Preoperative talar valgus deformity increases the technical difficulty of total ankle replacement (TAR) and is associated with an increased failure rate. Deformity of ≥15° has been reported to be a contraindication to arthroplasty. The goal of the present study was to determine whether the operative procedures and clinical outcomes of TAR for treatment of end-stage ankle arthritis were comparable for patients with preoperative talar valgus deformity of ≥15° as compared to those with <15°. We will describe the evolving surgical technique being utilized to tackle these challenging cases.

Fifty ankles with preoperative coronal-plane tibiotalar valgus deformity of ≥15° “valgus” group) and 50 ankles with valgus deformity of <15° (“control” group) underwent TAR. The cohorts were similar with respect to demographics and components used. All TARs were performed by a single surgeon. The mean duration of clinical follow-up was 5.5 years (minimum two years). Preoperative and postoperative radiographic measurements of coronal-plane deformity, Ankle Osteoarthritis Scale (AOS) scores and Short Form (SF)-36 scores were prospectively recorded. All ancillary (intraoperative) and secondary procedures, complications and measurements were collected.

The AOS pain and disability subscale scores decreased significantly in both groups. The improvement in AOS and SF-36 scores did not differ significantly between the groups at the time of the final follow-up. The valgus group underwent more ancillary procedures during the index surgery (80% vs 26%). Tibio-talar deformity improved significantly toward a normal weight-bearing axis in the valgus group. Secondary postoperative procedures were more common in the valgus group (36%) than the controls (20%). Overall, re-operation was not associated with poorer patient outcome scores. Metal component revision surgery occurred in seven patients (three valgus and four controls). These revisions included two deep infections (2%), one in each group, which were converted to hindfoot fusions. Therefore, 94% of the valgus group retained their original components at final follow-up

Thus far, this is the largest reported study that specifically evaluates TAR with significant preoperative valgus alignment, in addition to having the longest follow-up. Satisfactory midterm results were achieved in patients with valgus mal-alignment of ≥15°. The valgus cohort required more procedures during and after their TAR, as well as receiving more novel techniques to balance their TAR. Whilst longer term studies are needed, valgus coronal-plane alignment of ≥15° should not be considered an absolute contraindication to TAR if the associated deformities are addressed.

Multiligament knee injuries (MLKI) are rare and life-altering injuries that remain difficult to treat clinically due to a paucity of evidence guiding surgical management and timing. The purpose of this study was to compare injury specific functional outcomes following early versus delayed surgical reconstruction in MLKI patients to help inform timing decisions in clinical practice.

A retrospective analysis of prospectively collected data from patients with MLKIs at a single academic level 1-trauma center was conducted. Patients were eligible for inclusion if they had an MLKI, underwent reconstructive surgery either prior to 6wks from injury or between 12weeks and 2 years from injury, and had at least 12months of post-surgical follow-up. Patients with a vascular injury, open injuries or associated fractures were excluded. Study participants were stratified into early (12 weeks - 2 years from injury). The primary outcome was patient reported, injury specific, quality of life in the form of the Multiligament Quality of Life questionnaire (MLQOL) and its four domains (Physical Impairment, Emotional Impairment, Activity Limitations and Societal Involvement). We secondarily analyzed differences in the need for manipulation under anesthesia, and reoperation rates, as well as radiographic Kellgren Lawrence (KL) arthritis grades, knee laxity grading and range of motion at the most recent follow-up.

A total of 131 patients met our inclusion criteria, all having had surgery between 2006 and 2019. There were 75 patients in the early group and 56 in the delayed group. The mean time to surgery was 17.6 ± 8.0 days in the early group versus 279 ± 146.5 days in the delayed. Mean postoperative follow-up was 58 months. There were no significant differences between early and delayed groups with respect to age (34 vs. 32.8 years), sex (77% vs 63% male), BMI (28.3 vs 29.7 kg/m2), or injury mechanism (p>0.05). The early surgery group was found to include more patients with lateral sided injuries (n=49 [65%] vs. n=23 [41%]; p=0.012), a higher severity of Schenck Classification (p=0.024) as well as nerve injuries at initial presentation (n=35 [49%] vs n=8 [18%]; p0.05), when controlling for age, sex, Schenck classification, medial versus lateral injury, and nerve injury status. In terms of our secondary outcomes, we found that the early group underwent significantly more manipulations under anesthesia compare with the delayed group (n=24, [32%] vs n=8 [14%], p=0.024). We did not identify a significant difference in physical examination laxity grades, range of motion, KL grade or reoperation rates between groups (p>0.05).

