BACKGROUND:Ankle osteoarthritis is a condition that generates a level of disability comparable to that of heart failure, chronic kidney failure, and end-stage hip and knee arthritis. To date, no predictive model has been described to determine which patients will experience a more pronounced improvement in patient-reported disability following total ankle replacement. METHODS:In this prospective cohort study, we included all patients between 2003 and 2023 who after joint decision making with their surgeon elected to undergo a total ankle replacement. Patients undergoing primary ankle fusion, revision total ankle replacement, with a history of previous ankle infection or Charcot neuroarthropathy, and those who declined to participate in the registry were excluded. A total ankle arthroplasty was considered to have a good response if patients showed a difference greater or equal than 28 points between the pre-operative and the 1-2-year AOS score. A multivariable logistic regression using a stepwise method was performed, adding or removing variables, and analyzing demographic variables (age at the time of surgery, smoking status, diabetes, inflammatory pathology, and body mass index), prosthesis type (Infinity, InBone II, InVision, Agility, Hintegra, Mobility, Zimmer, and STAR), etiology, and the AOS at the time of enrollment. As variables were added or removed, the model's Akaike information criterion was compared, ultimately keeping the most parsimonious version. After model selection, overfitting was evaluated using a bootstrapping method with 1000 replications, and finally, the goodness of fit was assessed with the Hosmer-Lemeshow test. RESULTS:A total of 631 total ankle replacements were included. The average age at the time of surgery was 64.96 ± 9.7 years. The most frequently used total ankle replacement was Hintegra (n = 159), followed by Infinity (n = 151), Zimmer (n = 127), and Agility (n = 78). The variables included in the model were the AOS at the time of enrollment (OR 1.06, P < .01, 95% CI 1.05-1.08) and instability etiology (OR 5.1, P < .01, 95% CI 1.69-15.26). The AUC was 0.76, and when compared using the bootstrapping method, no differences were found, indicating that the model did not show overfitting. Finally, the Hosmer-Lemeshow test showed that calibration was satisfactory. CONCLUSION:Higher baseline disability and instability-related etiology were associated with increased likelihood of clinically meaningful improvement after TAR. This internally validated model may assist preoperative counseling and shared decision making. A baseline AOS score above 63 was associated with a high probability of clinically meaningful improvement. LEVEL OF EVIDENCE:Level II, prospective cohort study.

This multi-center study aimed to compare complication rates, reoperation rates, and patient-reported outcome measures (PROMs) between open ankle arthrodesis (OAA) and arthroscopic ankle arthrodesis (AAA) in treating end-stage ankle arthritis. This was a prospectively collected retrospective study utilizing data from three medical centers in the Canadian Orthopaedic Foot and Ankle Society (COFAS) database. Primary ankle arthrodeses for the treatment of end-stage arthritis with a minimum of 2 years follow up and valid PROM scores were included. Preoperative COFAS ankle arthritis type, validated PROMs including the Ankle Osteoarthritis Scale (AOS), Short Form-36 (SF-36) with 2 components (the Physical Component Summary (PCS) and Mental Component Summary (MCS)), as well as major complications including malunion, nonunion, infection, amputations, and reoperations related to the arthrodesis were evaluated using CROCS (Canadian Reoperation Coding System). 2,835 prospectively enrolled patients who underwent surgical treatment of end-stage ankle arthritis (COFAS ankle arthritis Types 1-4) from 2001 to 2020 were screened. 447 ankle arthrodeses were included (178 AAA, 269 OAA) with 1-15 years of follow up (7.13 yrs +/- 3.8). There was no difference between the two groups with respect to demographics except there were more cases of type 1 and 4 arthritis in the OAA group. There was a 6.9% incidence of major complications including 3.79% related operations around the ankle, 0.67% deep infection, 1.78% revisions due to nonunion or malunion, and 0.67% amputations. For the 4 types of arthritis, the AOS score improved significantly at 1 year, stabilized in the type 1 group, but fluctuated in the remaining 3 types of arthritis after 8 years postoperatively. The average postoperative AOS score was better in the AAA group. Better outcomes were found for the arthroscopic cohort. However differences may be less after correction for confounding factors such as surgeon, site, and COFAS grade. Revision surgery is rare in both groups

Adjacent joint arthritis poses a dilemma in end stage ankle arthritis. The purpose of this study was to compare the outcomes of patients undergoing total ankle arthroplasty with or without surrounding joint fusion in COFAS type 4 cases. Prospectively collected data was retrospectively reviewed on 148 ankles with type 4 COFAS arthritis undergoing total ankle arthroplasty by 7 different surgeons in three centres and analysed changes of their AOS and SF36 PCS scores post operatively. Patients with surrounding joint preservation (59 ankles) were compared to those with total ankle and surrounding joint fusion (89 ankles). Multivariant analyses was performed for potential demographic differences within the patient cohorts. Outcomes were measured using SF 36 physical component, and AOS pain and difficulty scores. Preoperative scores were compared with the most recent outcome score. Revision surgery data was collected and classified. At an average of 5 years follow up both groups exhibit equivalent post operative pain and functional improvement. The average AOS in patient who had surrounding joint preservation improved from 57.47 to 24.52. Those with surrounding joint fusion improved from 55.86 to 23.67. SF36 PCS scores improved from 33.87 to 40.02 for preservation, and 38.86 to 42.27 for fusions. There was no significant difference in the preoperative score or demographics of both groups, no difference in postoperative score, and no difference in the change of score. Both groups were able to achieve their peak scores across all measurement scales at the 2-year post operative mark. Results from multivariant analyses showed no difference in patients’ AOS scores between the two different surgical cohorts. Both surgical cohorts had similar rates of revisions. In combined arthritis of the hindfoot (COFAS type 4) preserving the hindfoot joints with TAA yields comparative results to TAA and hindfoot fusion. The authors recommend surrounding joint preservation and fusion later on the rare occasion as needed.

