Aims. This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years. Methods. We prospectively evaluated 89 patients who underwent transfibular TAA for end-stage osteoarthritis. Patients’ clinical and radiological examinations were collected pre- and postoperatively at six months and then annually for up to five years of follow-up. Three patients were lost at the final follow-up with a total of 86 patients at the final follow-up. Results. A total of 86 patients were evaluated at a mean follow-up of 65.4 months (60 to 90). At five-year follow-up, statistically significant improvements (p < 0.001) were found in the mean American Orthopaedic Foot & Ankle Society Ankle Hindfoot Score (from 33.8 (SD 14.3) to 86.1 (SD 8.8)), visual analogue scale for pain (from 8.5 (SD 1.7) to 1.5 (SD 1.2)), Short Form-12 Physical and Mental Component Scores (from 29.9 (SD 6.7) and 43.3 (SD 8.6) to 47.3 (SD 7.5) and 52.2 (SD 8.0), respectively), and mean ankle dorsiflexion and plantarflexion (from 6.2° (SD 5.5°) and 9.6° (SD 5.8°) to 23.9° (SD 7.7°) and 16.9° (SD 7.2°), respectively). Radiologically, the implants maintained neutral alignment without subsidence. Tibial or talar radiolucency was found in eight patients, but none of these patients was symptomatic. At five-year follow up, 97.7% of implants (95% confidence interval 91.2 to 99.4) were free from revision or removal with 84 implants at risk. We recorded two cases (2.3%) of failure for septic loosening. Conclusion. Transfibular TAA is safe and effective with a high survival rate at mid-term follow-up and satisfactory clinical and radiological results. Further studies are required to determine the long-term performance of these implants. Cite this article: Bone Joint J 2022;104-B(4):472–478

Aims. To assess the effect of age on clinical outcome and revision rates in patients who underwent total ankle arthroplasty (TAA) for end-stage ankle osteoarthritis (OA). Methods. A consecutive series of 811 ankles (789 patients) that underwent TAA between May 2003 and December 2013 were enrolled. The influence of age on clinical outcome, including the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and pain according to the visual analogue scale (VAS) was assessed. In addition, the risk for revision surgery that includes soft tissue procedures, periarticular arthrodeses/osteotomies, ankle joint debridement, and/or inlay exchange (defined as minor revision), as well as the risk for revision surgery necessitating the exchange of any of the metallic components or removal of implant followed by ankle/hindfoot fusion (defined as major revision) was calculated. Results. A significant improvement in the AOFAS hindfoot score and pain relief between the preoperative assessment and the last follow-up was evident. Age had a positive effect on pain relief. The risk for a minor or major revision was 28.7 % at the mean follow-up of 5.4 years and 11.0 % at a mean follow-up of 6.9 years respectively. The hazard of revision was not affected by age. Conclusion. The clinical outcome, as well as the probability for revision surgery following TAA, is comparable between younger and older patients. The overall revision rate of the Hintegra total ankle is comparable with other three component designs. TAA should no longer be reserved for low demand elderly patients, but should also be recognized as a viable option for active patients of younger age. Cite this article: Bone Joint J 2020;102-B(7):925–932

Aims. The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS). Methods. All patients included in the ‘ROutine vs on DEmand removal Of the syndesmotic screw’ (RODEO) trial received the Olerud-Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Hindfoot Score (AOFAS), Foot and Ankle Outcome Score (FAOS), and EuroQol five-dimension questionnaire (EQ-5D). Out of the 152 patients, 109 (71.7%) completed the mid-term follow-up questionnaire and were included in this study (53 treated with RR and 56 with ODR). Median follow-up was 50 months (interquartile range 43.0 to 56.0) since the initial surgical treatment of the acute syndesmotic injury. The primary outcome of this study consisted of the OMAS scores of the two groups. Results. The median OMAS score was 85.0 for patients treated with RR, and 90.0 for patients treated with ODR (p = 0.384), indicating no significant difference between ODR and RR. The secondary outcome measures included the AOFAS (88.0 in the RR group and 90.0 for ODR; p = 0.722), FAOS (87.5 in the RR group and 92.9 for ODR; p = 0.399), and EQ-5D (0.87 in the RR group and 0.96 for ODR; p = 0.092). Conclusion. This study demonstrated no functional difference comparing ODR to RR in syndesmotic injuries at a four year follow-up period, which supports the results of the primary RODEO trial. ODR should be the standard practice after syndesmotic screw fixation. Cite this article: Bone Jt Open 2023;4(12):957–963

