Aims. Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°. Methods. A matched cohort of patients similar for demographics and components used but differing in preoperative coronal-plane tibiotalar valgus deformity ≥ 15° (valgus, n = 50; 52% male, mean age 65.8 years (SD 10.3), mean body mass index (BMI) 29.4 (SD 5.2)) or < 15° (control, n = 50; 58% male, mean age 65.6 years (SD 9.8), mean BMI 28.7 (SD 4.2)), underwent TAA by one surgeon. Preoperative and postoperative radiographs, Ankle Osteoarthritis Scale (AOS) pain and disability and 36-item Short Form Health Survey (SF-36) version 2 scores were collected prospectively. Ancillary procedures, secondary procedures, and complications were recorded. Results. At mean 5.1 years follow-up (SD 2.6) (valgus) and 6.6 years (SD 3.3) (controls), mean AOS scores decreased and SF-36 scores increased significantly in both groups. Improvements in scores were similar for both groups – AOS pain: valgus, mean 26.2 points (SD 24.2), controls, mean 22.3 points (SD 26.4); AOS disability: valgus, mean 41.2 points (SD 25.6); controls, mean 34.6 points (SD 24.3); and SF-36 PCS: valgus, mean 9.1 points (SD 14.1), controls, mean 7.4 points (SD 9.8). Valgus ankles underwent more ancillary procedures during TAA (40 (80%) vs 13 (26%)) and more secondary procedures postoperatively (18 (36%) vs 7 (14%)) than controls. Tibiotalar deformity improved significantly (p < 0.001) towards a normal weightbearing axis in valgus ankles. Three valgus and four control ankles required subsequent fusion, including two for deep infections (one in each group). Conclusion. Satisfactory mid-term results were achieved in patients with preoperative valgus malalignment ≥ 15°, but they required more adjunctive procedures during and after TAA. Valgus coronal-plane deformity ≥ 15° is not an absolute contraindication for TAA if associated deformities are addressed. Cite this article: Bone Joint J 2020;102-B(12):1689–1696

Introduction/Purpose. A randomized clinical trial of first MTP joint hemiarthroplasty with a synthetic cartilage implant demonstrated equivalent pain, function and safety outcomes to first MTP joint arthrodesis at 2 years. Recognizing that many hemiarthroplasty and total toe implants have initially good results that deteriorate over time, the purpose of this study was to prospectively assess the safety and efficacy outcomes for the synthetic cartilage implant population and to determine if the excellent outcomes were maintained at >5 years. Methods. One hundred nineteen patients were evaluated at 5+ years; 23 could not be reached for follow-up, but implant status was available for 7 of these subjects. Patients completed a pain visual analogue scale (VAS) and Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) scores, preoperatively and at 2, 6, 12, 26, 52, 104 and 260 weeks postoperatively. Minimal clinically important differences are: ≥30% difference for pain VAS, 9 points for FAAM Sports, and 8 points for FAAM ADL. Great toe active dorsiflexion, weight-bearing radiographs, secondary procedures, and safety parameters were evaluated. Results. Of 119 patients available at mean 5.8 years follow-up (SD ±0.7; range: 4.4–8.0), 9 underwent implant removal and conversion to fusion in years 2–5, leaving 106 patients. The implant survival rate was 92.4% at 5.8 years. Pain and function outcomes at 5.8 years were similar to those at 2 years. VAS Pain, FAAM Sports, ADL Scores were maintained or improved at 5.8 years. No evidence of avascular necrosis, device migration or fragmentation was observed. There were no unanticipated safety events through 5.8 years. Ninety-three (93%) percent would have the procedure again. Conclusion. The synthetic cartilage hemiarthroplasty implant continues to demonstrate safety and efficacy for the treatment of advanced first MTP joint osteoarthritis with evidence of therapeutic effect and acceptable safety profile at 5.8 years

