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

Background. Ankle and hindfoot fusion in the presence of large bony defects represents a challenging problem. Treatment options include acute shortening and fusion or void filling with metal cages or structural allograft, which both have historically low union rates. Impaction grafting is an alternative option. Methods. A 2 centre retrospective review of consecutive series of 32 patients undergoing hindfoot fusions with impaction bone grafting of morselised femoral head allograft to fill large bony void defects was performed. Union was assessed clinically and with either plain radiography or weightbearing CT scanning. Indications included failed total ankle replacement (24 patients), talar osteonecrosis (6 patients) and fracture non-union (2 patients). Mean depth of the defect was 29 ±10.7 mm and mean maximal cross-sectional area was 15.9 ±5.8 cm. 2. Tibiotalocalcaneal (TTC) arthrodesis was performed in 24 patients, ankle arthrodesis in 7 patients and triple arthrodesis in 1 patient. Results. Mean age was 57 years (19–76 years). Mean follow-up of 22.8 ±8.3 months. 22% were smokers. There were 4 tibiotalar non-unions (12.5%), two of which were symptomatic. 10 TTC arthrodesis patients united at the tibiotalar joint but not at the subtalar joint (31.3%), but only two of these were symptomatic. The combined symptomatic non-union rate was 12.5%. Mean time to union was 9.6 ±5.9 months. One subtalar non-union patient underwent re-operation at 78 months post-operatively after failure of metalwork. Two (13%) patients developed a stress fracture above the metalwork that healed with non-operative measures. There was no bone graft collapse with all patients maintaining bone length. Conclusion. Impaction of morselised femoral head allograft can be used to fill large bony voids around the ankle and hindfoot when undertaking arthrodesis, with rapid graft incorporation and no graft collapse despite early loading. This technique offers satisfactory union outcomes without the need for shortening or synthetic cages

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.

Introduction. Total ankle replacement (TAR) is performed for post-traumatic arthritis, inflammatory arthropathy, osteoarthritis and a range of other indications. The Scottish Arthroplasty Project (SAP) began collection of data on TAR in 1997. In this study, using data from the SAP, we examined the annual incidence of TAR between 1997 and 2015. Implant survivorship and the rate of general and joint-specific complications were also analysed. Methods. We identified 601 patients from a national arthroplasty database who had undergone total ankle replacement between 1997 and 2015 and followed up these patients to a maximum of 20 years. We used established methods of linkage with national hospital episode statistics, population and mortality data to examine the incidence of complications and implant survivorship. Results. There were 601 primary TAR procedures with an overall incidence of 0.6 per 10. 5. population per year. Indications for ankle replacement included: posttraumatic arthritis/osteoarthritis 63%; inflammatory arthropathy 25% and other diagnoses including: haemophilia; haemochromatosis; psoriatic arthritis and avascular necrosis in 12%. The peak incidence was in the 6th decade. There was a female to male ratio of 1:1. The incidence of TAR increased over the study period (r= 0.9, p=< 0.0001). This may be due to a broadening range of indications and patient selection criteria, in turn due to increased surgeon experience with ankle replacement and the evolution of implant design. The overall 10 year survivorship was 90%. The rate of general and implant specific complications was comparable to published literature. Conclusion. This study examines a large number of ankle replacements from an established arthroplasty dataset. The prevalence of TAR has increased over 19 years. Overall survivorship was similar to other published registry data on ankle replacements. Further work will look at the effect of surgeon volume on rate of complications, reoperation and survivorship

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

Technique, inducations, complications and early outcomes with posterior ankle and subtalar arthroscopy. A. ANKLE ARTHROSCOPY: Tips and Pearls on Avoiding Complications. a. Introduction. i. understanding of the anatomy of the foot and ankle is critical to safe performance of arthroscopic procedures and prevention of complications. ii. understanding of the surface and intra-articular anatomy of the ankle/subtalaar region is essential. iii. topographical anatomy serves as a guide to the successful placement of arthroscopic portals in the ankle. iv. neurovascular and tendinous structures are most at risk. b. Indications for Posterior/Subtalar Arthroscopy. i. Posterior ankle/ST Impingement. ii. OLT Ankle (usually posteromedial). iii. Assist operative reduction of calc or post mal fractures. iv. Arthrodesis ankle/ST or both. c. Portals. i. Know the anatomy, use blunt dissection, minimize re-entry. ii. Preoperative plan for access, pathology, visualization. d. Prone Position. a. Posteromedial. b. Posterolateral. c. Accessory posterolateral. e. Set-up/instrumentation. i. Positioning -. ii. posterior, prone. iii. Distraction- non-invasive vs invasive (trans-calcaneal thin wire). iv. Equipment - general set-up/instruments. - scopes (4.0 for outside joint or fusions; 2.7 otherwise). - irrigation/pump (run at lowest flow possible). f. Tips on Avoiding Complications. i. Patient selection and education. ii. Careful preoperative planning, evaluation. iii. Know/respect your anatomy. iv. Meticulous portal placement/care. v. Limit operative time/distension/tissue damage. vi. Use mini C-arm to monitor. vii. Plan, plan and plan, if you are prepared, all will work out. viii. Rehabilitation protocol and follow up