Hallux valgus deformity remains one of the most common conditions seen in elective foot and ankle practice with an estimated prevalence of 35% in adults over the age of 65 years. When symptomatic and conservative measures have been exhausted a number of surgical osteotomy or fusion procedures may be utilized. The Lapidus procedure allows a large degree of correction to be obtained and involves fusion of the first tarsometatarsal joint. This has traditionally been performed with open incisions to prepare the first tarsometatarsal joint, release the first metatarsophalyngeal joint and insert hardware for fixation. Percutaneous techniques have been further developed in order to minimize soft tissue trauma, reduced postoperative pain and accelerated rehabilitation. Our technique involves percutaneous preparation of the first tarsometatarsal joint using a shannon burr for debridement, arthroscopy for visualization, and three full thread 4 mm non variable pitch headless chamfered cannulated screws for fixation. This technique retains subchondral bone for rigid fixation and stability. We aim to evaluate our complication rates following primary hallux valgus surgeries performed in our unit after the implementation of the percutaneous Lapidus procedure as the default surgical technique of the lead author. Patients over the age of 16 years undergoing percutaneous Lapidus procedure for primary hallux valgus deformity between 1st January 2018 and 1st April 2023 were retrospectively identified from our database. A minimum of 6-months postoperative follow-up was required for inclusion. Individual patient notes were retrospectively reviewed to assess for complications or requirements for further surgery to the foot for any reason. 149 percutaneous Lapidus procedures were performed in 130 patients. Twenty patients had bilateral procedures. Twelve patients were male (9.2%). All cases were performed by the lead author. Mean follow up was 34 months (Range 6 - 70 months). No patients were identified as developing deep infection or non-union requiring revision surgery within the follow-up period. Seventeen patients (11.4%) required removal of metalwork for soft tissue irritation at mean 17 months (Range 6 – 33 months). Three patients (2%) required subsequent first metatarsophalangeal joint fusion of the ipsilateral foot for symptomatic arthritis at mean 24 months (Range 8 – 40 months). In our experience percutaneous Lapidus fusion of the first tarsometatarsal joint appears to be safe and effective treatment for primary hallux valgus. We identified no cases of nonunion of the first tarsometatarsal joint in our cohort at minimum 6-month follow-up. Postoperative soft tissue irritation requiring removal of metalwork appears comparable to published open techniques for the treatment of primary hallux valgus.2