Introduction. Ankle fractures are common injuries presenting to trauma departments and ankle open reduction and internal fixation (ORIF) is one of the first procedures targeted in early orthopaedic training. Failure to address the fracture pattern with the appropriate surgical technique and hardware may lead to early failure resulting in revision procedures or premature degenerative change. Patients undergoing revision ORIF are known to be at much greater risk of complications, and many of these secondary procedures may be preventable. Method. A retrospective analysis of all patients attending our unit for ankle ORIF over a two year period was undertaken. Patients were identified from our Bluespier database and a review of X rays was undertaken. All patients undergoing re-operation within eight weeks of the primary procedure were studied. The cause of primary failure was established and potential contributing patient and surgical factors were recorded. Results. 236 patients undergoing ankle ORIF were identified. 13 patients (5.5%) returned to theatre for a secondary procedure within eight weeks. Within this group, 7 (54%) patients returned for treatment of a neglected or under treated syndesmotic injury, 3 (23%) for complete failure of fixation, 2 (15%) with wound problems and 1 (8%) for medial malleoulus mal-reduction. Of the patient group, 5 (38%) were known type 2 diabetics. Consultants performed 2 (15%) of procedures, supervised registrars 5 (39%) and unsupervised registrars 6 (46%) operations. Conclusion. Errors are being made at all levels of training in applying basic principles such as restoring fibula length and screening the syndesmosis intra-operatively. Appropriate placement and selection of hardware is not always being deployed in osteopenic bone resulting in premature failure of fixation and fracture patterns are not being fully appreciated. Patients are undergoing preventable secondary procedures in the operative treatment of ankle fractures

Introduction. Arthroscopic ankle fusion is an effective treatment for end stage ankle arthritis. It reliably improves pain but at the expense of ankle motion. Development of adjacent degenerative joint disease in the foot is thought to be a consequence of ankle fusion due to altered biomechanics. However, it has been reported to be present on pre-operative radiographs in many patients. There is very little evidence reporting the long-term outcomes of patients undergoing arthroscopic ankle fusion and particularly those requiring secondary procedures for adjacent joint disease. Material and methods. We reviewed the operative records of 149 patients who had undergone arthroscopic ankle fusion under the care of two consultant foot and ankle surgeons between 2002 and 2006. We contacted patients by telephone to determine whether they had required further investigation or surgery on the same foot after their index procedure. Secondary outcome measures included a Manchester Oxford Foot Questionnaire (MOQFQ) score and a patient satisfaction score. Results. 149 patients underwent 151 arthroscopic ankle fusions. Nine had died or developed dementia and 30 patients had incomplete hospital records leaving 111 available for follow-up with a response rate of 55% (65 ankles). The average time to follow-up was 12.0 years (9.5–16.6 years). 14 patients (22%) had undergone a secondary procedure including injections on the foot or ankle of the same side as the index procedure. Four of these procedures were arthrodeses and three of these were of the subtalar joint. Mean MOQFQ score was 18.0 (0–55). Overall 83% (54) patients were very satisfied or satisfied with their ankle fusion. Conclusions. Arthroscopic ankle arthrodesis results in high patient satisfaction rates at long-term follow-up. The number of patients requiring a secondary procedure due to ongoing pain and adjacent degenerative joint disease in their foot following ankle arthrodesis is low

Aims

The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan.

Aims

The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

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. Methods. Patients ≥18 years with Coughlin hallux rigidus grade 2, 3, or 4 were treated with implant MTPJ1 hemiarthroplasty or arthrodesis. Pain VAS, Foot and Ankle Ability Measure (FAAM) Sports and ADL, and SF-36 PF scores were obtained preoperatively, and at 2, 6, 12, 24, 52 and 104 weeks postoperatively. Final outcomes, MTPJ1 active peak dorsiflexion, secondary procedures, radiographs and safety parameters were evaluated for 129 implant hemiarthroplasties and 47 arthrodeses. Composite primary endpoint criteria for clinical success included pain reduction ≥30%, maintenance/improvement in function, and no radiographic complications or secondary surgical intervention at 24 months. Predictor variables included: grade; gender; age; BMI; symptom duration; prior MTPJ1 surgery; preoperative hallux valgus angle, ROM, and pain. Two-sided Fisher's Exact test was used (p< 0.05). Results. Patient demographics and baseline outcome measures were similar. Success rates between implant MTPJ1 hemiarthroplasty and arthrodesis were similar when stratified by hallux rigidus grade, gender, age, BMI, symptom duration, prior MTPJ1 surgery status, and preoperative VAS pain, hallux valgus and ROM (p0.05). Conclusion. Synthetic cartilage implant hemiarthroplasty (Cartiva) is an appropriate treatment for patients with hallux rigidus grade 2, 3 or 4 and is a reasonable choice in hallux rigidus in patients with < 20 degrees HVA, with a high degree of preoperative stiffness, irrespective of gender, age, BMI, hallux rigidus grade, preoperative pain, or duration of symptoms, in contrast to what might have been expected

