Recent advances in arthroplasty for the hip and the knee have motivated modern foot and ankle research to perfect the implant and technique for the optimal total ankle replacement. Unlike in the hip where different approaches can be done with similar implants, the approach of a total ankle is intimately associated to the prosthetic design. The anterior and lateral approaches have pros and cons regarding their respective soft tissue complications, osteotomy necessity, orientation of the bone cut and gutter visualization. While both have been studied independently, very few reports have compared both in the same setting. This study retrospectively looked at the difference in reoperations rate after each ankle arthroplasty within two years estimating that both had similar rate of return to the operating room.

A retrospective study was conducted from a single center between 2014 and 2017 including a total of 115 total ankles performed by one of four fellowship-trained foot and ankle surgeon. Re-operations were reported in the charts as an operative report. The index approach used was determined by the surgeon's practice preference. Patients were included when they had a primary TAR in the timeframe noted and had a complete dataset up to at least the two-year data.

This cohort comprised 67 anterior and 48 lateral with balanced demographic for age (95%CI 63–67 yo) and gender (47% F). The lateral group had more complex cases with higher COFAS type arthritis. Comparing the two groups, a total of 40 reoperations (7 anterior, 33 lateral) occurred in 27 patients (5A, 22L). One patient had up to four related reoperations. The only revision was in the anterior group. The only soft tissue reconstruction was an STSG in the lateral group. Nine reoperations were irrigation debridement related to an infective process (3 A, 6L). The majority (19/33) of reoperations in the lateral group were gutter debridement (8) or lateral hardware removal (11). Operative time was not statistically different. The odds ratio of having a reoperation with a laterally based TAR was 6.19 compared to the anterior group.

This retrospective study outlines the intermediate results at two years of lateral and anterior total ankle replacements. This is a first study of this kind in the literature. This study did show that there were more reoperations after a laterally-based TAR than an anterior TAR, recognizing the significant case complexity imbalance between groups. This speaks to the relative increase resource utilization of laterally based TAR patients. Both implant designs carry different reoperation rates favoring the anterior group however larger prospective datasets will be needed with patient-reported outcome.

Autologous bone has been the gold standard for grafting material in foot and ankle arthrodesis. While autograft use has been effective, the harvest procedure does present risks to the patient including readmission, infection, and persistent graft harvest site pain. Previous studies have examined graft harvest site pain, but most have focused on the iliac crest and none have long term follow-up. The purpose of this study was to examine long-term (7–10 year) harvest site pain in subjects undergoing autograft harvest from multiple sites for hindfoot and/or ankle arthrodesis.

Sixty (60) subjects underwent hindfoot or ankle arthrodesis supplemented with autograft as part of the control arm of a prospective, randomized trial. The mean subject age was 59.4 years (range, 24.7–76.8) and mean body mass index was 30.6 kg/m2 (range, 22.0–44.0). There were 29 males and 31 female subjects. Subjects had the tibiotalar (37.9%), subtalar (24.1%), talonavicular (10.3%), subtalar/talonavicular (5.1%), or subtalar/calcaneocuboid/talonavicular (22.4%) joints arthrodesed. Autograft was harvested from either the proximal tibia (51.7%), iliac crest (17.2%), calcaneous (15.5%), distal tibia (6.8%), or other location (8.6%). Graft harvest site pain was evaluated using a 100-point visual analog score (VAS), with clinically significant pain being any score greater than 20.

Subjects were followed a mean of 9.0 years (range, 7.8–10.5). The percentage of subjects who reported clinically significant pain was 35.7%, 21.4%, 18.2%, 10.5%, 8.9%, and 5.2% at 2, 6, 12, 24, 52 weeks, and final follow-up (7.8–10.5 years), respectively. The mean VAS autograft harvest site pain at final follow-up was 4.4 (range, 0.0–97.0), with 37.9% of subjects reporting at least some pain. For three subjects (5%) with clinically significant pain (VAS >20) at final follow-up, two had proximal tibial harvest sites and one had an iliac crest harvest site. There was no correlation between graft volume and harvest site pain.

This study is the first to examine long-term pain following autologous bone graft harvest for hindfoot and/or ankle arthrodesis. Over a third of patients reported having some pain at an average follow-up of nine years, with 5% experiencing clinically significant pain. The results of this study suggest that harvesting autograft bone carries a risk of persistent, long-term pain regardless of the volume of graft that is harvested. This potential for persistent pain should be considered when informing patients of procedure risks and when deciding to use autograft or a bone graft substitute material.