Large osteochondral lesions (OCLs) of the shoulder of the talus cannot always be treated by traditional osteochondral autograft techniques because of their size, articular geometry and loss of an articular buttress. We hypothesised that they could be treated by transplantation of a vascularised corticoperiosteal graft from the ipsilateral medial femoral condyle. . Between 2004 and 2011, we carried out a prospective study of a consecutive series of 14 patients (five women, nine men; mean age 34.8 years, 20 to 54) who were treated for an OCL with a vascularised bone graft. Clinical outcome was assessed using a visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. Radiological follow-up used plain radiographs and CT scans to assess graft incorporation and joint deterioration. . At a mean follow-up of 4.1 years (2 to 7), the mean VAS for pain had decreased from 5.8 (5 to 8) to 1.8 (0 to 4) (p = 0.001) and the mean AOFAS hindfoot score had increased from 65 (41 to 70) to 81 (54 to 92) (p = 0.003). Radiologically, the talar contour had been successfully reconstructed with stable incorporation of the vascularised corticoperiosteal graft in all patients. Joint degeneration was only seen in one ankle. . Treatment of a large OCL of the shoulder of the talus with a vascularised corticoperiosteal graft taken from the medial condyle of the femur was found to be a safe, reliable method of restoring the contour of the talus in the early to mid-term. . Cite this article: Bone Joint J 2015;97-B:1242–9

Aims. Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis. Methods. We retrospectively reviewed all the patients who underwent closed ankle arthrodesis (CAA) in Ilizarov Scientific Centre from 2013 to 2018 (Group A) and compared them with a similar group of patients (Group B) who underwent open ankle arthrodesis (OAA). We then divided the neuropathic patients into three arthritic subgroups: Charcot joint, Charcot-Maire-Tooth disease, and post-traumatic arthritis. All arthrodeses were performed by using an Ilizarov ring fixator. All patients were followed up clinically and radiologically for a minimum of 12 months to assess union and function. Results. The union rate for Group A was 81% (17/21) while it was 84.6% (33/39) for Group B. All the nonunions in Group A underwent revision with an open technique and achieved 100% union. Mean duration of IRF was 71.5 days (59 to 82) in Group A and 69 days (64.8 to 77.7) in Group B. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was similar in both groups. The postoperative hospital stay was shorter in Group A (21 days (SD 8)) than Group B (28 days (SD 9)). In the latter Group there were more problems with wound healing and greater requirement for antibiotic treatment. The mean operating time was 40 minutes (SD 9) in Group A compared to 80 minutes (SD 13) in Group B. Recurrence of infection occurred in 19% (4/21) and 15.5% (6/39) for Group A and Group B respectively. Conclusion. We found CAA using an IRF to be an effective method for ankle arthrodesis in infected neuropathic foot and ankle cases and afforded comparable results to open methods. Due to its great advantages, Ilizarov method of CAA should always be considered for neuropathic ankles in suitable patients. Cite this article: Bone Joint J 2020;102-B(4):470–477

