Aims. Despite the increasing numbers of ankle arthroplasties, there are limited studies on their survival and comparisons between different implants. The primary aim of this study was to determine the failure rates of primary ankle arthroplasties commonly used in the UK. Methods. A data linkage study combined National Joint Registry (NJR) data and NHS Digital data. The primary outcome of failure was defined as the removal or exchange of any components of the implanted device. Life tables and Kaplan-Meier survival charts were used to illustrate survivorship. Cox proportional hazards regression models were fitted to compare failure rates between 1 April 2010 and 31 December 2018. Results. Overall, 5,562 primary ankle arthroplasties were recorded in the NJR. Linked data show a one-year survivorship of 98.8% (95% confidence interval (CI) 98.4% to 99.0%), five-year survival in 2,725 patients of 90.2% (95% CI 89.2% to 91.1%), and ten-year survival in 199 patients of 86.2% (95% CI 84.6% to 87.6%). The five-year survival for fixed-bearing implants was 94.3% (95% CI 91.3% to 96.3%) compared to 89.4% (95% CI 88.3% to 90.4%) for mobile-bearing implants. A Cox regression model for all implants with over 100 implantations using the implant with the best survivorship (Infinity) as the reference, only the STAR (hazard ratio (HR) 1.60 (95% CI 0.87 to 2.96)) and INBONE (HR 0.38 (95% CI 0.05 to 2.84)) did not demonstrate worse survival at three and five years. Conclusion. Ankle arthroplasties in the UK have a five-year survival rate of 90.2%, which is lower than recorded on the NJR, because we have shown that approximately one-third of ankle arthroplasty failures are not reported to the NJR. There are statistically significant differences in survival between different implants. Fixed-bearing implants appear to demonstrate higher survivorship than mobile-bearing implants. Cite this article: Bone Joint J 2023;105-B(3):301–306

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. Methods. A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Medline, Embase, Cinahl, and Cochrane reviews were searched for relevant papers. Papers analyzing surgical treatment for failed ankle arthroplasties were included. All papers were reviewed by two authors. Overall, 34 papers met the inclusion criteria. A meta-analysis of proportions was performed. Results. Six papers analyzed all-cause reoperations of revision ankle arthroplasties, and 14 papers analyzed failures of conversion of a TAA to fusion. It was found that 26.9% (95% confidence interval (CI) 15.4% to 40.1%) of revision ankle arthroplasties required further surgical intervention and 13.0% (95% CI 4.9% to 23.4%) of conversion to fusions; 14.4% (95% CI 8.4% to 21.4%) of revision ankle arthroplasties failed and 8% (95% CI 4% to 13%) of conversion to fusions failed. Conclusion. Revision of primary TAA can be an effective procedure with improved functional outcomes, but has considerable risks of failure and reoperation, especially in those with periprosthetic joint infection. In those who undergo conversion of TAA to fusion, there are high rates of nonunion. Further comparative studies are required to compare both operative techniques. Cite this article: Bone Jt Open 2022;3(7):596–606

Ankle replacements have improved significantly since the first reported attempt at resurfacing of the talar dome in 1962. We are now at a stage where ankle replacement offers a viable option in the treatment of end-stage ankle arthritis. As the procedure becomes more successful, it is important to reflect and review the current surgical outcomes. This allows us to guide our patients in the treatment of end-stage ankle arthritis. What is the better surgical treatment – arthrodesis or replacement?