We found no difference in patient reported outcomes between those who underwent early versus delayed surgery following MLKI reconstruction. In our secondary outcomes, we found significantly more patients in the early surgery group required a manipulation under anesthesia following surgery, which may indicate a propensity for arthrofibrosis after early MLKI reconstruction.

Multiligament knee injuries (MLKI) are rare and life-altering injuries that remain difficult to treat clinically due to a paucity of evidence guiding surgical management and timing. The purpose of this study was to compare injury specific functional outcomes following early versus delayed surgical reconstruction in MLKI patients to help inform timing decisions in clinical practice.

A retrospective analysis of prospectively collected data from patients with MLKIs at a single academic level 1-trauma center was conducted. Patients were eligible for inclusion if they had an MLKI, underwent reconstructive surgery either prior to 6wks from injury or between 12weeks and 2 years from injury, and had at least 12months of post-surgical follow-up. Patients with a vascular injury, open injuries or associated fractures were excluded. Study participants were stratified into early (<6wks from injury) and delayed surgical intervention (>12 weeks – 2 years from injury). The primary outcome was patient reported, injury specific, quality of life in the form of the Multiligament Quality of Life questionnaire (MLQOL) and its four domains (Physical Impairment, Emotional Impairment, Activity Limitations and Societal Involvement). We secondarily analyzed differences in the need for manipulation under anesthesia, and reoperation rates, as well as radiographic Kellgren Lawrence (KL) arthritis grades, knee laxity grading and range of motion at the most recent follow-up.

A total of 131 patients met our inclusion criteria, all having had surgery between 2006 and 2019. There were 75 patients in the early group and 56 in the delayed group. The mean time to surgery was 17.6 ± 8.0 days in the early group versus 279 ± 146.5 days in the delayed. Mean postoperative follow-up was 58 months. There were no significant differences between early and delayed groups with respect to age (34 vs. 32.8 years), sex (77% vs 63% male), BMI (28.3 vs 29.7 kg/m²), or injury mechanism (p>0.05). The early surgery group was found to include more patients with lateral sided injuries (n=49 [65%] vs. n=23 [41%]; p=0.012), a higher severity of Schenck Classification (p=0.024) as well as nerve injuries at initial presentation (n=35 [49%] vs n=8 [18%]; p<0.001). Multivariable linear regression analyses of the four domains of the MLQOL did not demonstrate an independent association with early versus delayed surgery status (p>0.05), when controlling for age, sex, Schenck classification, medial versus lateral injury, and nerve injury status. In terms of our secondary outcomes, we found that the early group underwent significantly more manipulations under anesthesia compare with the delayed group (n=24, [32%] vs n=8 [14%], p=0.024). We did not identify a significant difference in physical examination laxity grades, range of motion, KL grade or reoperation rates between groups (p>0.05).

We found no difference in patient reported outcomes between those who underwent early versus delayed surgery following MLKI reconstruction. In our secondary outcomes, we found significantly more patients in the early surgery group required a manipulation under anesthesia following surgery, which may indicate a propensity for arthrofibrosis after early MLKI reconstruction.

There is limited literature on the effects of socioeconomic factors on outcomes after total ankle arthroplasty (TAA). In the setting of hip or knee arthroplasty, patients of a lower socioeconomic status demonstrate poorer post-operative satisfaction, longer lengths of stay, and larger functional limitations. It is important to ascertain whether this phenomenon is present in ankle arthritis patients. This is the first study to address the weight of potential socioeconomic factors in affecting various socioeconomic classes, in terms of how they benefit from ankle arthroplasty.