Patients' perspective and experience is heavily modulated by their understanding of their pre-operative disability along with their overall coping strategy and life philosophy. Given that evidence-based practice is relying on patient-reported outcomes more and more, the orthopaedic community must be diligent in differentiating patients that may have the same objective outcome but vary widely on a patient-reported subjective basis. In clinical practice, patient selection is often a sensitive, experience-based decision process that screens for catastrophization, recognizing that certain patients will not benefit from a simple surgery. It is well appreciated that patient's catastrophization can affect their subjective outcome but there is little reported literature on this abstract concept. The study set out to determine if post-operative outcomes correlated with pre-operative catastrophization scales.

This current study set out to look at a cohort of complex consecutive foot and ankle cases and describe the relationship between Patient Catastrophizing Score (PCS) and multiple functional outcomes that are used commonly in foot and ankle specifically (SF-12 & FAOS). The PCS has three subcategory rumination, helplessness and magnification. A single institution undertook recruitment in consecutive patients within three surgeon's practice. In the end, 46 patients were found to be eligible in the study with an average age of 54.72 ± 14.41 years-old, a majority female 30 / 46 (65.22%), a minority employed at the pre-operative visit 19/46 (41%) and with an average BMI of 26.2 ± 5.56.

We found that the mental component of the SF12 had a statistically significant negative effect with the rumination score (r=−1.03) (p = 0.01) and the helplessness score (r=−1.05) (0.001). There was no statistically significant effect for the physical component of the SF-12. Looking at the FAOS Pain component, it correlated was significantly with the PCS rumination (Multivariate : r= −7.6 (p=0.002) Univariate: r=−2 (0.03)) and helplessness (Multivariate : r=−6.73 (p=0.01) Univariate: r=−1.5 (p=0.03)). Otherwise the FAOS ADL component showed correlation as well with the PCS rumination (Multivariate: r=−4.67 (p=0.02) Univariate : r=−1.85 (p=0.01)), helplessness (Multivariate r=−5.89 (p = 0.01) Univariate r=−1.81 (p = 0.001)) and total score (Multivariate : r=3.74 (p=0.02) Univariate r=−0.75 (p=0.01)). The FAOS Quality of life component was statistically significant for the rumination score (Univariate r=−11.59) (p < 0.05) and the helplessness score (Univariate r=−9.65) (p = 0.002) also the PCS total (Univariate r=8.54) (p = 0.0003).

As layed out in our hypothesis, this study did show an association between an increase patient catastrophizing score pre-operatively and a worse outcome in the following scores: Mental component of SF12, FAOS Pain, FAOS ADL and FAOS Quality of life components. This is an association and no causality can be proven within the limits of this current pilot study, but remains alarming. In elective surgeries, catastrophization should be screened for using the PCS form and potentially modulated pre-operatively with the help of allied health therapist while a patient is on the waitlist.

Ankle arthrodesis and replacement are the widely accepted options in managing end-stage ankle arthritis. Ankle replacement as an alternate treatment option for ankle arthritis is relatively new and this is in large part to the successes observed with hip and knee arthroplasty for arthritis. Relative benefits of ankle replacement and arthrodesis remains a contentious topic. We conducted a multicenter pilot randomized controlled trial, first of its kind, comparing the clinical outcomes of ankle arthrodesis and ankle replacement in managing ankle arthritis. We hypothesized that clinical outcomes would be similar for both.

Patients recruited for this study were part of Canadian Orthopaedic Foot and Ankle Society (COFAS) Database. Canadian orthopaedic surgeons with fellowship training in foot and ankle surgery or extensive experience in the surgical treatment of end stage ankle arthritis determined whether the patient met the criteria for randomization, skeletal maturity, symptomatic ankle arthritis no longer amenable to non-operative management, and ability to give informed consent. Data was collected on patient demographics, follow-up time period, complication rates, and Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) scores. Our analysis of clinical outcomes was divided into two parts: (1) comparison of pre and postoperative data for each cohort separately, and (2) comparison of outcome scores, and revision rates between both cohorts. We employed the Student's t-test and calculated effect sizes in assessing improvements in AOS and SF-36 scores from baseline to latest follow-up within and between the two groups. We also examined postoperative complication and reoperation rates in the study population using the standardized coding system for reoperations following ankle replacement and arthrodesis.