Background:Over the last 30 years, total ankle arthroplasty (TAA) has become a viable surgical option for end-stage ankle arthritis1,2. The aim of TAA is to relieve pain and preserve ankle joint range of motion, which, by definition, shields adjacent joints3-6. Alignment is essential for the longevity and survival of TAA, since malalignment of TAA components can cause abnormal loading patterns with subsequent polyethylene wear and early implant failure7-12. Therefore, patient-specific instrumentation with higher accuracy of tibial and talar component placement and shorter operative times has major advantages in TAA13. This present video article describes the use of CT-based patient-specific instrumentation for TAA implantation. Description:On the basis of preoperative CT scans (PROPHECY Ankle CT Scan Protocol; Wright Medical Technology), a surgical plan is created with comments from an engineer that include the sizing and positioning of TAA implant components (INFINITY with ADAPTIS Technology Total Ankle System; Wright Medical Technology). This plan is reviewed by the surgeon with the opportunity for corrections and adjustments. After approval, the patient-specific cut guides for the TAA are manufactured. TAA with patient-specific cut guides is performed with the patient under general anesthesia, usually with a popliteal and saphenous nerve block for intraoperative and postoperative pain management. The patient is positioned supine with a bump underneath the ipsilateral hip in order to align the foot in neutral rotation. A thigh tourniquet is applied and set at 275 mmHg. Landmarks for the incision are outlined on the skin and the leg is exsanguinated. An anterior approach with a standard central incision is made, creating full-thickness skin flaps medially and laterally. Dissection of the superficial peroneal nerve (SPN) branches should be avoided. The interval between the tibialis anterior tendon and the extensor hallucis longus tendon is entered, and the neurovascular bundle with the deep peroneal nerve (DPN) and the anterior tibial artery is protected and retracted laterally. Hohmann retractors are placed medial and lateral, taking care not to place too much tension on the skin. The anterior distal tibia and the dorsal talus are cleaned of all soft tissues, periosteum, and possible residual cartilage in order to obtain a good cortical read. The patient-specific cut guides (INFINITY PROPHECY, Total Ankle System; Wright Medical Technology) are placed first at the distal tibia and are fixed with temporary pins. Anteroposterior (AP) and lateral fluoroscopic images are made in order to confirm alignment of the tibial alignment guide, which should be neutral relative to the mechanical tibial axis. Once the position is appropriate, the guide is switched to the tibial resection guide, followed by tibial resection with use of an oscillating saw. The patient-specific talar alignment guide is then placed and fixed with pins. Pins are placed through the anterior pin holes, and the guide is switched to the cut guide. AP and lateral fluoroscopic images are made in order to check the talar resection. The talar resection guide will not necessarily be the same size as that used during the tibial resection. A lamina spreader is inserted, and ligament balancing is performed. The posterior capsule can be released at this time if it is tight. Next, the tibial trial is placed over the pins and the appropriate AP positioning of the tibial component is determined and checked on lateral fluoroscopy. Once the position is set, the broaches for the pegs are inserted and tapped in with a mallet. A talar dome trial is inserted together with a polyethylene insert trial, which should engage with the tibial trial. The talar component alignment and rotation are checked clinically as well as under fluoroscopy. Under axial compression and ankle dorsiflexion and plantarflexion, the talar component will rotate into its anatomic position. Two 2.4-mm Steinmann pins are utilized to fix the talar trial component temporarily. The talar resection guide is placed. Temporary fixation screws are placed and tightened by hand. The chamfer cuts are made with an oscillating saw. The talar pilot guide is placed, and the talar reamer is utilized to plunge cut in order to prepare the talar surface. Once this is finished, the pins and the guides are removed, and the residual bone is removed with use of a rongeur. Irrigation is performed with a saline solution. The definitive components are opened, and the tibial component is implanted first and impacted. The tibial pegs must be in the prepared holes. Verification that the component is fully seated is confirmed under lateral fluoroscopic imaging. The talar component is then inserted and impacted. A trial polyethylene liner is inserted, and varus and valgus stress and range of motion are tested. The liner size is then determined. The liner insert guide rail is attached, and the liner is slid into the joint space. With a gentle tap on the liner with the impactor, the fixed-bearing mechanism is locked. Finally, osteophytes, which could block the range of motion, are removed. Final fluoroscopic images are made. After copious irrigation, the wound is closed in layers. Sterile dressings are placed over the wounds, and a padded tri-slab splint is fashioned to immobilize the limb in neutral ankle dorsiflexion. Alternatives:Nonoperative alternatives include shoe wear modification, the use of NSAIDs, physiotherapy, physical therapy, the use of an orthosis, ankle bracing, and intra-articular injections. Operative alternatives include joint-preserving osteotomies and ankle arthrodesis (AA) (arthroscopic or open). Rationale:In comparison to ankle arthrodesis, prospective and retrospective cross-sectional studies showed that several patient-reported outcomes were greater after TAA than after AA, without a significant difference in revision rates and complications14-17. The anterior approach is the most commonly used approach for TAA and gives the surgeon the best exposure of the ankle joint. Varus and valgus deformity of >15° is a relative contraindication, and >20° deformity is an absolute contraindication for TAA18. If these deformities are not addressed appropriately, long-term survival may be impaired. Multiple studies have shown that malalignment of TAA components can induce high joint contact pressures and therefore lead to early implant failure7-12. Patient-specific instrumentation in TAA may improve accuracy of implant positioning. Performing TAA using patient-specific cut guides enables the surgeon to plan intra-articular deformity correction, template bone resection, and implant alignment and sizing according to the patient's unique anatomy. Cut guides are based on preoperative CT scans and are single-use instrumentation guides to mark bone cuts for tibial and talar component positioning. Minimal bony resection to preserve the bone stock for future possible revision surgeries is essential, especially in younger patients with end-stage ankle arthritis (< 55 years). Additionally, operative time and fluoroscopy time has been decreased compared with the traditional standard referencing guide technique in TAA13. Longer operative times have been shown to place patients at higher risk for wound complications in TAA19, which could be reduced by performing TAA with patient-specific cut guides. Expected Outcomes:Patients start weight-bearing at 2 weeks postoperatively, which is approximately 4 weeks earlier than patients who undergo ankle arthrodesis17. Patient expectations are more likely to be met by TAA than by ankle arthrodesis20. Gait analysis has shown that walking speed is faster after TAA compared with ankle arthrodesis. Hindfoot and forefoot sagittal motion is greater following TAA, and gait also more closely resembles the patient's natural gait21. Analysis of prospective data showed that in the presence of complex deformity or adjacent joint arthritis, as determined by the Canadian Orthopaedic Foot and Ankle Society (COFAS) classification (COFAS 3 and 4 ankles), patient-reported outcomes were better in patients undergoing TAA compared with ankle arthrodesis. In cases of ankle arthritis without deformity, TAA yielded higher patient-reported outcome measures compared with open ankle arthrodesis. Nevertheless, patients who underwent TAA had a significantly higher rate of additional surgical procedures. TAA patients in general have also been shown to have higher reoperation rates, at around 6% to 7% within a 2-year follow-up window15,17. Long-term follow-up data on TAA have shown revision rates between 16% and 54%; however, these rates were for older implant designs, and these numbers might not be applicable for the implant utilized in the presently described technique22,23. The Infinity TAA has shown a revision rate of 3% after a 3-year follow-up study24. Infection rates after primary TAA have ranged from 1.4% to 2.4%25. Important Tips:Patient selection and implant selection are key factors for successful outcome in TAA.It is important to communicate expected outcomes and set patient expectations, as TAA often requires secondary minor operations.The aim of the procedure is to align the implant neutral relative to the mechanical axis of the tibia and to align the foot underneath the ankle joint with the foot progression angle in line with the second ray. In order to achieve this, additional procedures, or even a staged approach, might be required for ligament balancing and foot alignment restoration.There is a surgeon learning curve associated with the implantation of a TAA prosthesis, and adequate training at a high-volume center would be beneficial for early-career foot and ankle surgeons.A perfect fit of the patient-specific cut guides is essential to achieve the planned alignment of the implant. Therefore, a CT scan should be performed within 3 months prior to the surgery, since additional osteophyte development and joint wear over a longer time may result in suboptimal fit of the 3D-printed guides.Meticulous soft-tissue handling is essential to limit the risk of wound complications.Ensure that the medial and lateral gutters are cleared.Ensure that the ankle is balanced. If the gap is asymmetric, meticulously release structures in the concavity of the asymmetry. Potential malleolar osteotomies are required to balance the gap. If the gap is the result of soft-tissue laxity, be sure to reconstruct the incompetent ligaments.If a varus ankle cannot be reduced, be sure to assess the lateral talar process. If it is prominent and represents a block to reduction, resect it.Once the ankle is balanced, assess the sagittal motion. If appropriate rollback or dorsiflexion is not obtained, assess for the presence of a gastrocnemius or soleus contracture with the Silfverskjöld test. Release the contracted tissues as required. For a triceps surae contracture, perform a Hoke procedure. For an isolated gastrocnemius contracture, consider a modified Strayer procedure.Once the ankle prosthesis is in place, assess the position of the foot. If there is a component of cavovarus or planovalgus, address the deformity by additional procedures (i.e. calcaneal osteotomy or midfoot osteotomies). Acronyms and Abbreviations:TAA = total ankle arthroplastyNSAID = nonsteroidal anti-inflammatory drugCT = computed tomographyCOFAS = Canadian Orthopaedic Foot and Ankle SocietyAA = ankle arthrodesisSPN = superficial peroneal nerveDPN = deep peroneal nerveER = extensor retinaculumTA = tibialis anteriorEHL = extensor hallucis longusAP = anteroposteriorDVT = deep vein thrombosis.