Diagnosis. a. History and exam. i. True Lisfranc fracture dislocations are NOT difficult to diagnose. b. Midfoot sprains or subtle injuries. i. These are DIFFICULT to diagnose. - subtle x-ray findings with minimal displacement. i) Exam: - be “suspicious” of midfoot sprains. - TMT tenderness, swelling. - inability to WB. ii) Mechanism of injury:. - indirect twisting injury (athletic). - crush injury of the foot (trauma). - axial forefoot loading (dancers, jumpers). iii) Investigations:. - X-rays usually normal or subtle widening. need to assess all 3 views in detail. standing AP compare to the other side. -Stress x-rays: - if clinical symptoms indicate - severe injury + pain but x-ray looks normal. - MRI useful for anatomic/instability correlation. - CT scan good for subtle injuries/fractures and displacement. - Bone scan positive in subacute/chronic pain situation. Treatment. a) Surgical Indications. i) Any displacement/positive stress xrays/test. ii) Surgical technique. - open reduction or closed and percutaneus fixation. - anatomic reduction essential. - NWB period up to 6 weeks. - WB with protection for another 4-6 weeks. iii. Screw vs tightrope fixation. iv. Hardware removal. b) Non-operative. i) Stable non-displaced sprain (need to make sure this is stable, ie stress views). - 6 to 8 weeks NWB. - expect prolonged recovery up to 6 months with. proper treatment. Controversial Issues:. a. Do all injuries with mild displacement have to be fixed operatively?. b. Arthrodesis vs fixation for soft tissue lisfranc with mild displacement?. c. Arthrodesis vs fixation subacute or chronic presentation?. d. Hardware removal?

Aims

We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.

Aims

Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent.

We compared the clinical and radiographic results of total ankle replacement (TAR) performed in non-diabetic and diabetic patients. We identified 173 patients who underwent unilateral TAR between 2004 and 2011 with a minimum of two years’ follow-up. There were 88 male (50.9%) and 85 female (49.1%) patients with a mean age of 66 years (sd 7.9, 43 to 84). There were 43 diabetic patients, including 25 with controlled diabetes and 18 with uncontrolled diabetes, and 130 non-diabetic patients. The clinical data which were analysed included the Ankle Osteoarthritis Scale (AOS) and the American Orthopaedic Foot and Ankle Society (AOFAS) scores, as well the incidence of peri-operative complications.

The mean AOS and AOFAS scores were significantly better in the non-diabetic group (p = 0.018 and p = 0.038, respectively). In all, nine TARs (21%) in the diabetic group had clinical failure at a mean follow-up of five years (24 to 109), which was significantly higher than the rate of failure of 15 (11.6%) in the non-diabetic group (p = 0.004). The uncontrolled diabetic subgroup had a significantly poorer outcome than the non-diabetic group (p = 0.02), and a higher rate of delayed wound healing.

The incidence of early-onset osteolysis was higher in the diabetic group than in the non-diabetic group (p = 0.02). These results suggest that diabetes mellitus, especially with poor glycaemic control, negatively affects the short- to mid-term outcome after TAR.

Cite this article: Bone Joint J 2014;96-B:1674–80.

We carried out 123 consecutive total ankle replacements in 111 patients with a mean follow-up of four years (2 to 8). Patients with a hindfoot deformity of up to 10° (group A, 91 ankles) were compared with those with a deformity of 11° to 30° (group B, 32 ankles). There were 18 failures (14.6%), with no significant difference in survival between groups A and B. The clinical outcome as measured by the post-operative American Orthopaedic Foot and Ankle Surgeons score was significantly better in group B (p = 0.036). There was no difference between the groups regarding the post-operative range of movement and complications. Correction of the hindfoot deformity was achieved to within 5° of neutral in 27 ankles (84%) of group B patients. However, gross instability was the most common mode of failure in group B. This was not adequately corrected by reconstruction of the lateral ligament.

Total ankle replacement can safely be performed in patients with a hindfoot deformity of up to 30°. The importance of adequate correction of alignment and instability is highlighted.