Thirty-nine ankles were enrolled in the study with a mean follow-up of 5.1 ± 2.8 years. Ankle osteoarthritis scale scores improved significantly from baseline and last follow-up in both groups. The average baseline AOS total score for ankle replacement improved from 59.4 ±15.9 to 38 ±20 at last follow-up (p-value 19.7 to 31.8 ±16.5 at last follow-up (p-value 25.4 compared to ankle replacement's 20.3 ±23. Two major complications (10.5%) were observed in the ankle replacement cohort while the ankle arthrodesis cohort saw four major complications (20%).

Clinical outcomes of ankle replacement and arthrodesis were comparable. The ankle arthrodesis cohort held a slight advantage over ankle replacement in improvement of AOS scores, though not statistically significant. Rates of major complications and reoperations were higher with ankle arthrodesis.

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.

Introduction

A randomized clinical trial of first metatarsophalangeal (MTP) joint hemiarthroplasty with a synthetic cartilage implant demonstrated equivalent pain, function and safety outcomes to first MTP joint arthrodesis at 2 years. The implant cohort continues to be followed under an extension of the original study and we report on prospectively determined 5+ year outcomes for subjects assessed to date.

Reoperations may be a better way of tracking adverse outcomes than complications. Repeat surgery causes cost to the system, and often indicate failure of the primary procedure resulting in the patient not achieving the expected improvement in pain and function. Understanding the cause of repeat surgery at the primary site may result in design improvements to implants or improvements to fusion techniques resulting in better outcomes in the future. The COFAS group have designed a reoperation classification system. The purpose of this study was to outline the inter and intra observer reliability of this classification scheme.

To verify the inter- and intra-observer reliability of this new coding system, six fellow ship trained practicing foot and ankle Orthopaedic surgeons were asked to classify 62 repeat surgeries from a single surgeons practice. The six surgeons read the operation reports in random order, and reread the reports 2 weeks later in a different order. Reliability was determined using intraclass correlation coefficients (ICC) and proportions of agreement. The agreement between pairs of readings (915 for inter observer for the first and second read – 61 readings with 15 comparisons, observer 1 with observer 2, observer 1 with observer 3, etc) was determined by seeing how often each observer agreed. This was repeated for the 366 ratings for intra observer readings (61 times 6).

The inter-observer reliability on the first read had a mean intra-class correlation coefficient (ICC) of 0.89. The range for the 15 comparisons was 0.81 to 1.0. Amongst all 1830 paired codings between two observers, 1605 (88%) were in agreement. Across the 61 cases, 45 (74%) were given the same code by all six observers. However, the difference when present was larger with more observers not agreeing. The inter-observer reliability test on the second read had a mean ICC of 0.94, with a range of 0.90. There were 43 (72%) observations that were the same across all six observers. Of all pairs (915 in total) there was agreement in 804 pairs for the first reading (88%) and disagreement in 111 (12%). For the second reading there was agreement in 801 pairs (86%) and disagreement in 114 (14%). The intra-observer reliability averaged an ICC value of 0.92, with a range of 0.86 to 0.98. The observers agreed with their own previous observations 324 times out of 366 paired readings (89% agreement of pairs).

The COFAS classification of reoperations for end stage ankle arthritis was reliable. This scheme potentially could be applied to other areas of Orthopaedic surgery and should replace the Claiden Dindo modifications that do not accurately reflect Orthopaedic outcomes. As complications are hard to define and lack consistent terminology reoperations and resource utilisation (extra clinic visits, extra days in hospital and extra hours of surgery) may be more reliable measures of the negative effects of surgery.

Patients often comment on swelling after foot and ankle surgery. However the relationship between swelling and outcome (pain and function) has not previously been outlined. A recent study by Pinsker and Daniels demonstrated that while swelling was rated as important by patients it was rarely included in outcome scores. The purpose of this paper was to determine the relationship between swelling and outcome after ankle fusion or replacement. A secondary purpose was to determine how this relationship changed in time, how swelling score changed before and after surgery, and determine differences in swelling score between total ankle replacement (TAR), open ankle arthrodesis (OAA) and arthroscopic ankle arthrodesis (AAA).