Despite the increasing utilization of total ankle replacement (TAR) for end-stage ankle arthritis, there remains a paucity of long-term follow-up data comparing arthroplasty to arthrodesis. The aim of the current paper was to provide the long-term clinical outcomes of TAR and ankle arthrodesis (AA), measured with use of validated scoring instruments, in a prospective multicenter cohort of patients with ankle arthritis. This cohort from the Canadian Orthopaedic Foot and Ankle Society (COFAS) Prospective Ankle Reconstruction Database comprised patients who underwent TAR or AA between 2001 and 2007. Data collection included demographics, comorbidities, and Ankle Osteoarthritis Scale and Short Form-36 scores. A total of 211 patients were included in the present study, with a minimum follow-up of 10 years (range, 10 to 18 years) and a mean follow-up of 13.2 years. In this cohort, the baseline characteristics of those who underwent AA and those who underwent TAR differed with respect to mean age (53.8 versus 61.3 years; p < 0.001), smoking status (31% versus 50% with no smoking history; p < 0.001), and inflammatory arthritis diagnosis (2% versus 17%; p = 0.005). Patients in the AA group had a greater chance of having no further surgery following their index procedure compared with those in the TAR group (70% versus 58%; p = 0.02). The TAR and AA groups demonstrated similar functional outcomes. In conclusion, the long-term clinical outcomes of TAR and AA were similar in a diverse cohort in which the treatment was tailored to the condition of the patient.