Aims. The number of revision total ankle arthroplasties (TAAs) which are undertaken is increasing. Few studies have reported the survival after this procedure. The primary aim of this study was to analyze the survival of revision ankle arthroplasties using large datasets. Secondary aims were to summarize the demographics of the patients, the indications for revision TAA, further operations, and predictors of survival. Methods. The study combined data from the National Joint Registry and NHS Digital to report the survival of revision TAA. We have previously reported the failure rates and risk factors for failure after TAA, and the outcome of fusion after a failed TAA, using the same methodology. Survival was assessed using life tables and Kaplan Meier graphs. Cox proportional hazards regression models were fitted to compare failure rates. Results. A total of 228 patients underwent revision TAA. The mean follow-up was 2.6 years (SD 2.0). The mean time between the initial procedure and revision was 2.3 years (SD 1.8). The most commonly used implant was the Inbone which was used in 81 patients. A total of 29 (12.7%) failed; nine (3.9%) patients underwent a further revision, 19 (8.3%) underwent a fusion, and one (0.4%) had an amputation. The rate of survival was 95.4% (95% confidence interval (CI) 91.6 to 97.5) at one year, 87.7% (95% CI 81.9 to 91.7; n = 124) at three years and 77.5% (95% CI 66.9 to 85.0; n = 57) at five years. Revision-specific implants had a better survival than when primary implants were used at revision. A total of 50 patients (21.9%) had further surgery; 19 (8.3%) underwent reoperation in the first 12 months. Cox regression models were prepared. In crude analysis the only significant risk factors for failure were the use of cement (hazard ratio (HR) 3.02 (95% CI 1.13 to 8.09)) and the time since the primary procedure (HR 0.67 (95% CI 0.47 to 0.97)). No risk factors for failure were identified in multivariable Cox regression modelling. Conclusion. Revision TAAs have good medium term survival and low rates of further surgery. New modular revision implants appear to have improved the survival compared with the use of traditional primary implants at revision. Cite this article: Bone Joint J 2023;105-B(11):1184–1188

Introduction. When ankle arthroplasty fails the options are revision to arthrodesis or revision to arthroplasty. We report early outcomes of revision procedures for failed total replacement. Methods. Retrospective review of prospectively collected data including post-operative complications, union, survivorship and PROMS scores to compare revision to arthrodesis and revision to arthroplasty. Results. 31 revision procedures (10 revision to arthrodesis and 21 revision to arthroplasty) were performed for failed primary ankle arthroplasty (30 patients) between January 2012 and June 2019. 23 males: 8 females, average age of 68. Indications for revisions were aseptic loosening (13), cysts/lysis (6), pain (5), periprosthetic infection (3), fracture (2), fibula erosion (1), polyethylene dislocation (1). Union rate following arthrodesis was 77.9% after primary revision procedure. Impaction bone grafting technique was utilised in seven patients with a union rate of 83%. Survivorship following revision to arthroplasty was 100% at two years; 87.5% at three years and 75% at four years Failed revision arthroplasty was revised to arthrodesis successfully. Median MOxFQ was 73.5 for the arthrodesis group versus 17 in the arthroplasty group (p=0.02). Median AOS was 87 for the arthrodesis group versus 12 for the arthroplasty group (p=0.04). Discussion. This study demonstrated the potential advantages in the short term of revision arthroplasty over conversion to arthrodesis with statistically significant improvements in MOxFQ and AOS within the first two years following revision

Introduction. While advances in joint-replacement technology have made total ankle arthroplasty a viable treatment for end-stage arthritis, revision rates for ankle replacements are higher than in hip or knee replacements [1]. The questions asked in this study were (1) what retrieved ankle devices demonstrate about ankle arthroplasty failures, and (2) how do these failures compare to those seen in the hip and the knee?. Materials and Methods. An IRB-approved retrieval laboratory received retrieved polyethylene inserts and surgeon-supplied reason for revision from 70 total-ankles (7 designs, including five currently-marketed designs) from 2002 to the present. All retrievals were rated for clinical damage. Polyethylene inserts received six months or less after retrieval (n=45) were analyzed for oxidation using Fourier Transform Infrared (FTIR) spectroscopy, reported as maximum ketone oxidation index [2]. Insert sterilization method was verified using trans-vinylene index [3]. Oxidation measured in the 45 ankle inserts versus their time in vivo was compared to oxidation rates previously published for gamma-sterilized hip and knee polyethylene retrievals [6]. Statistical analysis was performed using IBM SPSS v.22. Results. The ankle devices were retrieved most commonly for loosening (n=22) followed by polyethylene fracture (n=9). These failure modes occurred after statistically different in vivo time (loosening: mean=4.4±3.6 years; polyethylene insert fracture: mean=9.5±4.1 years; p=0.002). Presence of clinical fatigue (cracking and/or delamination) was identified in 24 of the 70 retrieved inserts, and its presence correlated with in vivo time (Spearman's rho =0.449, p<0.001). Thirteen of these fatigued inserts were analyzed by FTIR. TVI analysis confirmed the sterilization method of the fatigued inserts: 12 gamma, 1 non-gamma sterilized. All 13 fatigued inserts had maximum ketone oxidation index (KOI) of 1.2 or higher. Presence of fatigue correlated with measured oxidation (Spearman's rho =0.685, p<0.001). Six of the 9 inserts that fractured in vivo were analyzed by FTIR. All were gamma-sterilized, and all had oxidation of 1.2 or higher. Oxidation rate determined for most of the 45 ankle inserts was at or above oxidation rates previously published for gamma-sterilized hip and knee polyethylene retrievals [6]. Discussion. This retrieval study concurs with the ankle arthroplasty literature that loosening is the most common reason for ankle revision [4]. Ankle inserts retrieved as a result of implant loosening had lower oxidation and no fatigue damage resulting from their shorter in vivo time. Fatigued and/or fractured inserts were in vivo for longer times, allowing more oxidation to occur. The effect of oxidation on polyethylene tensile strength and ductility has been reported for tibial inserts [5]. Oxidation above the critical value [5] has a dramatic effect on the ability of the polyethylene to resist fatigue damage and fracture, since the toughness of the polyethylene drops to near zero. All fatigued and fractured ankle inserts had oxidation that exceeded this critical oxidation. Most ankle inserts, whether gamma or non-gamma sterilized, oxidized at or above the oxidation rates previously published for gamma-sterilized hip and knee polyethylene retrievals [6]