Aims. There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure. Patients and Methods. A total of 39 patients (12 women, 27 men; mean age 47 years (28 to 72)) with a distal tibial recurvatum deformity were treated with a flexion osteotomy, between 2010 and 2015. Nine patients (23%) subsequently required conversion to either a total ankle arthroplasty (seven) or an arthrodesis (two) after a mean of 21 months (9 to 36). A total of 30 patients (77%), with a mean follow-up of 30 months (24 to 76), remained for further evaluation. Functional outcome, sagittal ankle joint OA using a modified Kellgren and Lawrence Score, tibial lateral surface (TLS) angle, and talar offset ratio (TOR) were evaluated on pre- and postoperative weight-bearing radiographs. Results. Postoperatively, the mean score for pain, using a visual analogue scale, decreased significantly from 4.3 to 2.5 points and the mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly from 59 to 75 points (both p < 0.001). The mean TLS angle increased significantly by 6.6°; the mean TOR decreased significantly by 0.24 (p < 0.001). Radiological evaluation showed an improvement or no progression of sagittal ankle joint OA in 32 ankles (82%), while seven ankles (18%) showed further progression. Conclusion. A flexion osteotomy effectively improved the congruency of the ankle joint. In 30 patients (77%), the joint could be saved, whereas in nine patients (23%), the treatment delayed a joint-sacrificing procedure. Cite this article: Bone Joint J 2019;101-B:682–690

Aims. We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity. Patients and Methods. We prospectively studied 28 calcaneal malunion patients (the study group) who were managed by subtalar distraction arthrodesis using local calcaneal bone graft. The study group included 16 male and 12 female patients. The median age was 37.5 years (interquartile range (IQR) 29 to 43). The outcome of the study group was compared with a control group of ten patients previously managed by subtalar distraction arthrodesis using iliac bone graft. The control group included six male and four female patients. The median age was 41.5 years (IQR 36 to 44). Results. The mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly in the study and the control groups (p < 0.001). Fusion was achieved in 27 patients in the study group at a median time of 13 weeks (IQR 12 to 14), while all the patients in the control group achieved fusion at a mean time of 13.2 weeks (11 to 15). The mean talocalcaneal height and talar declination angle improved significantly in both the study and the control groups (p < 0.001). There was no significant difference between both groups concerning the preoperative or the postoperative clinical and radiological measurements. Donor site morbidity was reported in four out of ten patients in the control group. Conclusion. Local calcaneal bone graft can successfully be used to achieve subtalar distraction arthrodesis with appropriate correction of alignment and calcaneal malunion. We recommend using local instead of iliac bone graft as it gave comparable results and avoids the possibility of donor site morbidity. Cite this article: Bone Joint J 2019;101-B:596–602

Aims. To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or tendon transfer. Methods. A total of 21 eligible patients (mean age 34.0 years (standard deviation (SD) 11.2); mean follow-up period 31.8 months (SD 7.7), and 12 healthy controls (mean age, 26.8 years (SD 5.9) were included. For patients, clinical evaluation of the donor ankle was performed preoperatively and postoperatively. Square hop test, ankle strength assessment, and MRI of distal calf were assessed bilaterally in the final follow-up. The morphological symmetry of peroneal tendons bilaterally was evaluated by MRI in healthy controls. Results. Among the patients, the mean pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Karlsson-Peterson score were 98.7 (SD 2.5; p = 0.480) and 98.5 (SD 2.4; p = 0.480), and 98.3 (SD 2.4; p = 0.162) and 97.9 (SD 2.5; p = 0.162), respectively. There was no significant difference between square hop test bilaterally (p = 0.109) and plantar flexion peak force bilaterally (p = 0.371). The harvested limb had significantly less eversion peak force compared to the contralateral limb (p < 0.001). Evidence of probable tendon regeneration was observed in all the patients by MRI and the total bilateral peroneal tendon index (mean ratio of harvested side cross-sectional area of peroneal tendon compared with the contralateral side) was 82.9% (SD 17.4). In 12 healthy controls, peroneal tendons (mean 99.4% (SD 4.3) were found to be morphologically symmetrical between the two sides. Conclusion. The current study showed satisfactory clinical foot and ankle outcomes after full-thickness PLT harvesting and indicated the regenerative potential of PLT after its removal. Level of Evidence: Level IV, therapeutic retrospective case series. Cite this article: Bone Joint J 2020;102-B(2):205–211