The purpose of the study is to determine whether the Infinity® ankle replacement is a more effective surgical procedure in comparison to ankle fusions (arthroscopic and open),assessed through patient-reported outcomes for patients with end-stage ankle arthritis. Patients at least 19 years old at the time of index procedure were selected. We compared 100 patients who had the INFINITY® TAA between 2013- August 1st, 2021, with 200 ankle fusion patients from 2008 -August 1st, 2021, all with minimum 1 year of follow up. The primary outcome was the Ankle Osteoarthritis Scale (AOS). Secondary outcomes were the MODEMS, and SF-36 scores. Revision fusion and revision INFINITY® patients were excluded. At 1 year follow up, Ankle Fusion AOS scores improved from a preoperative average of 55.25±19.31, to 26.01±21.64, vs 52.37±19.09 to 22.33±21.41 for INFINITY® TAA. At the last follow up after surgery (LFU), mean AOS scores in the Infinity cohort were significantly lower after linear regression for baseline variables with a mean difference of -6.76 (-12.52, -0.9995% CI) p-value 0.02. The difference remained significant after removing 1-year follow up, and 9-14 year follow up, at-6.58 (-12.89, -0.27 95% CI), p-value 0.041. The revision rate for ankle fusion was 3.5%, while revision rate for INFINITY® TAA was 2%. Patients undergoing INFINITY® TAA had significantly lower mean AOS scores than patients undergoing ankle fusion at their last follow up after surgery, both before and after linear regression for baseline variables. This remained significant after excluding earlier (1-year) follow up, and later (9-14 year) follow up that only had fusion cohort data.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus deformity remains prevalent in elective foot and ankle practice, affecting approximately 35% of adults aged over 65. When conservative treatments fail, surgical interventions like osteotomies or fusions are considered. The Lapidus procedure offers significant correction but traditionally involves open incisions. Percutaneous techniques have emerged to minimize soft tissue trauma, reduce postoperative pain, and expedite recovery. Our technique entails percutaneous preparation of the first tarsometatarsal joint using a Shannon burr for debridement, arthroscopy for visualization, and fixation with three full thread 4 mm non-variable pitch headless chamfered cannulated screws, preserving subchondral bone for stability. We aim to assess postoperative complications and radiographic correction achieved following primary hallux valgus surgeries using our percutaneous Lapidus procedure as the default surgical technique of the lead author. Methods: Patients aged 16 and above who underwent the percutaneous Lapidus procedure for primary hallux valgus deformity between January 1st, 2018, and April 1st, 2023, were retrospectively identified in our database. Inclusion criteria required a minimum of 6-month postoperative follow-up. Individual patient records and radiographic imaging were then reviewed retrospectively. 149 percutaneous Lapidus procedures were performed for primary hallux valgus in 130 patients. 19 patients underwent bilateral surgeries. 12 patients were male (9.2%). The mean follow-up period was 34 months (range: 6–70 months). 47 cases (31.5%) had percutaneous akin osteotomy in addition to percutaneous Lapidus. Outcome measures included revision surgeries and pre- and post-operative Intermetatarsal angle (IMA): normal < 9º, Hallux valgus angle (HVA): normal less than 15º, Distal articular metatarsal angle (DMMA): normal less than 10º and Sesamoid station measured as the distance between the lateral cortex of the first metatarsal and lateral cortex of the lateral sesamoid. Results: No cases of deep infection or non-union requiring revision surgery were identified during follow-up. Metalwork was removed for irritation in 17 cases (11.4%) at mean 17 months (range: 6–33 months) from surgery. Subsequent ipsilateral first metatarsophalangeal joint fusion for symptomatic arthritis occurred in 3 patients (2%) at mean 24 months (range: 8–40 months) from surgery. Complete pre and post-surgical radiographic imaging was available in 134 cases (90%). IMA reduced from mean 15.8 degrees (95% CI: 15.2-16.5) to mean 6.4 degrees (95%CI: 5.9-6.9). HVA reduced from mean 32.3 degrees (95%CI: 30.7-33.9) to mean 12.2 degrees (95%CI: 11.1-13.2). DMMA reduced from mean 30.6 degrees (95%CI: 28.6-32.7) to mean 10.1 degrees (95%CI: 9-11.2). Sesamoid station reduced from mean 9mm (95%CI: 8.5-9.5) to mean 2.8mm (95% CI: 2.4-3.2). Conclusion: In our experience percutaneous Lapidus fusion of the first tarsometatarsal joint appears to be a safe and effective treatment for primary hallux valgus. Within our cohort, we observed no instances of nonunion of the first tarsometatarsal joint with a minimum of 6-month follow-up. Incidents of postoperative soft tissue irritation requiring the removal of metalwork appear comparable to those reported in open techniques for primary hallux valgus treatment. We feel that in our cohort satisfactory radiographic correction was achieved in a wide spectrum of deformities.

Category: Ankle Arthritis; Ankle Introduction/Purpose: End-stage ankle arthritis (EAA) can diminish quality of life and handicap one’s daily activities. Ankle fusion or Total ankle arthroplasty (TAA) are two surgeries used to treat EAA. While ankle fusion has traditionally been the treatment of choice, it often impairs ankle functionality, and can increase the development of painful hindfoot arthritis. TAA typically has shorter recovery time and wider range of motion. Historically, TAA prostheses were inadequate due to frequent failures. Modern design and techniques have improved outcomes, decreased failure rates, allowed more normalized gait, and reduced adjacent joint arthritis development, but long-term performance remains ill-defined. The INFINITY ® Total Ankle System (Stryker Inc.) is a 2-component fixed-bearing, bone-sparing design that this study aims to compare to ankle fusion through patient reported outcomes. Methods: Patients at least 19 years old at the time of index procedure were selected. We compared 100 patients who had the INFINITY ® TAA between 2013- August 1st, 2021, with 200 ankle fusion patients from 2008 -August 1st, 2021, all with minimum 1 year of follow up. The primary outcome was the Ankle Osteoarthritis Scale (AOS). Secondary outcomes were the MODEMS, and SF-36 scores. Revision fusion and revision INFINITY ® patients were excluded. Results: At 1 year follow up, Ankle Fusion AOS scores improved from a preoperative average of 55.25±19.31, to 26.01±21.64, vs 52.37±19.09 to 22.33±21.41 for INFINITY ® TAA. At the last follow up after surgery (LFU), mean AOS scores in the Infinity cohort were significantly lower after linear regression for baseline variables with a mean difference of -6.76 (-12.52, -0.99 95% CI) p-value 0.02. The difference remained significant after removing 1-year follow up, and 9-14 year follow up, at -6.58 (-12.89, -0.27 95% CI), p-value 0.041. The revision rate for ankle fusion was 3.5%, while revision rate for INFINITY ® TAA was 2%. Conclusion: Patients undergoing INFINITY ® TAA had significantly lower mean AOS scores than patients undergoing ankle fusion at their last follow up after surgery, both before and after linear regression for baseline variables. This remained significant after excluding earlier (1-year) follow up, and later (9-14 year) follow up that only had fusion cohort data.