The COFAS prospective ankle arthritis database enrolls patients in 4 centers undergoing surgery by one of 6 surgeons since 2002. The MODEMS outcomes package from AAOS was used, with the validated ankle osteoarthritis score (AOS) score being used to assess outcomes in the pain and disability domains. The swelling score was indexed from 1 to 5, 1 being no swelling and 5 being severe swelling. Outcomes were recorded preoperatively and annually up to 2010. Statistical analysis was performed using 95% confidence intervals and correlations being determined using Pearson's correlation and r2 values.

The swelling score was correlated with AOS score with an r2 of 0.13 for postoperative patients. With the swelling score analysed categorically the difference of outcome was significant with a mean AOS score of 15.1 (CI 13.3 to 16.9) for a swelling score of 1, 23 (CI 21.7 to 24.9) for a swelling score of 2, 31 (CI 29.6 to 33.1) for 33.6 (CI 34.9 to 38.8) for 4, and 39 (CI 35.3 to 43.0) for 5. Swelling scores fell outside the 95% confidence intervals for all groups indicating that the AOS outcome of swelling score 5 patients was worse than the 4 group, 4 worse than 3, 3 worse than 2, and 2 worse than 1. Patients with swelling scores of 1 scored 24 points better than those with a swelling score of 5.

Swelling scores were the same preoperatively for total ankle arthroplasty, Arthroscopic and open fusions. However swelling scores were lower for arthroscopic fusions after surgery for all time periods at an average of 2.1 (CI 1.9 to 2.2), compared to total ankle arthroplasty (2.5, CI 2.4 to 2.6) and open ankle fusion (2.5, CI 2.4 to 2.6).

Swelling has a major relationship with outcome. Swelling may be the cause of poorer outcomes for open ankle fusion compared to arthroscopic. Swelling is an independent factor as swelling scores for TAA were higher compared to AAA despite similar outcomes. Arthroscopic surgery reduces the postoperative swelling. Methods to reduce swelling such as compression stockings, elevation, controlling bleeding may result in better outcomes. Minimising the invasiveness of surgery achieves this goal. Patient education about swelling, elevation and compression stockings would assist in these goals.

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.

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.

Introduction

Single photon emission computed tomography (SPECT) can be used to create a three dimensional image of a radiopharmaceutical bone scan. This combined with high resolution CT scan (SPECT-CT) with bone windows allows the linking of the information obtained in both investigations. The multiplanar anatomical information provided by CT is therefore linked with the functional, biological information of bone scintigraphy. The painful total ankle replacement has a number of potential causes of discomfort including impingement and loose components. Correct identification of the source of pain will assist surgeons in treating the source of the pain while avoiding unnecessary surgery. We present our experience of the use of SPECT-CT to investigate patients with ongoing pain following Total Ankle Replacement (TAR).

Background

Ankle arthrodesis results in significantly improved pain and function for patients with end-stage ankle arthritis. Arthroscopic ankle arthrodesis has gained increasing popularity with reports of shorter hospital stays, time to union and equivalent union rates to open arthrodesis. However, there remains a lack of good quality prospective data.

Introduction

Greater length of stay (LOS) after elective surgery results in increased use of health care resources and higher costs. Within the realm of foot and ankle surgery, improved perioperative care has enabled a vast majority of procedures to be performed as a day surgery. The objective of this study was to determine the perioperative factors that predict a prolonged LOS after elective ankle replacement or fusion.

Purpose

Weight loss is often advised to our patients and considered to make a substantial difference in most musculoskeletal symptoms. Patients with end stage ankle arthrosis have severe pain, diminished health related quality of life, and limited physical function.

They frequently refer to increased weight as a simple indicator of decline in their quality loose weight. Patients assume that weight loss will follow after surgery secondary to increased activity with reduced pain and disability.

In this study patients were randomized between surgeon chosen pressure (control) and an automatically determined tourniquet pressure(study group). Of 112 patients in the study group, 5% failed to obtain an automatic pressure. Of the remainder, the average tourniquet pressure was 198 +/− 20.2 mm Hg compared to 259.6 +/− 4.4 mmHg for the control group (p<0.0001). Of the study group 94 (88.6%) had good to excellent fields compared to the control group where 100 (77.5%) had good to excellent fields (p<0.05). The automatic measurement of limb occlusion pressure results in better operative fields at a lower pressure.

The purpose of this study was to compare the clinical outcome of patients treated surgically for end stage ankle arthritis using a total ankle arthroplasty or ankle arthrodesis.