Aims. We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants. Patients and Methods. Between November 1993 and February 2000, 200 consecutive STAR prostheses were implanted in 184 patients by a single surgeon. Demographic and clinical data were collected prospectively and the last available status was recorded for further survival analysis. All surviving patients underwent regular clinical and radiological review. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scoring system. The principal endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan–Meier survival curves were generated with 95% confidence intervals and the rate of failure calculated for each year. Results. A total of 84 patients (87 ankles) were alive by the end of this study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis (RA), n = 40; OA, n = 47), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery. A total of 32 implants failed (16%), requiring revision surgery. The mean time to revision was 80 months (2 to 257). The implant survival at 15.8 years, using revision as an endpoint, was 76.16% (95% confidence interval (CI) 64.41 to 87.91). We found a steady but low decrease in survival over the study period. The mean AOFAS score improved from 28 (10 to 52) preoperatively to 61 (20 to 90) at long-term follow-up. Conclusion. STAR prostheses in the United Kingdom have now been largely superseded by newer design TAAs, potentially with improved characteristics and surgical techniques. The long-term survivorship for the STAR prosthesis can provide a benchmark for these later designs of ankle arthroplasty

The aim of this study was to compare the outcome of bilateral sequential total ankle replacement (TAR) with that of unilateral TAR. We reviewed 23 patients who had undergone sequential bilateral TAR under a single anaesthetic and 46 matched patients with a unilateral TAR. There were no significant pre-operative differences between the two groups in terms of age, gender, body mass index, American Society of Anaesthesiologists classification and aetiology of the osteoarthritis of the ankle. Clinical and radiological follow-up was carried out at four months, one and two years. After four months, patients with simultaneous bilateral TAR reported a significantly higher mean pain score than those with a unilateral TAR. The mean American Orthopaedic Foot and Ankle Society hindfoot score and short-form 36 physical component summary score were better in the unilateral group. However, this difference disappeared at the one-and two-year follow-ups. Bilateral sequential TAR under one anaesthetic can be offered to patients with bilateral severe ankle osteoarthritis. However, they should be informed of the long recovery period

Talonavicular and subtalar joint fusion through a medial incision (modified triple arthrodesis) has become an increasingly popular technique for treating symptomatic flatfoot deformity caused by posterior tibial tendon dysfunction. The purpose of this study was to look at its clinical and radiological mid- to long-term outcomes, including the rates of recurrent flatfoot deformity, nonunion and avascular necrosis of the dome of the talus. A total of 84 patients (96 feet) with a symptomatic rigid flatfoot deformity caused by posterior tibial tendon dysfunction were treated using a modified triple arthrodesis. The mean age of the patients was 66 years (35 to 85) and the mean follow-up was 4.7 years (1 to 8.3). Both clinical and radiological outcomes were analysed retrospectively. In 86 of the 95 feet (90.5%) for which radiographs were available, there was no loss of correction at final follow-up. In all, 14 feet (14.7%) needed secondary surgery, six for nonunion, two for avascular necrosis, five for progression of the flatfoot deformity and tibiotalar arthritis and one because of symptomatic overcorrection. The mean American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score) at final follow-up was 67 (between 16 and 100) and the mean visual analogue score for pain 2.4 points (between 0 and 10). In conclusion, modified triple arthrodesis provides reliable correction of deformity and a good clinical outcome at mid- to long-term follow-up, with nonunion as the most frequent complication. Avascular necrosis of the talus is a rare but serious complication of this technique. Cite this article: Bone Joint J 2015; 97-B:668–74

Aims

Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined.

