Total ankle arthroplasty (TAA) has become a recognized solution for patients suffering from end-stage ankle arthritis. Despite advancements in implant design and surgical techniques over the past decade, the long-term survivorship of these implants remains ill-defined. A notable deficiency exists in published data regarding failure rates and the underlying causes of implant failures. As indications for TAA expand-with more complex deformities, the incidence of revision surgeries is expected to rise. Accordingly, surgeons need to be familiar with the principles of total joint revision to successfully modify these failures to avoid amputation or conversion to fusion.

In this article I reflect on almost 40 years of clinical practice. I remember the first day like it was yesterday, and I remember the last day, but the in between represents my soul, a soul that has been shaped by countless experiences. Some of these experiences were immediately impactful and left an indelible mark on my soul, but most of them were memorable only for a fleeting moment, soon to be forgotten. Yet the cumulation of these seemingly trivial experiences, in retrospect, served as the foundation of my career at Kaiser Permanente.

Reconstructive surgery of the symptomatic pes planus deformity is a very common procedure with relatively good outcomes. Many factors such as patient selection, patient expectations, and surgical execution can influence the results. In addition to achieving osseous union, the overall postoperative alignment is critical in determining functional outcome. Specifically, under- and over-correction respectively present their own unique problems and symptomatology . The purpose of this review is to discuss the adverse outcomes after mal-reduction of flatfoot reconstruction and emphasize the strategies to correct the subsequent deformity.

Peroneal subluxation is a rare but debilitating pathology that can be the result of a superior peroneal retinaculum tear or intrasheath laxity. On clinical examination of both cases, the pathology is observed when the ankle is circumducted in eversion and dorsiflexion. With a superior peroneal retinaculum tear, the tendons dislocate from the peroneal groove, whereas with intrasheath laxity the tendons remain in the groove. In the present case series, peroneal stabilization was performed for both superior peroneal retinaculum tear and intrasheath laxity. With our technique, the fibro-osseous connections of the peroneal tendon sheath are detached from the distal one third of the fibula. Drill holes are made through the fibula for suture to be passed through and the peroneal tendon sheath is reattached to the fibula through horizontal mattress sutures via pants over vest technique to restore tension to the sheath. A total of 5 patients underwent peroneal stabilization, 100% (5/5) of which had preoperative pain with palpation along the peroneal tendons and a palpable click with range of motion of the ankle joint. Postoperatively, 100% (5/5) of the patients were fully weight-bearing, compared to 60% (3/5) preoperatively. No patients had residual subluxation of the peroneal tendons postoperatively or a need for revisional surgery. Residual peroneal tendonitis was present in 20% (1/5) of patients and sural neuritis occurred in 20% (1/5) of patients. The peroneal tendons are physiologically tightened within the peroneal tendon sheath to mitigate the pathologic subluxation, without sacrificing tendons for transfer or using allograft material. Clinical Level of Evidence: Therapeutic, Case Series, Level 4

Traditional postoperative care after open reduction internal fixation (ORIF) of unstable ankle fractures with syndesmotic instability includes non-weightbearing for 6 to 8 weeks. However, prolonged non-weightbearing may be detrimental. The goal of this case series was to assess the outcomes of early protected weightbearing after operative treatment of acute ankle fractures with syndesmotic instability requiring screw stabilization. Fifty-eight consecutive patients, treated from January 2006 to January 2013, met the inclusion criteria with a minimum follow up of 1 year. Electronic medical records and radiographs were reviewed for patient and surgical characteristics, postoperative complications, and maintenance of reduction. Patients initiated walking at an average of 10 days (range 1 to 15) postoperatively. Surgical treatment consisted of operative reduction with standard fixation devices and 1 or 2 trans-syndesmotic screws that purchased 4 cortices. All 58 patients maintained correction after surgery when allowed to weightbear early in the postoperative recovery. Five complications (8.6%) occurred in the 58 patients, which included 3 superficial infections (5.2%) and 2 cases (3.4%) of neuritis. The maintenance of reduction and low complication rate in this study support the option of early protected weightbearing after ankle fracture ORIF with trans-syndesmotic fixation.

