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.

The prevalence of alcohol and opioids in severely injured patients has been widely reported from 30-80%. However, despite the increasing global misuse of stimulant drugs, there is a paucity of literature regarding the presence of stimulant drugs in trauma patients. The primary aim of this study was to define the prevalence of stimulant drugs that were detected in patients who presented to Level One Trauma Centers throughout North America, and their effect on length of stay and mortality.

Our triage criteria for admittance to the regional trauma centre are based on the recommendations by the American College of Surgeons Committee on Trauma, who now recommend toxicology screening on every patient. This was a retrospective analysis of data from the Trauma Quality Improvement Program, including all patients presenting emergently to participating Level 1 Trauma Centers from January 2017 to December 2018. A stimulant drug was defined as the detection of cocaine, amphetamine, or methamphetamine. Adults aged 18-64 years were included. Patient risk factors were included adjusted for in the analysis: age, sex, body mass index (BMI), alcohol screening results and smoking status. Univariate analysis was performed for all variables. Multivariable logistic regression and liner regression were used for mortality and length of stay, respectively.

Of a total of 110,561 patients included in the study, 15,958 patients (14.4%) had positive screens for stimulants. The average age in the stimulants cohort was 40.8 years, with a 77.6% male preponderance, BMI of 26.9, blood alcohol content of 0.07, and ISS of 11.3. The control cohort was comparable, though 71.1% male (p<0.001) Patients who tested positive for stimulants had 1.79 times (95% CI, 1.09-2.93) the odds of dying in the emergency department as the control group (p=0.02). Following transfer from the emergency department, the odds ratio for deaths in hospital (OR=1.02, 95% CI 0.90-1.15) was comparable to the control group (p=0.78). The mean length of stay was significantly higher in the stimulant group (2.84 days) compared to the control group (1.79 days) (p<.001). In the Intensive Care Unit, length of stay was 0.64 days in the stimulant group versus 1.65 in the control (p=0.48).

Stimulant misuse is a relevant issue in the trauma population, associated with a longer hospital stay and higher mortality in the emergency department. The continued routine drug screening of trauma patients may be beneficial in trauma centers, to implement preventative measures and optimise resource allocation.

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°.

Researchers and clinicians measuring outcomes following total ankle replacement (TAR) are challenged by the wide range of outcome measures used in the literature without consensus as to which are valid, reliable, and responsive in this population. This review identifies region- or joint-specific outcome measures used for evaluating TAR outcomes and synthesises evidence for their measurement properties.

A standard search strategy was conducted of electronic databases MEDLINE, EMBASE and CINAHL (to June 2015) to identify foot/ankle measures in use. A best evidence synthesis approach was taken to critically appraise measurement properties [COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)] of identified measures. The review was restricted to English publications and excluded cross-cultural adaptations. Measurement properties collected from each article were coded for validity, reliability, responsiveness, or interpretability. Clinimetric evidence exists for identified measures tested in non-TAR populations, but were not the focus of this review.

The search identified 14 studies to include in the best evidence synthesis with 32 articles providing clinimetric evidence for eight of the measures (one CBO, seven PRO), however only five measures were tested in a TAR population (Foot Function Index, Ankle Osteoarthritis Scale, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale [AOFAS], Foot and Ankle Outcome Score, Self-Reported Foot and Ankle Score). Five studies provided clinimetric evidence in a TAR population and their methodological quality was assessed: (1) Validity—two good quality studies examining different measures provide moderate evidence supporting construct validity (FFI, AOS, AOFAS self-reported items; SEFAS); (2) Reliability—two good quality studies examining different measures provide moderate evidence supporting internal consistency and test-retest reliability (FFI, AOS, AOFAS self-reported items; FAOS, SEFAS); (3) Responsiveness—three poor quality studies, thus unknown evidence for responsiveness; (4) Interpretability—two studies provide interpretability values (AOS, FFI, AOFAS self-reported items; AOS).

This review offers a basis for choosing the most appropriate instrument for evaluating TAR outcomes. Numerous outcome measures were identified with evidence supporting their use in populations with various foot/ankle conditions, but none have strong evidence supporting use in a TAR population. Measures must have adequate clinimetric properties in all patient groups in which they are applied. Evidence supporting or critiquing an instrument should not be based on studies with poor quality methodology, as identified by this review. Further testing in a TAR population would benefit identified measures with emphasis on adequate sample sizes, testing a priori hypotheses, and evaluating their content validity for a TAR population.

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.

Purpose

The failure rate of total ankle arthroplasty (TAA) in rheumatoid patients may be higher than in osteoarthritis patients due to the medications used to treat rheumatoid arthritis and the comorbidities associated with this disease. The purpose of this study was to prospectively look at the intermediate-term outcomes of TAA in patients with rheumatoid arthritis and to compare the results to a matched cohort of patients with ankle osteoarthritis undergoing TAA.