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. Conclusion. In patients requiring surgery for advanced stage hallux rigidus, treatment with a small synthetic cartilage implant resulted in comparable clinically important pain relief and functional outcomes compared to 1. st. MTP arthrodesis while preserving and often improving great toe motion. Secondary surgical intervention was similar in the implant and arthrodesis groups. Revision from a small implant plug to arthrodesis can be performed if needed

Introduction:. We report the outcomes of salvage procedures in total ankle replacement (TAR) in a single surgeon series. Methods:. This study was a retrospective review of patients who had undergone salvage procedures with tibio-talo-calcaneal (TTC) fusion for failed TAR over a period from 1999–2013 in a single centre. In this period, 317 TAR were performed of which 11 have failed necessitating conversion to TTC fusion. Clinical documentation and radiographs were reviewed for cause of failure, type of graft for fusion, time to radiological/clinical union and complications including further surgeries. Results:. The causes of failure of the TAR were pain from instability/impingement in 8, fracture in one, subsidence of the talar component in one and infection in one. From the group of 11 patients, 8 patients went onto union at a mean of 10 months (7–14). All 8 patients had femoral head structural allografts to maintain limb length for the procedure and 3 required a secondary procedure to dynamise the nail. 2 patients with femoral head structural allografts developed infections necessitating removal of the graft and conversion to an external fixator of which one united and the other developed a painless fibrous union. 1 patient developed non-union with progressive deformity of the ankle resulting in a Symes amputation. Conclusions:. From our series of patients we have demonstrated that failure of TAR requiring salvage procedures is a relatively rare event (3.5%). The use of TTC fusion is successful in the majority of patients and the use of femoral head structural allografts allows preservation of leg length with good rates of union

Aims

A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

Data is scant on the critical question of whether patients with endstage ankle arthritis are better served by a fusion or a replacement. The STAR trial, a prospective case control study, comparing safety and efficacy of STAR ankle replacement at 24 months for 158 replacements and 66 fusions:. This FDA trial showed the STAR ankle replacement had better function, equivalent pain relief and a higher rate of complications and secondary procedures as ankles treated with fusion. A separate prospective cohort comparison of 200 ankle replacements vs. 94 ankle fusions performed by the collaborative consortium of Canadian Orthopaedic Foot and Ankle Surgeons (COFAS) suggests similar patient oriented outcomes at 24 months. Patients' self-assessment questionnaires do not show significant differences between the two groups. The main medium/long-term concerns with ankle replacement remain component subsidence (especially talar subsidence) and polyethylene wear. Forces across the ankle are considerable, and the orientation of those forces to the underlying trabecular structure are a concern. Whether 2 or 3 part ankles will provide better bearing wear results remains unknown. With older designs, at 10 years the Swedish registry found approximately 60% survivorship. This registry has also shown better survivorship in patients with rheumatoid disease and with increased surgeon experience. More recent results related to the Hintegra and AES components show better midterm (5 year) revision rates in selected surgeons hands, than seen with older designs. A large meta-analysis of ankle fusion and replacement published data by Haddad et al reported a mean nonunion rate of 10%. The main long-term concerns with ankle fusion are limitations of motion, and the development of premature arthritis in adjacent foot joints. In a study of an average of 9 year outcome of the Agility ankle replacement suggested that the incidence secondary arthritis is halved by replacement as compared to fusion