Distraction bone-block arthrodesis has been advocated for the treatment of the late sequelae of fracture of the os calcis. Between 1997 and 2003 we studied a consecutive series of 17 patients who had in situ arthrodesis for subtalar arthritis after fracture of the os calcis with marked loss of talocalcaneal height. None had undergone any previous attempts at reconstruction. We assessed the range of dorsiflexion and plantar flexion and measured the talocalcaneal height, talocalcaneal angle and talar declination angle on standing lateral radiographs, comparing them with the normal foot. The mean follow-up was for 78.7 months (48 to 94). The mean American Orthopaedic Foot and Ankle Society hindfoot score improved from 29.8 (13 to 48) to 77.8 (48 to 94) (Student’s t-test, p < 0.001). The mean loss of talocalcaneal height was 10.3 mm (2 to 17) and the mean talar declination angle was 6.7° (0° to 16°) which was 36% of the normal side. One patient suffered anterior ankle pain but none had anterior impingement. Two patients complained of difficulty in ascending slopes and stairs and four in descending. The mean ankle dorsiflexion on the arthrodesed side was 11.6° (0° to 24°) compared with 14.7° (0° to 24°) on the normal side, representing a reduction of 21.1%. The mean plantar flexion on the arthrodesed side was 35.5° (24° to 60°) compared with 44.6° (30° to 60°) on the normal side, a reduction of 20.4%. These results suggest that anterior impingement need not to be a significant problem after subtalar arthrodesis for fracture of the os calcis, even when the loss of talocalcaneal height is marked. We recommend in situ arthrodesis combined with lateral-wall ostectomy for all cases of subtalar arthritis following a fracture of the os calcis, without marked coronal deformity, regardless of the degree of talocalcaneal height loss

We investigated the clinical and radiological outcome after unilateral fracture of the lateral process of the talus in 23 snowboarders with a mean follow-up of 3.5 years (12 to 76 months). In this consecutive cohort study both operative and non-operative cases were considered. The mean American Orthopaedic Foot and Ankle Society hindfoot score was 94 (82 to 100). The non-operative group of seven with a minimally-displaced fracture scored higher (98 points) than the operative group of 16 with displaced or unstable fractures (93 points). In 88% of operative cases, significant concomitant hindfoot injuries were found at operation. All but eight (35%) patients (six operative and two non-operative) regained their pre-injury level of sporting activity. Subtalar osteoarthritis was present in nine (45%) of the 20 patients available for radiological review, including one late-diagnosed non-operative case and eight operative cases with associated injuries or fracture comminution. The outcome after fracture of the lateral process of the talus in snowboarders is favourable provided an early diagnosis is made and adequate treatment, which is related to the degree of displacement and associated injuries, is undertaken

Aims

The aim of this study was to capture 12-month outcomes from a representative multicentre cohort of patients undergoing total ankle arthroplasty (TAA), describe the pattern of patient-reported outcome measures (PROMs) at 12 months, and identify predictors of these outcome measures.

Aims

The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes.

Aims

The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome.

Aims

Flexor hallucis longus (FHL) tendon transfer is a well-recognized technique in the treatment of the neglected tendo Achillis (TA) rupture.

Chronic infections and ulceration around the tendo Achillis are difficult to manage. Split-skin grafts do not survive even on healthy exposed tendon. Refractory cases may require plastic surgical intervention with the use of free flaps. Patients with significant vascular disease are not suitable for such techniques. Flexor hallucis longus tendon transfer is an established treatment for chronic ruptures of the tendo Achillis.

We report the successful treatment of an infected tendo Achillis with excision and reconstruction with flexor hallucis longus transfer. The muscle belly of this tendon allowed later skin grafting while the tendon transfer provided good functional recovery.

A consecutive series of 23 patients (25 ankles) with osteoarthritis of the ankle and severe varus or valgus deformity were treated by open arthrodesis using compression screws. Primary union was achieved in 24 ankles one required further surgery to obtain a solid fusion. The high level of satisfaction in this group of patients reinforces the view that open arthrodesis, as opposed to ankle replacement or arthroscopic arthrodesis, continues to be the treatment of choice when there is severe varus or valgus deformity associated with the arthritis.