Purpose

Coronal plane malalignment at the level of the tibiotalar joint is not uncommon in advanced ankle joint arthritis. It has been stated that preoperative varus or valgus deformity beyond 15 degrees is a relative contraindication and deformity beyond 20 degrees is an absolute contraindication to ankle joint replacement. There is limited evidence in the current literature to support these figures. The current study is a prospective clinical and radiographic comparative study between patients who underwent total ankle arthroplasty with coronal plane varus tibiotalar deformities greater than 10 degrees and patients with neutral alignment, less than 10 degrees of deformity.

Purpose

To investigate the effect of obesity on functional outcome following total ankle arthroplasty.

Purpose: The treatment of large osteochondral lesions of the talus (OLT) remains a challenge. Fresh Osteo-chondral Allograft is a method that has been used for the treatment of larger lesions, with the advantage of transplanting living cartilage that is biologically attached to the subchondral bone. The purpose of this clinical series is to prospectively review the clinical and radiographic outcomes of patients that have undergone a Fresh Osteochondral Allograft.

Method: Between January 2003 and January 2007, 17 feet in 8 male and 8 female patients at a mean age of 35.8 (15–53) years underwent fresh osteochondral talar allo-grafting by a single surgeon. Data was prospectively collected, including preoperative and postoperative AOFAS, AOS, AAOS foot & ankle worksheets and SF-36 scores. Statistical analysis consisted of one tailed student T-test with alpha set a 5%. All patients were followed up clinically and radiographically by x-ray and CT scan.

Results: Average follow up was 3.2 (0.9–6.2) years. All scoring systems showed significant improvement postoperatively, except for AAOS shoe comfort scores, and the Mental Component Summary of the SF-36 questionnaire. The AOFAS score improved significantly (p=0.0001) from a mean score of 53.4 (30–71) to 86.3 (72–96). AOS pain scores improved significantly (p=0.0053) from a mean score of 45.4 (8.7–72.2) to 24.1 (4.2–58.9). AOS disability score improved significantly (p=0.0013) from a mean of 53.8 (7.8–77.3) to 25.9 (6.6 – 62.5). The AAOS foot & ankle core scale (standardized mean) improved significantly (p=0.0015) from a mean of 52.3 (21–81) to 80.1 (56–99). The AAOS foot & ankle core scale (normative score) improved significantly (p=0.0016) from a mean of 16.9 (−9 to 40) to 39.5 (20–55). The SF-36 Physical Component Summary improved significantly from a mean of 34.9 (24.2–43.8) to 47.3 (36.6–59.8). There was successful osseous graft incorporation in 16/17 feet (94%) verified on CT scan. Of the 16 grafts which had successfully incorporated, radiographic follow up showed 4/16 feet (25%) had signs of progressive OA and 3/16 feet (19%) had developed new osteolysis around the graft.

Conclusion: Although patients’ functional outcome can be substantially improved with the use of fresh osteochondral allografts the early radiographic findings are of concern with 43% demonstrating progression of arthritis or osteolysis of the graft during the process of graft incorporation.

Purpose: The objective of this study is to compare items from patient-reported questionnaires measuring musculoskeletal outcomes with items generated by pre-and post-operative ankle arthrodesis and arthroplasty patients using the Patient-Specific Index (PSI-P). The International Classification of Functioning, Disability and Health (ICF) was used as an external reference.

Method: A literature review identified six questionnaires that assess lower extremity outcomes (AAOS, patient-reported portion of AOFAS, FFI, LEFS, SMFA, WOMAC). Surgical patients (n=142) from an orthopaedic surgeon’s practice completed the patient-selected items from PSI-P. Items from questionnaires and PSI-P were coded by three reviewers and linked to the ICF. The ICF is divided into four components (Body Functions and Structures, Activities and Participation, Environmental Factors, and Personal Factors) which are then further divided into second level categories. A higher number of second level categories would indicate a questionnaire that captures a broader range of experiences.

Results: Patient’s responses from PSI-P identified 690 meaningful concepts that were linked to 45 second level ICF categories. Most PSI-P responses fell into Activities and Participation (60.6%) and Body Functions and Body Structures (35.2%) including the second level categories Walking (19.1%), Pain (16.5%), and Recreation and Leisure (15.4%). There was no statistical difference between arthrodesis and arthroplasty patients nor between pre-operative versus postoperative patients in terms of the proportion of patient responses that fell into each ICF component. A total of 237 meaningful concepts were identified in the 6 questionnaires studied and linked to 38 second level ICF categories. Overall, SMFA addressed the most number of second level categories and had the closest proportion of Body Function (23.0%) and Activities and Participation (68.9%) concepts as compared to PSI-P. The patient-reported portion of AOFAS addressed the fewest categories. LEFS only contained items from Activities and Participation. AAOS was the only questionnaire to address the issue of ‘swelling’, though it represented 4.9% of all PSI-P responses.

Conclusion: Questionnaires differ largely in their content and no single questionnaire captured all of the concerns identified by PSI-P. This analysis will guide us in the development of a new and more comprehensive instrument for evaluating ankle outcomes following fusion or replacement.