Ankle replacements appear to offer a good alternative to fusion in most arthritic conditions. Use of mobile bearings have significantly improved results of ankle replacement. These have a significant minor complication rate including nerve injury, fractures. One of the significant complications noted in our series was medial impingement. 34 Buechel-Pappas total ankle replacements performed by the senior author from October 1999 to May 2004 were reviewed retrospectively. Mean follow up of 2.8 years. 8 patients reported medial impingment symptoms at follow up. 3 patients underwent repeat surgery for this problem. One patient underwent arthroscopic debridement of scar tissue and impinging bone by another surgeon which gave good symptomatic relief. Two other patients had tibialis posterior tendonitis and underwent surgical decompression of the tendon. Both were found to be having degenerative tendons with partial tears. We discuss the findings, literature review and other complications of ankle replacements as well. Whether medial impingement is due to implant design or inherent pathology of ankle has to be studied further. Other implant designs like Agility may treat arthritis in medial and lateral gutters but can still cause soft tissue impingement. Whether these are due to implant design, residual arthritis in medial recess or soft tissue pathology is uncertain. This may be caused by the cylindrical shape of talar component (the physiologic talus has a cone shape with smaller radius on medial side). This has not been proven yet, but has been addressed in newer designs like Salto and Hintegra prostheses

Introduction. Postoperative pain following the 3 component ankle arthroplasty (AA) (Mobility™) is a recognised problem without any apparent cause. This study aimed to determine pattern of postoperative pain following Total Ankle Arthroplasty (TAA) and its management options. Materials and methods. In prospective observational study 167 patients who had (AA) and minimum follow-up of 24 months were included. FAOS ankle score, patients' satisfaction, SF36 and diagrammatic mapping of postoperative pain among other parameters were collected preoperatively and postoperatively at 3 months, 6 months and the annually. 20 Patients (12%) had moderate to severe postoperative ankle pain following the ankle arthroplasty. Results. Most of patients with mild pain and low AOFAS score during first year improved by the 2 year review. The pain was localised to the medial aspect of the ankle in 10 patients, lateral side in 8 patients, and both medial and lateral side in 1 patient and global in 1 patient with complex regional pain syndrome. 8 patients with medial or lateral pain needed a re-operation. 5 patients with medial pain were treated by complete release of deltoid ligament along with bony decompression of the medial compartment. None of the above implants were loose intra-operatively. 2 AA with lateral pain needed subtalar arthrodesis. 1 patient needed removal of metalwork from the calcaneum for relief of symptoms. A significant improvement of pain and AOFAS scores was observed in 3 out of the 5 patients who underwent medial compartment decompression and both patients who underwent subtalar arthrodesis. Conclusion. There are 10–13% of low AOFAS scores following Ankle Arthroplasty due to pain. In our series, the pain did not co-relate to implant loosening. Our treatment protocol of mapping of pain and re-do surgery could improve the long term outcome in a significant proportion of the patients

Aims

The aim of this study was to capture 12-month outcomes from a representative multicentre cohort of patients undergoing total ankle arthroplasty (TAA), describe the pattern of patient-reported outcome measures (PROMs) at 12 months, and identify predictors of these outcome measures.