We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently.

We report the incidence and intensity of persistent pain in patients with an otherwise uncomplicated total ankle replacement (TAR). Arthroscopic debridement was performed in selected cases and the clinical outcome was analysed.

Among 120 uncomplicated TARs, there was persistent pain with a mean visual analogue scale (VAS) of 2.7 (0 to 8). The intensity of pain decreased in 115 ankles (95.8%). Exercise or walking for more than 30 minutes was the most common aggravating factor (62 ankles, 68.1%). The character of the pain was most commonly described as dull (50 ankles, 54.9%) and located on the medial aspect of the joint (43 ankles, 47.3%).

A total of seven ankles (5.8%) underwent subsequent arthroscopy. These patients had local symptoms and a VAS for pain ≥ 7 on exertion. Impingement with fibrosis and synovitis was confirmed. After debridement, the median VAS decreased from 7 to 3 and six patients were satisfied. The median VAS for pain and the American Orthopaedic Foot and Ankle Society score of the ankles after debridement was similar to that of the uncomplicated TARs (p = 0.496 and p = 0.066, respectively).

Although TAR reduces the intensity of pain, residual pain is not infrequent even in otherwise uncomplicated TARs and soft-tissue impingement is the possible cause.

Cite this article: Bone Joint J 2013;95-B:378–83.

The purpose of this study was to evaluate the clinical results of a newly designed prosthesis to replace the body of the talus in patients with aseptic necrosis. Between 1999 and 2006, 22 tali in 22 patients were replaced with a ceramic prosthesis. A total of eight patients were treated with the first-generation prosthesis, incorporating a peg to fix into the retained neck and head of the talus, and the remaining 14 were treated with the second-generation prosthesis, which does not have the peg. The clinical results were assessed by the American Orthopaedic Foot and Ankle Society ankle/hindfoot scale.

The mean follow-up was 98 months (18 to 174). The clinical results of the first-generation prostheses were excellent in three patients, good in one, fair in three and poor in one. There were, however, radiological signs of loosening, prompting a change in design. The clinical results of the second-generation prostheses were excellent in three patients, good in five, fair in four and poor in two, with more favourable radiological appearances. Revision was required using a total talar implant in four patients, two in each group.

Although the second-generation prosthesis produced better results, we cannot recommend the use of a talar body prosthesis. We now recommend the use of a total talar implant in these patients.

In distal fibular resection without reconstruction, the stabilising effect of the lateral malleolus is lost. Thus, the ankle may collapse into valgus and may be unstable in varus. Here, we describe a child who underwent successful staged surgical correction of a severe neglected valgus deformity after excision of the distal fibula for a Ewing’s sarcoma.

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy is a well-recognised form of treatment for stage II posterior tibial tendon dysfunction. Although excellent short- and medium-term results have been reported, the long-term outcome is unknown. We reviewed the clinical outcome of 31 patients with a symptomatic flexible flat-foot deformity who underwent this procedure between 1994 and 1996. There were 21 women and ten men with a mean age of 54.3 years (42 to 70). The mean follow-up was 15.2 years (11.4 to 16.5). All scores improved significantly (p < 0.001). The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up. The mean pain component improved from 12.3 to 35.2 (20 to 40). The mean function score improved from 35.2 to 45.6 (30 to 50). The mean visual analogue score for pain improved from 7.3 to 1.3 (0 to 6). The mean Short Form-36 physical component score was 40.6 (sd 8.9), and this showed a significant correlation with the mean AOFAS score (r = 0.68, p = 0.005). A total of 27 patients (87%) were pain free and functioning well at the final follow-up. We believe that flexor digitorum longus transfer and calcaneal osteotomy provides long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

Cite this article: Bone Joint J 2015;97-B:346–52.