Treatment of painful or malaligned ankle arthrodesis can present as a challenging issue. Several published studies have demonstrated that takedown of a painful ankle arthrodesis to total ankle arthroplasty can assist in restoring some sagittal plane motion and improving functional scores. The goal of this study was to contribute to the limited body of literature with the largest cohort and longest follow-up to date. A retrospective analysis was performed on patient and surgical characteristics of those who underwent a conversion of a painful ankle arthrodesis to a total ankle arthroplasty by 1 of 3 experienced total ankle arthroplasty surgeons from February 2003 to December 2016 with ≥2 years of follow up. Seventy-seven subjects were included for evaluation, with an implant retention rate of 88% (68 of 77) and mean follow-up of 8.3 years (range 2.6 to 15.8). Of the 11 (14%) failures (defined as retrieval or exchange of metallic components), 8 (10%) were revised to a total ankle replacement, 2 (2%) underwent revision arthrodesis, and 1 (1%) elected for below-the-knee amputation. The mean time since the primary arthrodesis was 8.6 years (range 1 to 44), and the longer time interval between primary arthrodesis to takedown total ankle arthroplasty did not correlate with poorer outcome scores or increased risk of failure. The mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot, Buechel-Pappas, and visual analog pain scale scores improved from preoperative values, with less satisfaction noted in those who needed revision surgery. The conversion of a painful ankle arthrodesis to a total ankle implant is a viable option to obtain range of motion and improved patient satisfaction scores similar to primary total ankle replacement.

The use of cannulated screws in foot and ankle surgery has increased over the years, but remains controversial and largely subject to surgeon preference. A research roundtable of questions has been submitted to 6 invited foot and ankle surgeons relative to their individual use of these cannulated devices. The purpose of this symposium is to explore some of the pertinent controversies between traditional solid screws and cannulated screws. With our current worldwide health care cost concerns, design, and manufacturing there will be a convergence in a quest for value in our implants. I am excited to have such an experienced and well-known group of foot and ankle surgeons participate in this dialogue. 1)Is there any situation in foot and ankle surgery where a solid screw cannot be used and you must use a cannulated?

Background: The incidence rate of venous thrombotic events (VTEs) following foot and ankle surgery is low. Currently, there is no consensus regarding postoperative prophylaxis or evidence to support risk stratification. Methods: A 2-part study assessing the incidence and factors for the development of VTE was conducted: (1) a retrospective observational cohort study of 22 486 adults to calculate the overall incidence following foot and/or ankle surgery from January 2008 to May 2011 and (2) a retrospective matched case-control study to identify risk factors for development of VTE postsurgery. One control per VTE case matched on age and sex was randomly selected from the remaining patients. Results: The overall incidence of VTE was 0.9%. Predictive risk factors in bivariate analyses included obesity, history of VTE, history of trauma, use of hormonal replacement or oral contraception therapy, anatomic location of surgery, procedure duration 60 minutes or more, general anesthesia, postoperative nonweightbearing immobilization greater than 2 weeks, and use of anticoagulation. When significant variables from bivariate analyses were placed into the multivariable regression model, 4 remained statistically significant: adjusted odds ratio (aOR) for obesity, 6.1; history of VTE, 15.7; use of hormone replacement therapy, 8.9; and postoperative nonweightbearing immobilization greater than 2 weeks, 9.0. The risk of VTE increased significantly with 3 or more risk factors (P = .001). Conclusion: The overall low incidence of VTE following foot and ankle surgery does not support routine prophylaxis for all patients. Among patients with 3 or more risk factors, the use of chemoprophylaxis may be warranted.

Correction of severe valgus deformity of the foot and ankle with ankle replacement is challenging. We describe the controversies and specific issues of surgical management and provide a detailed surgical strategy for management of this common deformity. A reliable technique for deltoid reconstruction is also described and illustrated in detail.

Conversion of ankle arthrodesis to total ankle arthroplasty has recently gained popularity. However, technical challenges are present when treating patients without a sufficient fibular buttress. We describe a technique for restoration of an adequate fibular buttress using an iliac crest bone graft or malleolar relocation. The results of 10 patients with an average follow-up period of 56 (range 24 to 123) months are presented. Of the 10 patients, 3 underwent tricortical iliac bone augmentation of the fibula, 4 underwent repositioning of the remnant fibula, and in 3, the in situ fibula was used. The average interval from fusion to takedown was 15.1 (range 5 to 35) years, and the average age at takedown was 52.8 (range 33 to 75) years. The average improvement in the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale and Buechel-Pappas scale scores was 35.8 (range 30 to 46) and 34 (range 25 to 42), respectively. Three patients underwent a total of 7 subsequent operations related to the ankle implant. Only 1 of the patients had any residual frontal plane deformity. None of the patients exhibited any component subsidence; however, 2 patients experienced asymptomatic lateral talar component overgrowth. The improvement in the clinical scores in this group of patients suggests that takedown of an ankle arthrodesis with an insufficient fibula is a viable option to improve function. Various techniques to restore the lateral buttress can be used even with complete absence of the distal fibula.