This is retrospective cohort study of 447 patients who underwent a TAA. Primary outcomes included pre-operative and final follow-up AAOS pain, AAOS disability, and SF-36 scores. We then used postal codes to determine median household income using Canadian 2015 census data. Incomes were divided into five groups based on equal amounts over the range of incomes. This method has been used to study medical conditions such as COPD and cardiac disease. These income groups were then compared for differences in outcome measures. Statistical analysis was done using unpaired t-test.

A total of 447 patients were divided into quintiles by income. From lowest income to highest income, the groups had 54, 207, 86, 64, and 36 patients, respectively. The average time from surgery to final follow up was 85.6 months. Interestingly, we found that patients within the middle household income groups had significantly lower AAOS disability scores compared to the lowest income groups at final follow-up (26.41 vs 35.70, p=0.035). Furthermore, there was a trend towards middle income households and lower post-operative AAOS pain scores compared to the lowest income group (19.57 vs 26.65, p=0.063). There was also a trend toward poorer AAOS disability scores when comparing middle income groups to high income groups post-operatively (26.41 vs 32.27, p=0.058). Pre-operatively, patients within the middle-income group had more pain, compared to the lowest and the highest income groups. No significant differences in SF-36 scores were observed. There were no significant differences seen in middle income groups compared to the highest income group for AAOS pain post-operatively. There were no significant differences found in pre-operative AAOS disability score between income groups.

Patients from middle income groups who have undergone TAA demonstrate poorer function and possibly more pain, compared to lower and higher income groups. This suggests that TAA is a viable option for lower socioeconomic groups and should not be a source of discouragement for surgeons. In this circumstance there is no real disparity between the rich and the poor. Further investigation is needed to explore reasons for diminished performance in middle class patients.

Outcomes following carpal tunnel release are generally favorable. Understanding factors that contribute to inferior outcomes may allow for strategies targeted at improving results in these patients. Our purpose was to determine if patients' underlying personality traits, specifically resiliency and catastrophization, impact their post-operative outcomes following carpal tunnel release.

A prospective case series was performed. Based on our power analysis, 102 patients were recruited. Patients completed written consent, the Boston Carpal Tunnel Questionnaire (BCTQ), the Pain Catastrophizing Scale (PCS) and the Brief Resiliency Scale (BRS). A single surgeon, or his resident under supervision, then performed an open carpal release under local anaesthetic. Our primary outcome measure was a repeat BCTQ at three- and six-months. Univariate and multivariate analysis was performed to assess the correlation between PCS and BRS scores and final BCTQ scores.

Forty-three and sixty-three participants completed the BCTQ at three and six months respectively. All patients showed improvement in their symptoms (p = 0.001). There was no correlation between patients PCS or BRS and the amount of improvement. There was also no correlation between PCS or BRS and the patients' raw scores at baseline or follow-up.

Patients self-assessed resiliency and degree of pain catastrophization has no correlation with the amount of improvement they have three or six months post-operatively. Most patients improved following carpal tunnel release, and patients with low resiliency and high levels of pain catastrophization should expect comparable outcomes to patients without these features.

Fibular head avulsion fractures represent a significant injury to the posterolateral corner of the knee. There is a high rate of concomitant injuries including rupture of the cruciate ligaments. Surgical fixation is indicated to restore stability, protect repaired or reconstructed cruciate ligaments and possibly decrease the likelihood of degenerative change. The current presentation describes a novel technique which provides secure fixation to the fibular head, restoring integrity of the posterolateral ligament complex and facilitating early motion. We also present a case series of our experience by a single surgeon at our tertiary referral center.

Twenty patients underwent open reduction and internal fixation between 2006 and 2016 using a large fragment cannulated screw and soft tissue washer inserted obliquely from the proximal fibula to tibia. Fixation was augmented with suture repair of the lateral collateral ligament and biceps tendon. The orientation of the fracture was assessed based on preoperative imaging. Repair / reconstruction of concomitant injuries was performed during the same procedure. Early range of motion was initiated at 2 weeks postoperatively under physical therapy guidance.

All patients returned for clinical and radiographic assessment (average 3.5 years). All fractures went on to bony union. There were no reoperations for recurrent instability. All patients regained functional range of motion with mean extension of 0.94 degrees and mean flexion of 121.4 degrees. Two patients underwent hardware removal. One patient developed a late local infection, which occurred greater than 5 years after surgery. Eleven patients underwent postoperative varus stress radiographs which demonstrated less than 1 mm difference between the operated and contralateral side. Fracture morphology typically demonstrated an oblique pattern in the coronal plane and a transverse pattern in the sagittal plane.