This is a multicentered prospective clinical outcome study of the surgical treatment of patients with EAA using an ankle arthrodesis (n= 117) or total ankle arthroplasty (n= 210). Clinical outcome was assessed using health related quality of life (SF36v2) and joint specific (Foot Function Index, Ankle Osteoarthritis Scale, American Orthopedic Foot and Ankle Hindfoot Scale and the AAOS Foot and Ankle Baseline Questionnaire(version 2000)) outcome scores.

Preoperatively, all patients had significant physical and psychological morbidity. All symptom and functional SF36 subscales were approximately two standard deviations below normal population scores. Approximately 25% of patients were three standard deviations below population values, indicating increased risk of mortality. There was no evidence that age or gender influenced the level of disability. There was a significant improvement in the health related quality of life and the joint specific clinical outcome scores at six and twelve months follow up but no consistent difference was noted between the two cohorts.

This is the first multicentered prospective clinical outcome study that demonstrates equal efficacy for early follow up of patients treated for EAA with total ankle arthroplasty or ankle arthrodesis.

This study is a retrospective review of transmetatarsal amputation (TMA) outcomes in patients with diabetes and non-healing ulcers of the forefoot. All were treated by single stage TMA and insertion of antibiotic beads in the surgical wound. Healing time was approximately eighteen weeks with a failure rate (subsequent BKA) of 25%. This is in contrast to literature values of healing times (not isolated to diabetics) of twenty-eight weeks and BKA rates of 34–40%. The decreased morbidity associated with our surgical procedure may address the costly management of diabetic foot ulcers (presently estimated to be $600 million per year).

The purpose of this study was to review the outcome of transmetatarsal amputation (TMA) in diabetic patients as a single stage procedure using antibiotic pellets in the wound.

We report faster healing times and a decreased rate of subsequent below-knee amputation (BKA) when compared with related studies in the literature.

1) Our procedure may decrease morbidity in a problem (diabetic foot ulcer management) costing approximately $600 million per year. 2) This study uniquely addresses TMA in diabetics.

Mean healing time was eighteen weeks (range six to forty weeks). Patients with intact foot pulses or reconstructed vasculature had a mean recovery time of 12.5 weeks. Healing times for unreconstructable vasculature or documented deep infection were thirty weeks and twenty weeks respectively. The overall failure rate (BKA) was 25%. Neither vascular status nor the presence of deep infection predicted subsequent BKA.

Retrospective review of patient charts. Forty consecutive diabetic patients (mean age 58.3 yrs, range 40–77) with foot ulcers of > twelve weeks duration had TMA performed at a tertiary care center by one of three surgeons. Data tabulated included demographics, diabetes profiling, vascular interventions and follow-up parameters.

Diabetic foot ulcer morbidity is a significant cost burden to health care; despite this, salvage procedures for this problem are not well studied. Previous papers (not isolated to diabetics) report TMA healing times of twenty-eight weeks and subsequent BKA rates of 34–40%. Refinements of the TMA technique in diabetics may decrease early and late morbidity and thus address this costly problem.

Twenty-one symptomatic flat feet from the surgical wait list were compared with twenty-one matched controls. The radiographs were digitized, blinded and the measurements made two occasions by two observers in different order.

On the lateral radiograph the talar to first metatarsal angle reached greatest significance at p< 0.0001, and had an inter and intra observer reliability of 0.83 and 0.75 respectively (r² value). Only three other of the twelve measurements made reached statistical significance. Radiographic assessment of reconstructive procedures should show restoration of the arch of the foot: We recommend using the talar neck to first metatarsal angle on the lateral view as the correct indicator of loss or restoration of an arch.

The purpose of this study was to determine the radiographic measures that differentiate the symptomatic adult flat foot from a normal foot, and determine the reliability of the measurements.

Although many radiographic measures of flat foot are described, only four out of twelve measurements studied were significantly different between symptomatic adult flat foot and normal adults.

Radiographic assessment of reconstructive procedures should show restoration of the arch of the foot: We recommend using the talar neck to first metatarsal angle on the lateral view as the correct indicator of loss or restoration of an arch.

Twenty-one symptomatic flat feet from the surgical wait list were compared with twenty-one matched controls. Diagnoses included rheumatoid arthritis and posterior tibial tendonitis. All previously described measures of loss of arch were measured on standing AP and lateral radiographs of the foot taken using the same radiographic technique at a single facility. The radiographs were digitized, blinded and the measurements made two occasions by two observers in different order.