With total ankle arthroplasty , documented complications can be categorized chronologically into intraoperative, postoperative, and late complications. Factors such as patient selection, surgeon experience, implant features, and prosthetic device selection can influence functional outcomes as well as incidence of complications. Even with impeccable surgical technique and optimal patient selection, complications that require revision may still arise and the most common complications with revision solutions are discussed in this article.

We read with interest 2 recent publications by Brigido et al regarding component migration after total ankle arthroplasty in The Journal of Foot & Ankle Surgery®. The papers are entitled, “Evaluating component migration after modular stem fixed-bearing total ankle replacement” [J Foot Ankle Surg 54:326–331, 2015] and, more recently, “Evaluating component migration: comparing two generations of the INBONE total ankle replacement” [J Foot Ankle Surg 54:892–895, 2015]. The collective total joint literature involving the knee and hip has struggled with the same questions regarding component subsidence and migration. While component migration clearly is an area that deserves more attention in the total ankle literature, we have concerns that the foundation of the research herein is significantly flawed. Our concerns are as follows:1.It was most disappointing to us that the authors ignored the basic principles of component migration to the extent that the entire investigation is invalid. Independent of the methodology of measurement, every valid investigation of component migration in the total joint literature uses an osseous reference point. How else can you determine that the device is settling into the bone without first knowing the starting point? Component migration simply cannot be determined by measuring the total height of the prosthesis, At best, this measurement could potentially measure linear polyethylene wear over time, but this was not the focus of these articles.2.The term radiostereometric analysis was mentioned (without reference) in the discussion of the first paper as a measurement technique standard with which we agree. However, with the use of the authors' new measurement technique, it was surprising that a more detailed description of historic validated measurement techniques were not summarized in these articles based on the references cited and the limited information available in the total ankle literature (1Carlsson A. Patrik M. Sundberg M. Radiostereometric analysis of the double-coated STAR total ankle prosthesis: a 3–5-year follow-up of 5 cases with rheumatoid arthritis and 5 cases with osteoarthrosis.Acta Orthop. 2005; 76: 573-579Crossref PubMed Scopus (34) Google Scholar, 2Fong J.W. Veljkovic A. Dunbar M.J. Wilson D.A. Hennigar A.W. Glazebrook M.A. Validation and precision of model-based radiostereometric analysis (MBRSA) for total ankle arthroplasty.Foot Ankle Int. 2011; 32: 1155-1163Crossref PubMed Scopus (12) Google Scholar). Nevertheless, the inference that their measurement technique is valid and can be utilized to establish clinical guidelines for component migration is misguided at best.3.They discuss the wide variability in radiographic technique at their institution as justification to ignore the lateral radiograph yet fail to discuss how they assured replication of the precise positioning of the radiographic equipment and patient each and every time there was an anterior-posterior radiograph. It implies that there is some unknown mechanism that assures accuracy of the technique in one view but not the other. The high inter- and intra-rater reliability coefficients to justify this method as a means of evaluating component migration is illogical and obtuse.While it may be a moot point based on the invalid methods employed in these manuscripts, it has been clearly determined that digitized radiography is highly inaccurate (3.9–12.3 mm) in the assessment of component migration in the hip (3Malchau H. Karrholm J. Wang Y.X. Herberts P. Accuracy of migration analysis in hip arthroplasty digitized and conventional radiography, compared to radiostereometry in 52 patients.Acta Orthop Scand. 1995; 66: 418-424Crossref PubMed Scopus (209) Google Scholar). This results from image distortion based primarily on beam alignment and patient positioning variables, variables that were uncontrolled in the studies in question. Highly accurate measurement techniques are essential when magnitudes of migrations are small.4.There is a significant difference between early physiological versus pathological prosthetic component migration. The former occurs naturally in all prosthetic placements, generally for a couple of weeks after placement, and the migrations are small in magnitude (1Carlsson A. Patrik M. Sundberg M. Radiostereometric analysis of the double-coated STAR total ankle prosthesis: a 3–5-year follow-up of 5 cases with rheumatoid arthritis and 5 cases with osteoarthrosis.Acta Orthop. 