This study represents a novel surgical technique for the repair of fibular head avulsion fractures with a large fragment cannulated screw placed obliquely from the fibula to tibia. Fixation is augmented with a soft tissue washer and suture repair. Our results suggest that this technique allows for early range of motion with maintenance of reduction, high rates of union, and excellent postoperative stability.

Introduction

The risk of hip dislocation after revision total hip arthroplasty is up to 20% following surgery for periprosthetic fractures. A technique was developed by the senior authors, involving a transtrochanteric osteotomy and superior capsulotomy to attempt to minimise this risk(1).

Introduction & aims

Satisfaction following total knee replacement (TKR) surgery remains suboptimal at around 80%. Prediction of factors influencing satisfaction may help manage expectations and thus improve satisfaction. We investigated preoperative variables that estimate the probability of achieving a successful surgical outcome following TKR in several outcomes important to patients.

End-stage ankle arthritis (ESAA) is a debilitating disease that does not affect all individuals equally. Gender differences have been identified in patients with end-stage hip and knee arthritis and have stimulated research to explain these findings. The present study was undertaken to examine if gender has a significant effect on pre-operative disability and post-operative outcomes in patients with ESAA.

Patients undergoing ankle arthrodesis (AA) or total ankle replacement (TAR) with minimum 2-year follow-up were identified in the Canadian Orthopaedic Foot and Ankle Society prospective ankle reconstruction database. Demographic data, revision data, patient satisfaction questionnaires, and outcome data using the Ankle Osteoarthritis Scale (AOS) and Short-form 36 (SF-36) health survey were collected.

TAR: 384 patients were included, with 198 females and 186 males. Patient BMI, comorbidities, and duration of follow-up were similar between groups. Males were slightly older at the time of surgery (65.1 vs 62.4 years, p=0.01)). The most common etiology was post-traumatic arthritis for both genders, however females had a higher rate of rheumatoid arthritis (17% vs 5%, p=0.001). Implant types included STAR, Hintegra, and Mobility, and were similar between groups. Preoperatively females had higher rates of pain and disability, demonstrated by lower SF-36 physical component scores (PCS) (31.0 vs 34.5, p<0.001), and higher AOS pain (54.7 vs 51.1, p=0.05) and AOS disability scores (66.5 vs 59.6, p<0.001). Postoperatively, both groups had significant improvement in PCS, AOS pain, and AOS disability scores. Females, however, continued to demonstrate lower PCS scores (38.3 vs 41.9, p<0.001) and higher AOS disability (31.0 vs 25.8, p=0.02) than males. Regression analysis found that preoperative PCS, gender, age, and arthritis etiology all had a significant impact on postoperative PCS scores, with preoperative PCS scores having the largest impact. Preoperative AOS pain and disability scores had the largest impact on postoperative AOS pain and disability scores, respectively. Gender had no significant impact on AOS pain and disability scores postoperatively. Patient satisfaction was similar between males and females postoperatively. Secondary surgery was performed in 13.6% of females and 16.1% of males. Five males and five females underwent revision to arthrodesis.

In patients with ESAA, females tend to have higher pre-operative levels of pain and disability compared to males, which persists post-operatively. This is consistent with the hip and knee arthroplasty literature. This finding may be due to females undergoing surgery at more advanced disease states, arthritis etiology, referral bias, or treatment bias. Both males and females have significant and similar degrees of improvement in pain and disability scores after TAR, and reoperation rates and patient satisfaction rates are similar despite the apparent disparity in outcomes.

We identified 26 tibial tubercle osteotomies (TTOs) performed in 23 revision knee arthroplasties between 2009 and 2013. Average age at last operation was 66 (33–92). Mean follow-up period was 14 months (3–33).