Purpose: 1/ To compare patients treated with both ankle arthroplasty or ankle fusion using validated functional outcome measures and a computerized motion analysis system that measures three-dimensional kinematics and temporal data. 2/ To compare the functional outcome and gait mechanics of ankle arthroplasty and ankle arthrodesis to a healthy control group. Methods: Fifteen patients underwent seventeen ankle arthroplasties with the Scandinavian Total Ankle Replacement (STAR), twenty-three patients underwent ankle arthrodesis, and twenty-three healthy control patients were enrolled in this study. Assessment included: 1/ Ankle Osteoarthritis Scale (AOS) and general health status (SF-36). 2/ Gait data, including temporal-spatial, kinematic, and kinetic parameters using a seven-camera VICON 370 system (Oxford Metrics, UK). Comparison between groups was done using one-way ANOVA post hoc Bonferroni (p< 0.05). Results: Kinematic gait parameters for post-op arthrodesis, post-op arthroplasty and a control group are summarized in Table 1. Postoperative arthrodesis patients had significantly reduced ankle range of motion in the sagittal and frontal plane when compared to both postoperative arthroplasty patients and a control group (p< 0.05). Forefoot range of motion was also significantly reduced in the sagittal and frontal planes for arthrodesis patients when compared to the control group, however there were no significant differences between patient groups or between arthroplasty patients and controls (p< 0.05).|Functional questionnaire (AOS) data for the three groups is summarized in Table 2. There were no significant differences in patient perception of pain and disability, however AOS scores compared between arthrodesis patients and a control group were significant (p< 0.05). No difference was noted in AOS scores between ankle arthroplasty and control patients at one year post operative. Conclusions: Functional outcome analysis of treatment methods of end-stage ankle arthritis clearly shows the advantage of ankle arthroplasty over arthrodesis when comparing kinematic and outcome questionnaire data against controls. The results of this study will help determine the best surgical treatment for patients with end-stage ankle arthritis failing non-operative treatment

Abstract: The early stages of ankle arthroplasty were complicated by unsatisfactory surgical results and poor patient satisfaction. This paper reveals far greater patient satisfaction and excellent surgical results achieved from the STAR uncemented ankle replacement. Materials and Methods: We reviewed the first 29 STAR ankle replacements carried out by the senior author. Patients were reviewed clinically and radiographically according to the AAOS hind-foot score. Failure was deemed to be revision of the implant. Reason for surgery was rheumatoid arthritis in twelve patients and primary or secondary osteoarthritis in seventeen patients. Results: One patient required revision surgery. This was an osteopoenic rheumatoid patient and the revision was for component subsidence. Three patients from the initial stages required minor soft tissue and bony resection at a second procedure with retention of the prosthesis. Patient satisfaction was high. Clinically, the average ROM was 5deg dorsiflexion and 12 deg plantarflexion. Patient satisfaction was extremely high. While the AAOS score does not give a grading, we also applied the Kofoed scale and 28 of our patients achieved a good or excellent result. Conclusion: We conclude that the STAR uncemented ankle replacement achieves very good clinical results and excellent patient satisfaction

After catastrophic failure of first generation, joint replacement as treatment option for ankle osteoarthritis is undergoing a revival with improved second generation designs. Short to mid-term results reportedly equal those of ankle arthrodesis in terms of complications and revision, but preserving joint motion and protecting neighbouring midfoot joints from overuse and consecutive osteoarthritis. However, most reports derive from developers centres excluding the learning curve. We present clinical results and subjective outcome of an initial patient series undergoing ankle replacement in an independent centre. From January 2004 to January 2008 a Hintegra. ®. prosthesis was implanted in 39 consecutive patients (41 ankles), average age 60.7 years (range 36.6–85.0), 13 males and 25 females. Repeated clinical follow up was done for an average of 2.2 years (range 0.5–4.3). All patients whose operation had been more than 0.7 years before were sent the FAOS (Foot and Ankle Outcome Score) in order to record the subjective outcome. Pre-operative diagnoses were posttraumatic osteoarthritis in 26 cases (63.4%), primary osteoarthritis in 9 cases (22%) and rheumatoid arthritis in 6 cases (14.6%). Clinical examination did not show significant improvement of mean range of motion, dorsiflexion and plantarflexion compared with the preoperative status. The change in motion highly correlated with the preoperative mobility (r=0,8; p< 0.001): patients with the largest preoperative range of motion were the ones to lose most mobility, whereas patients with low preoperative motion gained mobility. About 60% of the patients achieved 25° to 30° total range of motion regardless of their preoperative mobility. Early postoperative complications occurred in 14 patients (34.1%). In all five subclasses of the FAOS a significant improvement was achieved within the observation period. Reduction of pain had the greatest impact on the improvement of quality of life, whereas change in mobility did not have any influence. Joint replacement is a valuable treatment option for ankle osteoarthritis. There are however a series of early complications and restrictions of subjective outcome a surgeon has to be aware of when selecting an individual patient for ankle replacement. Further studies are needed to detect in which cases arthrodesis or prosthesis is preferable