On the lateral radiograph the talar to first metatarsal angle reached greatest significance at p< 0.0001, and had an inter and intra observer reliability of 0.83 and 0.75 respectively (r² value). The medial cuniform to 5^th metatarsal height also reached signficance, but had poor intraobserver reliability (r² =0.09). On the AP view, only the talar head uncoverage distance reached significance (p< 0..0001) but had poor inter and intraobserver reliability (r²=0.05 and 0.08).

Purpose: To assess patients quality of life, pain, and functional limitations with with endstage ankle arthritis (EAA) and compared this to a similar cohort of patients with endstage hip arthritis (EHA).

Methods: Preoperative data (Short Form SF36) was collected prospectively from patients (n=130) with end stage ankle arthritis and compared to a similar cohort of patients (n=130) with end stage hip arthritis. Patients with ankle arthritis were registered in the Canadian Orthopedic Foot and Ankle Society (COFAS) multi-center study investigating the clinical outcome of ankle arthroplasty and fusion and patients with hip arthritis were randomly selected from the Halifax Joint Replacement Registry Database.

Results: All symptom and functional SF36 subscales for patients with EAA or EHA, were approximately two standard deviations below normal population scores. All differences between ankle and hip SF36 subscales scores were less than 4 points (40% of STD) in both direct and adjusted comparisons. A direct comparison of SF36 scores revealed that patients with EAA had significantly worse mental health according to the SF36 Mental Component Summary Score (MCS) (p= 0.0059), physical limitations with work and daily activities - role physical score (p= < 0.0001), and general health (p= 0.0004). Patients with EHA reported poorer physical function (p= 0.0007) although the Physical Component Summary Score (PCS) for the SF36 was not significant (p= 0.0510). Total Summary SF36, Physical Component Summary (PCS), bodily pain, vitality, role-emotional, social functioning, and mental health subscales were all not significantly different between cohorts (p> 0.05).

Conclusions: Patients with EAA have devastating losses of quality of life, which are comparable to patients with EHA. These findings suggest that increased resources should be directed towards alleviating the severe pain and disability associated with ankle arthritis.

Testing of cadaver ankle specimens was conducted to investigate the changes in kinematics with lateral ligament reconstructions. Testing included an intact condition, after injury at the ATFL and CFL sites, and separately a Brostrom repair and an anatomical gracil-lis graft reconstruction. Calcaneal range of motion was determined about the axis of applied moment in plantarflexion-dorsiflexion and in inversion-eversion directions. The injury and reconstructions were most sensitive during IE applied moment. Both reconstructions appeared to behave similar to intact motion. Failure of some Brostrom repairs however, suggest that the gracillis-graft reconstruction is initially a stronger repair.

Limited research has biomechanically investigated lateral ankle ligament reconstruction procedures. The objective of this study was to determine the changes in ankle kinematics with a dual ligament Brostrom repair and an anatomical gracillis graft reconstruction.

Seven cadaveric ankle specimens were tested independently in an intact condition, after an ATFL/CFL injury model, and two reconstructions. The anatomical graft reconstruction wove a gracillis tendon through the calcaneus and fibula to dually reconstruct the ATFL and CFL, and anchored to the talus. Moments were applied to the calcaneus for three cycles in plantarflexion-dorsiflexion (PD) and inversion-eversion (IE) while allowing unconstrained motion. Three dimensional motions of the calcaneus and tibia were optoelectronically tracked. Range of motion (ROM) was calculated about the axis of applied moment for the calcaneus with respect to the tibia.

The ROM increase from the intact condition with the injury model was only significant for IE (p=0.001). No significant differences were found between intact and any treatments in the PD configuration. In IE, both the graft reconstruction and the Brostrom repair were significantly different from the injury model (p=0.002 and p=0.015 respectively), where the gracillis reconstruction appears more similar to the intact condition. For two specimens the Brostrom repaired ATFL failed during applied inversion moment.

The injury and reconstructions were most sensitive during IE applied moment. Both reconstructions appeared to behave similar to the intact condition. Failure of some Brostrom repairs however, suggest that the gracillis-graft reconstruction is initially a stronger repair.

Funding: Workers Compensation Board of British Columbia