Introduction. Comminuted mid-foot fractures are uncommon. Maintenance of the length and alignment of the medial column, with restoration of articular surface congruity, is associated with improved outcomes. Conventional surgery has utilised open or closed reduction with K-wire fixation, percutaneous techniques, ORIF, external fixation or a combination of these methods. In 2003 temporary bridge plating of the medial column was described to reconstruct and stabilise the medial column. The added advantage of locking plates is the use of angle-stable fixation. We present our experience with temporary locking plates in complex mid-foot fractures. Materials and methods. Prospective audit database of 12 patients over a 6 year period (2003-2009). 5 males 7 females mean age 41.9. Mechanism of injury: 11 high-energy injuries (6 falls from height, 5 RTCs), 1 low energy injury. Fracture type: All involved the medial column - 12 fracture dislocations of the medial column. 4 concomitant injuries to the lateral column. All underwent ORIF, realignment, and stabilisation with locking plates across the mid-foot. Results. Median length of time to plate removal: 3 months (range 2-6). Prior to removal of the metalwork, there was no loss of reduction, no infections, and no implant breakage. 10 out of 12 required plate removal at 3 months. Long-term follow-up (Mean 12.4 months, range 4-32): 11 have minimal symptoms of swelling or discomfort from the midfoot which does not restrict their ADLs, whilst 1 patient developed post-traumatic arthritis with medial arch collapse. No secondary procedures following plate removal. The two patients with the plate in-situ were asymptomatic with regards to the metalwork at final follow-up. Conclusion. Locking plates provide adequate stabilisation following open reduction and internal fixation of complex and unstable midfoot fracture dislocations. However, the majority will require removal of the metalwork. Following removal of the metalwork, satisfactory length and alignment, and stability of the midfoot, is maintained

Aims

This paper documents the epidemiology of adults (aged more than 18 years) with a calcaneal fracture who have been admitted to hospital in England since 2000. Secondary aims were to document whether publication of the United Kingdom Heel Fracture Trial (UK HeFT) influenced the proportion of patients admitted to hospital with a calcaneal fracture who underwent surgical treatment, and to determine whether there has been any recent change in the surgical technique used for these injuries.

Open reduction and internal fixation of high-energy pilon fractures are often associated with serious complications. Various methods have been used to treat these injuries, with variable results. A total of 17 consecutive patients with pilon fractures of AO/OTA type 43-B3 (n = 1), type C2 (n = 12) and type C3 (n = 4) were treated by indirect reduction by capsuloligamentotaxis and stabilisation using an ankle-spanning Ilizarov fixator. The calcaneal ring was removed at a mean of 3.7 weeks (3 to 6). A total of 16 patients were available for follow-up at a mean of 29 months (23 to 43). The mean time to healing was 15.8 weeks (13 to 23). Nine patients had pin-track infections but none had deep infection or osteomyelitis. Four patients (25%) had malunion. Fair, good or excellent ankle scores were found in 14 patients. External fixation with a ring fixator achieves stable reduction of the fractured fragments without additional trauma to soft tissues.

With minimum complications and good healing results, the Ilizarov apparatus is particularly useful for high-energy pilon fractures.

Our study describes the clinical outcome of total ankle replacement (TAR) performed in patients with moderate to severe varus deformity. Between September 2004 and September 2007, 23 ankles with a varus deformity ≥ 10° and 22 with neutral alignment received a TAR. Following specific algorithms according to joint congruency, the varus ankles were managed by various additional procedures simultaneously with TAR.

After a mean follow-up of 27 months (12 to 47), the varus ankles improved significantly in all clinical measures (p < 0.0001 for visual analogue scale and American Orthopaedic Foot and Ankle Society score, p = 0.001 for range of movement). No significant differences were found between the varus and neutral groups regarding the clinical (p = 0.766 for visual analogue scale, p = 0.502 for American Orthopaedic Foot and Ankle Society score, p = 0.773 for range of movement) and radiological outcome (p = 0.339 for heterotopic ossification, p = 0.544 for medial cortical reaction, p = 0.128 for posterior focal osteolysis). Failure of the TAR with conversion to an arthrodesis occurred in one case in each group.

The clinical outcome of TAR performed in ankles with pre-operative varus alignment ≥ 10° is comparable with that of neutrally aligned ankles when appropriate additional procedures to correct the deformity are carried out simultaneously with TAR.