Category: Ankle Arthritis; Ankle Introduction/Purpose: This multi-center study aimed to compare complication rates, reoperation rates, and patient-reported outcome measures (PROMs) between open ankle arthrodesis (OAA) and arthroscopic ankle arthrodesis (AAA) in treating end-stage ankle arthritis. Methods: This was a prospectively collected retrospective study utilizing data from three medical centers in the Canadian Orthopaedic Foot and Ankle Society (COFAS) database. Primary ankle arthrodeses for the treatment of end-stage arthritis with a minimum of 2 years follow up and valid PROM scores were included. Preoperative COFAS ankle arthritis type, validated PROMs including the Ankle Osteoarthritis Scale (AOS), Short Form-36 (SF-36) with 2 components (the Physical Component Summary (PCS) and Mental Component Summary (MCS)), as well as major complications including malunion, nonunion, infection, amputations, and reoperations related to the arthrodesis were evaluated using CROCS (Canadian Reoperation Coding System). Results: 2,835 prospectively enrolled patients who underwent surgical treatment of end-stage ankle arthritis (COFAS Types 1-4) from 2001 to 2020 were screened. 447 ankle arthrodeses were included (178 AAA, 269 OAA) with 1-15 years of followup (7.13 yrs +/- 3.8). There was no difference between the two groups in demographics except more cases of type 1 and 4 arthritis in OAA group. There was a 6.9% incidence of major complications (3.79% related operations around the ankle, 0.67% deep infection, 1.78% revisions for nonunion/malunion, 0.67% amputations). For the 4 types of arthritis, AOS score improved significantly at 1 year, stabilized in type 1 group, but fluctuated in the remaining 3 types of arthritis after 8 years postoperatively. Average postoperative AOS score was better in the AAA group. Conclusion: Better outcomes were found for the arthroscopic cohort. However differences may be less after correction for confounding factors such as surgeon, site, and COFAS grade. Revision surgery is rare in both groups. AOS Treated Total Scores in Arthroscopic versus Open Ankle Arthrodesis Groups

Background: Postoperative outcomes may be affected by the patient’s preoperative morbidity. It is hypothesized that patient’s pain catastrophization prior to foot and ankle surgery may affect their patient-reported outcomes. Methods: This study prospectively assessed a consecutive cohort of 46 patients undergoing foot and ankle reconstruction to describe the relationship between Pain Catastrophizing Scale (PCS) and patient-reported outcomes measured by 12-item Short Form Health Survey and Foot and Ankle Outcome Score (FAOS). Results: The 1-year postoperative FAOS pain, activities of daily living, and quality of life scores correlated significantly with all baseline PCS subcategories. We found that the mental domain of the SF-12 had a statistically significant correlation with the rumination and helplessness PCS subcategories. Conclusion: This study showed a significant association between a high preoperative PCS and a worse 1-year FAOS. As such, catastrophization could be screened for and potentially treated preoperatively to improve patient-reported outcomes in elective foot and ankle surgery. Level of Evidence: Therapeutic, Level III Evidence

Category: Trauma; Ankle Introduction/Purpose: Syndesmosis injuries result in potential separation to the intimate distal tibial and fibular connection/articulation and can result in meaningful ongoing disability and the development of early post-traumatic arthritis. The injury pattern includes ligament injuries, cartilage damage, and/or fractures. These injury patterns may predicate outcomes. The associated fractures and ligament injuries may also determine the nature of fixation and management required. While classification exists for posterior malleolar, fibular, and ankle fractures, no systematic approach exists for the classification and treatment of syndesmosis injuries. This study aims to describe a comprehensive classification system for syndesmosis injuries and determine its validity. Methods: Descriptive system: The ankle was divided into five zones based on bony and soft tissue anatomic locations: lateral (L), medial (M), posterior (P), anterior (A), and intraarticular (I). In each location no injury is type 0, soft tissue/avulsion injury type 1, and boney injury type 2. (Figure 1). Study group: Patients with operative syndesmosis injuries in a single institution between January 2002 and December 2012 were reviewed. Injury patterns were classified by 3 experts, 2 semi-experts, and 2 musculoskeletal radiologists based on orthogonal anteroposterior and lateral radiographs. Statistical analysis: A 103-patient cohort was deemed to be sufficient based on power analysis Weighted kappa statistics with quadratic weights was used for test retest analysis. For inter-rater reliability, a separate analysis was completed for experts, semi-experts, and radiologists. Intraclass correlation coefficients were obtained. Results: All injuries could be classified according to the proposed classification. The most frequent pattern was the type B221 (13%) and C221 (12%). The interobserver agreement among all observers was excellent for the medial (ICC of 0.847) and lateral aspect (ICC of 0.762), good for the posterior aspect (ICC of 0.615), and poor for the anterior aspect (ICC of 0.233) (Table 1). The classification showed good to excellent intraobserver agreement except for the anterior aspect, which had poor agreement for the semi-expert raters (Table2). Conclusion: The syndesmosis classification is a valid system to represent the complexity of injuries that may occur. Inter- and intraobserver agreement among raters with different levels of expertise in classifying injuries based only on X-ray was good to excellent, with the exception of the anterior aspect which may require additional imaging techniques for proper classification. The categorization of different injuries by their location allows for a better understanding of how injurie presents. It should lead to improved research outcomes and communication between professionals regarding injury patterns and potential treatments in the future, as not all syndesmosis injuries are the same.