We describe the early results of a prospective study of 100 total ankle replacements (96 patients) at a single centre using the Mobility Total Ankle Replacement. At final review, six patients had died and five ankles (5%) had been revised, two by fusion and three by exchange of components. All remaining patients were reviewed at a minimum of three years. The mean follow-up was 43 months (4 to 63). The three-year survival was 97% (95% confidence interval (CI) 91 to 99). The four-year survival was 93.6% (95% CI 84.7 to 97.4). The portion of bony interface that was visible on plain radiograph was divided into 15 zones and a radiolucent line or osteolytic cavity was seen in one zone in 14 ankles. It was not seen in more than one zone. In five ankles it was > 10 mm in width.

This study suggests that the early outcome of ankle replacement is comparable to that of other total joint replacements.

We report the clinical and radiological outcome of total ankle replacement performed in conjunction with hindfoot fusion or in isolation. Between May 2003 and June 2008, 60 ankles were treated with total ankle replacement with either subtalar or triple fusion, and the results were compared with a control group of 288 ankles treated with total ankle replacement alone.

After the mean follow-up of 39.5 months (12 to 73), the ankles with hindfoot fusion showed significant improvement in the mean visual analogue score for pain (p < 0.001), the mean American Orthopaedic Foot and Ankle Society score (p < 0.001), and the mean of a modified version of this score (p < 0.001). The mean visual analogue pain score (p = 0.304) and mean modified American Orthopaedic Foot and Ankle Society score (p = 0.119) were not significantly different between the hindfoot fusion and the control groups. However, the hindfoot fusion group had a significantly lower mean range of movement (p = 0.009) and a higher rate of posterior focal osteolysis (p = 0.04). Both groups showed various complications (p = 0.131) and failure occurring at a similar rate (p = 0.685).

Subtalar or triple fusion is feasible and has minimal adverse effects on ankles treated with total ankle replacement up to midterm follow-up. The clinical outcome of total ankle replacement when combined with hindfoot fusion is comparable to that of ankle replacement alone. Thus, hindfoot fusion should be performed in conjunction with total ankle replacement when indicated.

We describe the medium-term results of a prospective study of 200 total ankle replacements at a single-centre using the Scandinavian Total Ankle Replacement. A total of 24 ankles (12%) have been revised, 20 by fusion and four by further replacement and 27 patients (33 ankles) have died. All the surviving patients were seen at a minimum of five years after operation. The five-year survival was 93.3% (95% confidence interval (CI) 89.8 to 96.8) and the ten-year survival 80.3% (95% CI 71.0 to 89.6).

Anterior subluxation of the talus, often seen on the lateral radiograph in osteoarthritic ankles, was corrected and, in most instances, the anatomical alignment was restored by total ankle replacement. The orientation of the tibial component, as seen on the lateral radiograph, also affects the position of the talus and if not correct can hold the talus in an abnormal anterior position. Subtalar arthritis may continue to progress after total ankle replacement. Our results are similar to those published previously.

We describe the results of a randomised, prospective study of 200 ankle replacements carried out between March 2000 and July 2003 at a single centre to compare the Buechel-Pappas (BP) and the Scandinavian Total Ankle Replacement (STAR) implant with a minimum follow-up of 36 months. The two prostheses were similar in design consisting of three components with a meniscal polyethylene bearing which was highly congruent on its planar tibial surface and on its curved talar surface. However, the designs were markedly different with respect to the geometry of the articular surface of the talus and its overall shape.

A total of 16 ankles (18%) was revised, of which 12 were from the BP group and four of the STAR group. The six-year survivorship of the BP design was 79% (95% confidence interval (CI) 63.4 to 88.5 and of the STAR 95% (95% CI 87.2 to 98.1). The difference did not reach statistical significance (p = 0.09). However, varus or valgus deformity before surgery did have a significant effect) (p = 0.02) on survivorship in both groups, with the likelihood of revision being directly proportional to the size of the angular deformity. Our findings support previous studies which suggested that total ankle replacement should be undertaken with extreme caution in the presence of marked varus or valgus deformity.