Background. Postoperative pain following (Mobility TM) ankle arthroplasty (AA) is recognised problem. This study aimed to determine pattern of postoperative pain following Ankle arthroplasty (AA). Materials and Methods. In prospective observational study 135 patients who had (AA) and follow-up of 12–36 months were included. AOFAS ankle score, patients' satisfaction, SF36 and diagrammatic mapping of postoperative pain among other parameters were collected preoperatively and postoperatively at 3 months, 6 months and the annually. Patients with AOFAS of < 50 with postoperative ankle pain were examined in details. Results. From total of 135 of patients with follow-up of 12 months, (12.5%)17 patients have low AOFAS score and ankle pain, 11(12.5%) of 85 patients with 2 year follow-up and (10.6%),5 of 47 patients with 3 year follow-up. Most of patients with low AOFAS score during first year have improved but 3 patients. Different group patients developed ankle pain during the second and third year. 3 patients of 5, in year 3 follow-up have medial side ankle pain and 2 lateral; similarly there is more medial sided pain during year 2 review (7/11). There is more medial sided pain noticed during first postoperative year as well. Lateral pain seems to relate with subtalar joints problems. Medial side pain is less understandable, it might be due to tension in medial ankle ligaments. Our study showed improvement in AOFAS score and pain relief associated with medial ligaments release or medial malleolus fracture. Conclusion. There are 10–13 % of low AOFAS scores following Ankle Arthroplasty with ankle pain. There are emerging evidences explaining postoperative ankle pain. Further studies are required in this field

Aim. A prospective cohort of patients undergoing total ankle arthroplasrty for arthritis following pilon fractures was included in the present study. This group of patients generally have poor soft tissue envelope and have had previous surgical interventions prior to the ankle arthroplasty, making the arthroplasty more difficult as well as prone to complications. Methods. The data collected included patient demographics, American Orthopaedic Foot and Ankle Score (AOFAS) and patient reported outcomes (FAOS, SF-36, patient satisfaction) The data was collected preoperatively and at 1 & 2 years postoperatively. The minimum follow-up period was 2 years post-operatively. Results. A total of 167 total ankle arthroplasties were performed by the senior author between Jan 2006 and June 2010. Of this cohort, the indication for 12 arthroplasties was arthritis following pilon fractures of the distal tibia. The average of the patients at the time of the surgery was 64.2yrs. The average number of previous surgeries prior to the ankle arthroplasty was 1.5. There were significant improvements in the AOFAS scores from an average of 18 to 75 at final review. The WOMAC scores improved from 31 to 71 for pain, stiffness improved from 31 to 60 and function improved from 33 to 63. The improvement of the SF36 and patient satisfaction score is similar to the ones for primary ankle osteoarthritis. The complications were: 1 case of superficial wound infection which settled with antibiotics, one fracture of medial malleolus and one case of undisplaced distal tibial fracture treated conservatively to union. Conclusion. The Indications for TAR can be safely broadened to include younger patients with arthritis following pilon fractures of the tibia. The Outcomes after TAR for patients with arthritis following pilon fractures are comparable to those for primary osteo arthritis of the ankle

Introduction. Ankle replacement is now common in the UK. In a tertiary referral NHS practice, between 1997–2011 we implanted two types of cementless mobile bearing total ankle replacements (TAR). Methods. We reviewed our operative database and electronic patient records and confirmed the number of prosthesis with our theatre records. All case notes and radiographs were reviewed. Failure was taken as revision, and patients were censored due to death or loss to follow-up. The survivorship was calculated using a life table (the Kaplan-Meier method), with 95% confidence intervals. Results. We found a total of 358 NHS patients had a TAR from Jan 1997 to April 2012 total ankle replacements; the mean follow up was 76 months. The principle indications for surgery included primary OA (n=146) and inflammatory arthritis in (n=79). Overall survival was 90.9% (94–84) at 10 years. A complication requiring revision developed in 42 ankles and 36 were revised or fused. Thirty-two TAR's underwent further hind foot fusions which were not attributed as a failure of the prosthesis. We arthroscoped 6 TAR's for hetrotrophic calcification. When we separated the implants we found the STAR (implanted from 1997–2004) had a 5-year survival of 95.2% (98–91) and the Mobility (implanted from 2004–11) of 92.6% (96–88). We found early failures (within 2 years of implantation) were higher within 2 years of introduction of TAR and on changing our prosthesis. Conclusion. In a study of TAR undertaken at one centre principally by an experienced surgeon and team, we have shown a learning curve. Cementless mobile bearing total ankle replacements (TAR) conducted on a routine basis with careful patient selection has a 90.9% survivorship over a 10-year period. The difference in survival for two implants is not statistically significant