Patient-physician communication has the potential to improve outcomes and satisfaction through the shared decision-making process (SDM). This study aims to assess the relationship between perception of SDM and demographic, clinical, and patient-reported outcomes in patients undergoing Hallux Valgus (HV) correction. A prospective analysis of 306 patients scheduled for HV surgery was completed. The CollaboRATE score was used to measure SDM. Multivariable linear regression model was used to assess whether SDM scores were associated with preoperative characteristics or postoperative outcome scores. The mean CollaboRATE score was 2.9 (SD 0.9) and did not differ by age, socioeconomic status, or sex. Lower CollaboRATE scores were associated with more symptoms of depression, lower socioeconomic status, and lower general health scores (p-value < 0.05). There was no association between SDM scores and postoperative outcome scores. In this study, patients with depressive symptoms and lower socioeconomic status had worse perceptions of SDM. There was no difference in postoperative outcomes among participants based on SDM scores. Level of Evidence: Level III, prospective observational study

Category: Ankle Arthritis, Hindfoot Introduction/Purpose: Adjacent subtalar (STJ) or talonavicular (TNJ) joint arthritis poses a dilemma in end stage ankle arthritis. The Canadian Orthopaedic Foot & Ankle Society (COFAS) Classification defines such cases as Type 4. In these cases, undergoing total ankle arthroplasty (TAA), fusion of the STJ and/or TNJ or preservation of these joints are both options. Joint preservation may reduce operative time and potential complications but has potential for ongoing hindfoot pain reflected in outcome scores. Hindfoot fusion may offer the potential of greater pain relief, but at the risk of increased OR time and complications. The purpose of this study was to compare the outcomes of patients undergoing TAA with or without STJ and/or TNJ fusion in COFAS type 4 cases. Methods: We retrospectively reviewed prospectively-collected multi-center data on 148 ankles with COFAS Type 4 arthritis that underwent TAA by 7 different surgeons and analyzed the trend of their Ankle Osteoarthritis Scale (AOS) and SF36 Physical Component Summary (PCS) scores pre-operatively and at 1, 2 and 3-5 years post-operatively. Scores were compared between those who underwent fusion of the STJ and/or TNJ (Fusion Group [FG], n=89) and those who did not (Preservation Group [PG], n=59). Multivariant analyses were also performed to account for potential demographic differences within the patient cohorts. The primary outcome measure was the AOS score at latest follow-up (LFU). Secondary outcomes included the SF36 PCS score, COFAS Reoperation Coding System (CRoCS) rates and survivorship. Results: Mean follow up was 6.9 years. Mean pre-operative AOS scores for FG and PG were similar (55.9 and 57.5, respectively, p=0.56). Mean AOS scores at LFU for both groups were insignificantly different (FG – 24.6; PG – 25.2; p=0.89). SF36 PCS scores improved (32.9 pre-operatively to 42.2) at LFU for FG, (33.9 to 40.0) for PG; differences pre-operatively and at LFU were insignificant (p=0.51, p=0.26, respectively). Both groups achieved best mean scores 2 years post-operatively. Multivariant analyses controlling for demographics, comorbidities, surgeon, TAA implant type, and pre-operative score showed no significant difference in mean AOS scores at LFU between both Groups. Reoperations in PG included 2 Code3 procedures (hindfoot fusion) and 2 Code9 procedures (revision of metal components). FG had no Code3 or Code9 procedures. Conclusion: In COFAS Type 4 ankle arthritis cases with adjacent hindfoot arthritis undergoing TAA, our data suggests preservation of hindfoot joints yields similar outcomes to fusion of the hindfoot while potentially avoiding greater operative time, immobilization period, and additional wound/hardware risks associated with concomitant hindfoot fusion. However, preservation carries risk of requiring future reoperation for hindfoot fusion, as seen in 3% of our cases, though this may be countered by the risk of nonunion requiring reoperation when hindfoot fusion is performed primarily. Our results suggest that deferral of hindfoot fusion is a reasonable option in COFAS Type 4 ankles undergoing TAA.

Category: Hindfoot Introduction/Purpose: TTC fusions are often performed as a salvage procedure in patient with severe hindfoot arthritis or hindfoot deformity. Comorbidities in this patient collective are frequent, leading to increased risk of postoperative complication. The purpose of this study was to evaluate the surgical outcome regarding union rate, reoperation rate and adverse events using a retrograde hindfoot fusion nail. Methods: Patient records of a single center were retrospectively reviewed in which a retrograde hindfoot fusion nail was utilized for hindfoot fusion between July 1st, 2009 and August 31st, 2018. These records included age, gender, BMI, comorbidities, indications for surgery, non-union, re-operation rates and adverse events related to the surgery. The fusions were performed by 4 fellowship trained foot and ankle surgeons at a tertiary care teaching hospital. 58 cases were identified consecutively, in 51 cases a TTC fusion was performed, in 7 cases a tibiotalar fusion with preexisting talocalcaneal fusion. 22 fusions were arthroscopic and 36 open. The average age of patients was 59 years, the average BMI 29. Main indication for the hindfoot fusion were arthritis (55%) and complex hindfoot deformity (43%). Results: An overall union rate of 89.66% was achieved, 5 non-union tibiotalar and 1 non-union tibiotalar + talocalcaneal was documented. In the group of arthroscopic fusion the non-union rate was 9.09%, in the open group 11.11% respectively. The non- union group included patient with elevated BMI (50%), Diabetes mellitus (33%) and smoking (33%). Adverse events were documented in 21%. The reoperation rate was 17%, mostly due to deep infection or wound complication requiring surgical debridement. No patient in the arthroscopic fusion group needed a reoperation due to deep infection or wound complication, whereas in open surgery this rate was 27.78%. Conclusion: A union rate of 89.66% was achieved using a retrograde hindfoot fusion nail in a high risk patient population for non- union. Arthroscopic preparation of the tibiotalar and the subtalar joint seem to prevent postoperative wound complications.