Eleven TTOs were performed in 10 knees for single stage revisions and 15 TTOs were performed in 13 knees for 2 stage revisions in the setting of deep infection. In this infected subset 11 patients had a TTO performed at the first stage. This osteotomy was left unfixed to avoid leaving metalwork in a potentially contaminated wound, reopened, and then definitively secured with screws at the second stage. Our technique involves fashioning a long 7×1cm tibial tuberosity osteotomy without a proximal step-cut.

All osteotomies united with no fractures. Minor proximal migration was noted in one case associated with screw loosening. There was no proximal migration noted in the 2 stage cases where the osteotomy had been left initially unfixed. There were no extensor lags.

We conclude that TTO is a safe and reproducible procedure when adequate exposure cannot be obtained in revision knee arthroplasty. In 2 stage revisions sequential osteotomies does not decrease union rates and leaving the osteotomy unfixed after the first stage does not cause any issues.

Eligible patients were randomly allocated to PMI or standard intramedullary jigs. Smith and Nephew's patient specific cutting blocks (Visionaire) were used for PMI. Postoperative component positioning was investigated using the ‘Perth CT protocol’. Deviation of more than 3° from the recommended position was regarded as an outlier. Exact Mann-Whitney U test was used to compare component positioning and difference in proportion of outliers was calculated using Chi Squared analysis.

Fifty-five knees were enrolled in the standard instrumentation group and fifty-two knees in the PMI group.

Coronal femoral alignment was 0.7 ± 1.9° (standard) vs 0.5 ± 1.6° (PMI) (P=0.33). Outliers 9.4% vs 7.4% (P=0.71). Coronal tibial alignment was 0.4 ± 1.5° (standard) vs 0.6 ± 1.4° (PMI) (P=0.56). Outliers 1.9% vs 1.9% (P=0.99). Sagittal femoral alignment was 0.6 ± 1.5° (standard) vs 1.3 ± 1.9° (PMI) (P=0.07). Outliers 3.8% vs 13.2% (P=0.09). Tibial slope was 1.7 ± 1.9 ° (standard) vs 1.8 ± 2.7° (PMI) (P=0.88). Outliers 13.2% vs 24.1% (P=0.15). External rotation of femoral component was 0.6 ± 1.4° (standard) vs 0.2 ± 1.8° (PMI) (P=0.14). Outliers: 3.8% vs 5.6% (P=0.66).

Compared to standard intramedullary jigs, patient matched instrumentation does not improve component positioning or reduce alignment outliers.

Roentgen stereophotogrammetric analysis (RSA) is the most accurate radiographic technique for the assessment of three-dimensional micromotion in joints. RSA has been used previously to study the kinematics of the anterior cruciate ligament (ACL)-deficient knee and to measure knee laxity after bone-tendon-bone (BTB) reconstructions. There is no published evidence on its use in assessing hamstring grafts in vivo, in comparing hamstring versus BTB reconstruction, or in-depth analyses of graft performance.

The aim of this project was to use RSA to measure laxity in both BTB and hamstring reconstructions, and to attempt a detailed analysis of graft behaviour in both reconstructions, with particular attention to graft stretching and slippage of the bony attachments.

A prospective study was undertaken on 14 patients who underwent ACL reconstruction. Seven had BTB reconstruction, and seven had four-stranded semitendinosus/gracilis (STG). Tantalum markers were inserted at the time of surgery, into distal femur and proximal tibia, and also directly into the graft itself. Stress radiographs (90N anterior and 90N posterior force) were taken early post-operatively, and then at 6 weeks, and 3, 6 and 12 months.

In addition to measuring total anteroposterior knee laxity, a detailed analysis of the graft itself was possible. The BTB grafts had stretched by an average of 1.54%, and the bone plugs had migrated by 0.50 mm at the femoral end and by 0.61mm at the tibial end. The hamstring grafts had stretched on average 3.94%, and the intraosseous ends had migrated by 3.96mm at the femoral end and by 7.10mm at the tibial end. This is believed to be the most detailed application of RSA in analysing the performance of the two commonly used grafts in ACL reconstruction. Details such as graft stretching and fixation slippage have not been available previously; the data obtained in this study may have implications for clinical practice.

Aim

The aim of this study was to compare a single-incision minimally invasive (MI) posterior approach with a standard posterior approach in a double-blind prospective randomised controlled trial.