We performed 52 cemented ankle arthroplasties for painful osteoarthritis (OA) (25) or rheumatoid arthritis (RA) (27) using an ankle prosthesis with a near-anatomical design. We assessed the patients radiologically and clinically for up to 14 years using an ankle scoring system. The preoperative median scores were 29 for the OA group and 25 for the RA group and at ten years were 93.5 and 83, respectively. Six ankles in the OA group and five in the RA group required revision or arthrodesis. Survivorship analysis of the two groups showed no significant differences with 72.7% survival for the OA group and 75.5% for the RA group at 14 years

In a retrospective study we compared 32 HINTEGRA total ankle replacements (TARs) and 35 Mobility TARs performed between July 2005 and May 2010, with a minimum follow-up of two years. The mean follow-up for the HINTEGRA group was 53 months (24 to 76) and for the Mobility group was 34 months (24 to 45). All procedures were performed by a single surgeon. There was no significant difference between the two groups with regard to the mean AOFAS score, visual analogue score for pain or range of movement of the ankle at the latest follow-up. Most radiological measurements did not differ significantly between the two groups. However, the most common grade of heterotopic ossification (HO) was grade 3 in the HINTEGRA group (10 of 13 TARs, 76.9%) and grade 2 in the Mobility group (four of seven TARs, 57.1%) (p = 0.025). Although HO was more frequent in the HINTEGRA group (40.6%) than in the Mobility group (20.0%), this was not statistically significant (p = 0.065).The difference in peri-operative complications between the two groups was not significant, but intra-operative medial malleolar fractures occurred in four (11.4%) in the Mobility group; four (12.5%) in the HINTEGRA group and one TAR (2.9%) in the Mobility group failed (p = 0.185). Cite this article: Bone Joint J 2013;95-B:1075–82

Introduction. Ankle replacement is a major surgery with significant soft tissue dissection and bleeding. The skin quality is often poor in these patients due to age, edema, venous congestion, arteriopathy or previous procedures and soft tissue injury. The chances of wound infection increase with delayed wound healing. Absorbent non-adherent dressing (ABD) and VAC dressing applied in theatre after ankle replacement were assessed in a cohort of 147 patients with wound complications, pain, satisfaction and length of stay as outcome measures. Patients and methods. 71 consecutive patients were treated with ABD post-operatively after ankle replacement. The practice was then changed to VAC dressings for 76 consecutive patients. 44 patients had additional procedures performed with ankle replacement (11 from ABD group and 33 from VAC group). Retrospective analysis of prospectively collected data was performed. All patients had daily pain score, wound status, hospital stay, satisfaction and range of movement recorded. Results. Patients with VAC had mean pain score of 3/10 post operatively compared with 6/10 with ABD. There was a significant difference between the length of stay between the groups (p=0.02). The average stay of stay was 9 days with ABD and 7 days with VAC dressing. One of the patients with VAC dressing had blisters and 1 patient developed a superficial wound infection. Of the ABD group, 3 patients developed blisters and 7 patients had wound complications after ABD. Range of movement was similar in both groups of patients. Patient's satisfaction with VAC dressing was 8/10. Conclusion. VAC is better than ABD as primary dressing after ankle replacement

