study was to report the elective results of combined subtalar and ankle arthrodesis using one design of dynamic retrograde intramedullary compression nail-the T2 Ankle Arthrodesis Nail(Stryker)

Retrospective review identified 53 consecutive patients who had 55 tibiotalocalcaneal arthrodesis procedures by two surgeons(ITS and NJT) using T2 Ankle nail fixation. 3 patients died of unrelated causes before follow up was complete which left 50 patients(52 nails); the largest consecutive series in the use of this device. Mean follow up was 23.5(3-72) months with the average age of patients being 61(range 22-89) years. An 84% response was achieved to a function and patient satisfaction questionnaire. Main indications for treatment were combined ankle and subtalar arthritis(63%-33/52) or complex hindfoot deformities(23%-12/52). Outcome was assessed by a combination of Clinical notes review, clinical examination, and telephone questionnaire.

46 patients(83.6%) achieved union at a mean time of 3.7 months. 8 patients required an allograft(femoral head) bone block procedure. 4 patients(10%) subjectively thought that the procedure was of no benefit or had a poor result whilst 35(83%) had a good or excellent result. The mean visual analog scale(VAS) score for preoperative functional pain was 7.1 compared to the mean post operative (VAS) score of 1.9(p<0.001). Complications consisted of 2 amputations, 2 deep infections and 5 removals of broken or painful screws. The use of preoperative functional aids and orthotics dropped from 32% to 18% and 22% to 18% respectively.

This device and technique is a safe and effective treatment of hindfoot arthrosis and deformity giving reliable compression and subsequent fusion with excellent results in terms of patient satisfaction and pain relief.

We present the clinical and radiological outcome of a prospective series of 22 Buechel-Pappas Total Ankle Replacements (TAR) implanted in 19 patients with a mean follow-up of 9 years (range 6 to 13). The only published long term results of this prosthesis in the literature are from the originators' unit.

Patients have been prospectively reviewed yearly since 1991. None was lost to follow-up. The primary diagnosis was rheumatoid arthritis in 11 and osteoarthritis in 8 patients. 12 patients were female. Mean patient age was 64 (range 39 to 81). At the time of review 4 patients (6 ankles) had died between 12 and 69 months post-operatively of unrelated causes with their prostheses in situ. One patient had a below knee amputation for chronic venous ulceration 11 years after a TAR which until that point had continued to function well. One patient with severe rheumatoid arthritis had the implant removed at 8 weeks for deep infection. Another patient with rheumatoid arthritis had the TAR revised to a tibio-talar-calcaneal fusion 59 months post-operatively for talar avascular necrosis. One patient has pain from impingement and another patient with rheumatoid arthritis has intermittent pain at 8 years following her TAR. Every other implant continues to function well. The New Jersey LCS ankle assessment scores increased from a mean of 35 pre-operatively to 82 post-operatively. The increases were largely due to pain relief and improved function with the pre-operative range of motion being preserved. These scores have been maintained in the long term. No surviving implant is radiologically loose.

Our results suggest that the Buechel-Pappas TAR offers good clinical and radiological long-term results to patients with often disabling ankle arthritis

To evaluate if adequate restoration of the medial cortical buttress reduces the high reported incidence of mechanical complications when using the AO unreamed femoral nail with spiral blade (UFN-SB) in the management of subtrochanteric femoral fractures. The clinical notes and radiographs of sixty-five patients treated with the UFN-SB between November 1996 and February 1999 were retrospectively reviewed. Twenty-eight of these fractures were subtrochanteric. Mean patient age was seventy-five and thirteen patients had metastatic disease. At the time of review the patients or their doctor were contacted by telephone to establish accurately the associated morbidity and mortality. Follow up information was obtained for every patient. Post-operative radiographs were assessed for accuracy of fracture reduction.

The medial cortical buttress was adequately restored in every case. This required open fracture reduction in eleven patients and cerclage wires augmented the reduction in eight of these cases. Open reduction did not significantly increase time to fracture union or transfusion requirement. Every surviving patient was fully weight bearing within three months. One patient required a second operation for spiral blade migration but there were no implant breakages or other mechanical complications after a mean follow-up of thirty-seven months.

Conclusion: Adequate restoration of the medial cortical buttress allows the UFN-SB to function as a load-sharing device and achieves reliable skeletal stability in these potentially unstable fractures that typically occur in osteoporotic or pathological bone.

Introduction The Buechel-Pappas Total Ankle Replacement (BP TAR) has been used in Cornwall since 1991. The early results were presented to the Foot Society in 1997. The only published long term results of this pros-thesis are from the designer’s unit.

Method We present the clinical and radiological outcome of a prospective series of 22 BP TARs implanted in 19 patients with a mean follow-up of 9 years (range 6–13). The primary diagnosis was rheumatoid arthritis (RA) in 11 and osteoarthritis in eight patients. Twelve patients were female. Mean patient age was 64 years (range 39–81). Patients were reviewed at yearly intervals. None were lost to follow-up.

Results At the time of review, four patients (six ankles) had died between 12 and 69 months post-operatively of unrelated causes with their prostheses in situ. One patient had a below knee amputation for chronic venous ulceration, 11 years after a BP TAR which was functioning well. One patient with severe RA had the implant removed at 8 weeks for deep infection. A second patient with RA had the TAR revised to a tibiotalocalcaneal fusion 59 months post-operatively for talar avascular necrosis. One patient has pain from impingement and another patient with RA has intermittent pain at 8 years following TAR. Every other implant remains asymptomatic. The New Jersey LCS ankle assessment scores increased from a mean of 35 pre-operatively to 82 post-operatively. The increases were largely due to pain relief and improved function with the pre-operative range of motion being preserved. These scores have been maintained in the long term. No surviving implant is radiologically loose.

Conclusion Our results suggest that the BP TAR offers good clinical and radiological long-term results to patients with often disabling ankle arthritis.

We present a retrospective clinical and radiological review to assess the use of the AO unreamed femoral nail and spiral blade in the treatment of subtrochanteric fractures. Treatment of the subtrochanteric fracture remains a challenge. A combination of high stress concentration, poor cortical bone quality and comminution leads to a high incidence of problems. The abovementioned implant has been recommended for use in such fractures. However, several authors have reported mechanical failure and spiral blade migration. We have used the unreamed femoral nail since 1996 in 65 femoral fractures, and of these 32 were subtrochanteric fractures. A retrospective clinical and radiological study was undertaken to assess the use of the implant.

Clinical notes and radiographs were obtained for patients with subtrochanteric fractures treated with the AO unreamed femoral nail from November 1996 to November 1999. Fracture pattern was classified according to Seinsheimer. Assessments were made of callus formation and fracture healing. Any complication or implant failure was noted.

Thirty-two patients required an unreamed femoral nail. There were 20 females and 12 males, with an average age of 75 years. There were 16 fractures due to a fall, 15 pathological fractures, and one due to a car accident. Classification was: Type I: 6; Type II: 13; Type III: 6; Type IV: 3; Type V: 1. Mean follow-up was five months (range 3 to 18). Eight deaths occurred within one month. There were two pain-free non-unions, one revision with bone graft for non-union, and one spiral blade back out. No breakage of implants occurred.

We found that this implant provides stable fixation in these difficult fractures if adequate reduction is obtained. We have not experienced the implant failures reported in other series. We recommend the use of the implant, especially in those patients who are elderly or have pathological fractures.