2005; 76: 573-579Crossref PubMed Scopus (34) Google Scholar, 2Fong J.W. Veljkovic A. Dunbar M.J. Wilson D.A. Hennigar A.W. Glazebrook M.A. Validation and precision of model-based radiostereometric analysis (MBRSA) for total ankle arthroplasty.Foot Ankle Int. 2011; 32: 1155-1163Crossref PubMed Scopus (12) Google Scholar). The latter is generally related to prosthetic loosening and has a greater potential to threaten prosthesis longevity with much larger magnitudes of migration. We feel there is still considerable benefit in reviewing serial digital radiographs longitudinally using a case series model when evaluating pathological migrations. Good examples of this are the AgilityTM total ankle prosthesis longitudinal mid-term and long-term series (4Pyevich M.T. Saltzman C.L. Callaghan J.J. Alvine F.G. Total ankle arthroplasty: a unique design. Two to twelve-year follow-up.J Bone Joint Surg Am. 1998; 80: 1410-1420PubMed Google Scholar, 5Knecht S.I. Estin M. Callaghan J.J. Zimmerman M.B. Alliman K.J. Alvine F.G. Saltzman C.L. The Agility total ankle arthroplasty. Seven to sixteen-year follow-up.J Bone Joint Surg Am. 2004; 86-A: 1161-1171PubMed Google Scholar); the technique for measuring component migration used a digitized lateral radiograph (using the bone cut scar as an osseous reference) to report incidence of migration of either tibial or talar components. Uneven component migration was recorded as an angular change of the components, which required radiographs taken from 2 planes of view.5.The authors cited the Karrholm et al reference in both papers to define component migration in bone over time (6Karrholm J. Borssen B. Lowenhielm G. Snorrason F. Does early micro motion of femoral stem prosthesis matter? 4–7 year steroradiographic analysis.J Bone Joint Surg Br. 1994; 76: 912-917PubMed Google Scholar). However, we could not find this definition within this reference, but discovered that the definition should be attributed to Fong et al (2Fong J.W. Veljkovic A. Dunbar M.J. Wilson D.A. Hennigar A.W. Glazebrook M.A. Validation and precision of model-based radiostereometric analysis (MBRSA) for total ankle arthroplasty.Foot Ankle Int. 2011; 32: 1155-1163Crossref PubMed Scopus (12) Google Scholar). Despite this repetitive error, the authors should have used Fong et al (2Fong J.W. Veljkovic A. Dunbar M.J. Wilson D.A. Hennigar A.W. Glazebrook M.A. Validation and precision of model-based radiostereometric analysis (MBRSA) for total ankle arthroplasty.Foot Ankle Int. 2011; 32: 1155-1163Crossref PubMed Scopus (12) Google Scholar) reference as the fundamental predicate for their investigations.6.In the second paper, the authors hypothesized that so-called core decompression would weaken the talus in the Inbone I® compared to Inbone II®, thereby expecting more migration in the Inbone I®. Clearly, the readers should understand the basic physics and design regarding contemporary ankle implants. The talar component is designed to cover most of the peripheral cortical rim to prevent subsidence that was so prevalent in earlier implant designs (4Pyevich M.T. Saltzman C.L. Callaghan J.J. Alvine F.G. Total ankle arthroplasty: a unique design. Two to twelve-year follow-up.J Bone Joint Surg Am. 1998; 80: 1410-1420PubMed Google Scholar, 5Knecht S.I. Estin M. Callaghan J.J. Zimmerman M.B. Alliman K.J. Alvine F.G. Saltzman C.L. The Agility total ankle arthroplasty. Seven to sixteen-year follow-up.J Bone Joint Surg Am. 2004; 86-A: 1161-1171PubMed Google Scholar). Based on earlier design failures, it is illogical to expect the cancellous bone to support the implant in the first place. It is not surprising that there was no difference in the degree of migration because the hoop stresses on the respective tali are the same in either Inbone® designs (7Calderale P.M. Garro A. Barbiero R. Fasolio G. Pipino F. Biomechanical design of the total ankle prosthesis.Eng Med. 1983; 12: 69-80Crossref PubMed Scopus (35) Google Scholar). Lastly, it is clear the surgical community at large needs to know the extent and tendency of component migration over time; however, this is not the technique that should be utilized for this purpose. Evaluating Component Migration After Modular Stem Fixed-Bearing Total Ankle ReplacementThe Journal of Foot and Ankle SurgeryVol. 54Issue 3PreviewTo date, no studies have evaluated implant migration after implantation of a modular stem fixed-bearing total ankle replacement. The purpose of the present report was to determine the inter-rater and intrarater reliability of our proposed measurement technique and to assess implant migration over time. Twenty consecutive patients (aged 59.3 ± 12.2 years) who had undergone implantation with this modern, third-generation prosthetic were included. To assess implant migration, measurements were made from non-weightbearing, postoperative radiographs immediately after surgery and again at 1 year and 2 years. Full-Text PDF Evaluating Component Migration: Comparing Two Generations of the INBONE® Total Ankle ReplacementThe Journal of Foot and Ankle SurgeryVol. 54Issue 5PreviewAlthough total ankle replacement (TAR) designs have radically evolved, the compressive forces at the ankle can cause aseptic loosening, talar subsidence, and implant failure. The purpose of the present report was to compare the implant migration associated with the INBONE® I, a TAR system with a stemmed talar component, and the newer generation INBONE® II, a TAR system without a stemmed talar component (Wright Medical Technology, Inc., Arlington, TN). Because core decompression could weaken the integrity of the talus, we hypothesized that the stemmed component would result in greater implant migration. Full-Text PDF Technique for Measuring Total Ankle Component Migration a Reasonable OptionThe Journal of Foot and Ankle SurgeryVol. 55Issue 2PreviewWe would like to thank Drs. Christensen, Schuberth, and Steck for their comments on our papers regarding prosthetic migration in the ankle. We agree that component migration is an important and controversial topic to understand and that this topic deserves a significant amount of attention due to its complexities; both in understanding the pathogenesis and its ability to quantify. Full-Text PDF