Total ankle replacement (TAR) is increasingly used in the treatment of end-stage ankle arthropathy, but much debate exists about the clinical result. The goals of present study are: 1) to provide an overview of the clinical outcome of 58 TAR's in a single centre and 2) to assess the association between radiological characteristics and clinical outcome. We reviewed a prospective included cohort of 58 TAR's in 54 patients with a mean age of 66.9 (range 54–82) and a mean follow-up of 21.6 months (range 1.45–66.0). The TAR's where performed by a single surgeon in a single centre (MUMC) between 2010 and 2015, using the CCI ankle replacement. A standard surgical protocol and standardized post-op rehabilitation was used. Patients were followed-up pre-op and at 1 day, 6 weeks, 3–6–12 months and yearly thereafter post-op. The AOFAS and range of motion (ROM) were assessed and all complications, re-operations and the presence of pain were recorded. Radiographic assessment consisted of the estimation of prosthesis alignment, migration, translation and radiolucent lines using the Rippstein protocol (1). The clinical outcome was compared with a systematic review of TAR outcome. Ten intra-operative complications occurred and 9 were malleolar fractures. Post-operative complications occurred in 20 out of the 54 patients (37.0%). Impingement (5/54 patients), deep infection (4/54 patients), delayed wound healing (3/54 patients) and minor nerve injuries (3/54 patients) were the most frequently recorded. 18 patients (31.0%) underwent one or more re-operations and 12 of these 18 patients underwent a component revision (mostly the PE insert) or a conversion to arthrodesis. Despite the complications and revisions, the functional outcome improved. Radiologically 15.8% of the TAR's were positioned in varus and 1.8% in valgus. Migration in the frontal and sagittal plane is seen in 3 and 2 TAR's respectively. Radiolucency is significantly increasing with the follow-up time (p=0.009). Migration in the frontal plane is significantly associated with conversion to arthrodesis (p=0.005) and migration in the sagittal plane to revision of a component or conversion to arthrodesis (p=0.04). Finally, pain is significantly associated with re-operations (p=0.023) and complications (p=0.026). Remarkable is that the clinical outcome is independent of the direct post-op alignment of the TAR. The complication-, re-operation and revision or conversion to arthrodesis rates makes the clinical outcome of TAR still questionable favourable. Especially the complication and re-operation incidences are greater than found in the systematic review. However, it is remarkable that the minor complications and re-operations not related to the TAR are not often mentioned in the literature. Radiographic characteristics could be of value in predicting this clinical outcome and thereby influence the post-operative handling. In conclusion, our results show relatively high incidences of complications (37.0%) and re-operations (31.0%) when minor complications and re-operations are included. TAR clinical outcome can be predicted by radiographic migration characteristics and pain

As an alternative to ankle replacement, ankle arthrodesis remains a mainstay in the treatment of end-stage arthritis. Arthroscopic techniques for ankle arthrodesis have more recently been developed, although there has been limited research exploring the cost of arthroscopic (AAA) versus open ankle arthrodesis (OAA), and comparing ankle fusions to replacement (TAA). We hypothesise that resource use after AAA will be lower than that after OAA, and both will be lower than TAA. We performed a retrospective review of a prospectively collected database. The COFAS database was used to identify patients with >2 years of follow up who have undergone AAA, OAA or Hintegra TAA at St Paul's Hospital between 2003–2010. Ninety patients with TAA, 52 with AAA and 56 with OAA met our inclusion criteria. The following data were documented: patient demographics (age, gender, presence of diabetes, inflammatory arthritis or any smoking history), factors related to the index surgery (type of surgery, OR time, length of stay) and factors relating to the post-operative course (number of post-operative clinic visits, OR time for re-operations, length of stay for additional hospital admissions). In terms of the index surgery, AAA required less initial OR time compared to either OAA or TAA. Initial length of hospital stay was significantly longer for both TAA and OAA, compared to AAA. Patients attended more follow-up visits after TAA or OAA compared to after AAA. In terms of additional OR time required, no significant differences were found among the groups. The most common reason for re-operation was infection or wound breakdown (38% of re-operations), followed by removal of hardware (15%). TAA also required significantly more additional days in hospital compared to either OAA or AAA. For all significant comparisons, p < 0.05. For each primary TAA, on average an additional one hour of surgery, three days in hospital and seven clinic visits were required on top of the cost factored for the primary arthroplasty. For each primary AAA, an additional four clinic visits, 23 minutes of revision surgery and one day in hospital were required. For each primary OAA, an average additional five clinic visits, three minutes of OR time, and 0.2 days of additional hospital stay occurred during follow up. Using several measures of resource use, we find that arthroscopic ankle fusions compare favourably to both ankle replacements and open ankle fusions. We also show that resource utilisation measurements can be a useful surrogate for complications, and that resource utilisation can demonstrate the practical implications of complications for patients, surgeons and health care resources