Dear Editor: We read with interest “The Fate of the Fixed Syndesmosis Over Time” by Gennis et al published in the October 2015 issue of FAI. We are pleased that the authors endeavored to challenge the seminal conclusion in our paper that was seemingly the impetus for their investigation. Indeed, one of the reasons that we performed our study was to shed light on this controversial topic and stimulate further research. One of us (J.M.S.) also had the privilege of hearing Dr Tornetta discuss his feelings on our manuscript at the AOFAS/OTA combined symposium in March 2014, during AOFAS specialty day. It has become clear, now that this work has been published, that our respective studies had marked differences in the postoperative protocol and statistical analysis, which may explain the disparate conclusions. First, all of our patients were weight bearing well before the 12-week landmark used in this protocol. In fact, some of our patients were weight bearing as early as 14 days after surgery. Many were released to regular shoe gear as early as 7 weeks. The early unprotected load to the syndesmosis may have contributed to a less stable mortise and subsequent spread once the screws were removed. Second, we did not apply the Bonferroni correction in our statistical analysis. We would like to point out that by applying this method, the risk of introducing false negatives increases. Further, we did not want to create a type II error such that we would mask the differences in the pre– and post–screw removal radiographs. In fact, analysis of Tables 3 and 4 in the Gennis et al study reveals an actual increase of the tibia-fibula clear space and maintenance of the medial clear space in almost all of the categories. These trends are synchronous with ours, and the purported differences are most likely explained on the statistical methods used rather than reality. Although the issue of whether patients should be allowed to bear weight before the 12-week threshold can be debated elsewhere, we did change our practice pattern based on the results of our study insofar that we now leave the screws in and have exactly the same discussion with our patients that is offered in the Gennis et al study. On the basis of both of our studies, we still believe that some loss of the syndesmosis integrity occurs after screw removal, but the medial clear space remains intact.

Posterior tibial tendon transfer has been described to reduce and balance the cavovarus deformity in those patients who receive a total ankle replacement for end-stage arthritis. In this article, we discuss the indications and provide a detailed description of the technique for this powerful procedure. Case examples that demonstrate the utility of the procedure are provided.

BACKGROUND:Sagittal displacement in patients with end stage ankle arthritis has been described as the tibiotalar ratio (TTR). Yet the incidence, distribution and predictive factors of talolisthesis are unknown.METHODS:The radiographs of 470 cases of ankle arthritis were compared with a control group of 49 normal ankles. The TTR was measured for both groups. Additional co-variables included the anterior and lateral distal tibial angles, and talar tilt.RESULTS:The mean TTR in the arthritis cohort was 34.8+9.12 compared to the normal group of 34.1+2.62. Twenty-eight percent of the ankles had anterior displacement and twenty-eight percent had posterior talolisthesis, while forty-four percent had normal tibiotalar alignment. Multivariate linear regression revealed significant predictors of anterior distal tibial angle (p<0.0001) and talar tilt (p=0.0007) for abnormal TTR.CONCLUSION:Sagittal displacement is common in end stage ankle arthritis and is affected by ligamentous laxity and joint morphology.