Category: Ankle; Ankle Arthritis; Arthroscopy Introduction/Purpose: End-stage ankle arthritis has long been managed surgically with open ankle arthrodesis (OAA). More recently, arthroscopic ankle arthrodesis (AAA) is thought to be associated with improved patient-reported outcome measures (PROMs) and fewer complications. The objective of this study was to systematically compare these two approaches in long-term PROMs, major complication rates and survivorship of the ankle fusion. Methods: In this retrospective longitudinal cohort study, all patients with an ankle fusion done at our institution and a minimum two-year follow-up were screened for inclusion. Patients demographics at baseline were collected including: age, gender, BMI, smoking status, diabetes status as well as preoperative ankle arthritis COFAS (Canadian Orthopedic Foot and Ankle Society) type. The following PROMs were completed preoperatively, at 6-months and annually thereafter to five years: AAS, AOS, SF-36, expectation, satisfaction and swelling scores. PROMs were compared at all timepoints using a mixed-effects regression model adjusted for baseline patients' demographics, COFAS type and PROMs. Major postoperative complications and survival analysis/rate of revision of the ankle fusions were also compared. Results: Of 874 patients screened for inclusion, 351 ankle fusions done between 2003 and 2019 were eligible for the study, 223 AAA and 128 OAA. The two groups were similar at baseline with respect to demographics, but COFAS type was higher in the OAA group and AAS and AOS scores were better in the AAA group. At one-year post-operatively, there was a higher mean AAS score in the AAA group, but there were no other differences in outcomes at any other timepoint. Survivorship of the ankle fusion in the arthroscopic group was lower (ie higher rate of revision) due to a higher rate of amputation or fusion. Deep infection and wound complications were more common with OAA and accounted for most ankle fusion revisions in this group. Conclusion: There were no consistent differences in PROMs of patients who underwent AAA versus OAA patients up to five- years postoperatively. Ankle fusions done arthroscopically had a lower survivorship rate compared to those done with the open approach due to a higher rate of major complications. Previously proposed advantages of AAA over OAA may therefore need to re-assessed and weighed against the technical challenges and associated complications of the arthroscopic technique.

Category: Bunion Introduction/Purpose: Hallux valgus can be corrected by a variety of procedures. The Lapidus procedure corrects the first ray position in three planes using a first tarsometatarsal fusion (TMTF) and distal release and realignment. In a single surgeon practice the procedure was performed open until 2017, when burrs became available to perform the procedure percutaneously. This study compares the early radiographic results and complications of the percutaneous procedure with the open procedure. Methods: 47 patients undergoing the percutaneous procedure were compared with 44 patients undergoing the open procedure prior to July 2017. Radiographic measures preoperatively were compared to the postoperative measures for intermetataral angle (IMA), Hallux valgus angle (HVA), foot width (FW), distal metatarsal articular angle (DMMA), sesamoid station, metatarsus adductus angle (MAA), first metatarsal to second metatarsal length, and elevation of the first metatarsal. Early 30 day complications were recorded, as well as repeat surgeries. Demographics: There were 81 female and 10 male patients; The average age was MIS 58+/- 13, open 62+/-13. BMI was 28.4 vs 25.1. 1% of patients had diabetes, and 15% were smokers. Statistical analysis was performed using ANOVA. Because of multiple comparisons p<0.005. Error is quoted as 95% standard deviation. Grouped statistics were compared with a chi square test. Results: There is less correction in the MIS group in HV angle. The IM angle reduced from 15.8o+/-4.6 o to 6.3 o +/- 3.3 o compared to 17.7 o to 4.8 o +/- 3.6 o for the open group (p<0.05 and p>0.005). The change was 9.5 o compared to 12.9 o. HVA in the MIS group went from 34.6 o +/- 9.1 o to 14.5 o +/- 7.9 o (20.1 o change) compared to the open group where HVA went from 40.7 o +/- 10.5 o down to 11.6 o +/- 6.1 o (29.1 o change) (p<0.001). The wound complication rate trended higher in the open group (4 versus 0) out of 51 in each group (p>0.05). The nonunion rate was higher in the open group (0 MIS vs 4). The revision rate for deformity correction was the same in both groups (2 versus 2). Conclusion: In this single surgeon series between the two cohorts the MIS group showed a trend towards less correction than the open group. In particular the correction of the Hallux valgus angle was less. At the current time the distal release and realignment may not be as effective as in the open surgery, so more Aitken osteotomies may be required.However there was a trend for less wound complications and less non unions in the MIS group. The comparison included the initial experience with MIS as so the correction may not be as good as the technique evolves.

Background: End-stage ankle arthritis has long been managed surgically with open ankle arthrodesis (OAA). Since the first published report in 1983, arthroscopic ankle arthrodesis (AAA) has been thought to be associated with improved patient-reported outcome measures (PROMs) and fewer complications. The purpose of the present study was to compare the long-term PROMs, major complications, and reoperations for these 2 approaches at up to 15 years of follow-up. Methods: This longitudinal cohort study included patients at our institution who underwent primary ankle arthrodesis for the treatment of end-stage arthritis. Demographic data and preoperative COFAS (Canadian Orthopaedic Foot and Ankle Society) ankle arthritis type were collected for all patients. PROMs were completed preoperatively, at 6 months, and annually thereafter to 5 years. PROMs were compared at all time points with use of a mixed-effects regression model that adjusted for preoperative variables and scores. Major complications and reoperations at the site of the ankle arthrodesis were also compared. Results: Of 1,294 patients who were screened for inclusion, 351 who had undergone ankle arthrodesis between 2003 and 2019 were eligible for the study. Of those, 223 had undergone AAA and 128 had undergone OAA. The 2 groups were similar preoperatively with respect to demographics, but COFAS Type-4 arthritis was relatively more common in the OAA group and Type-1 arthritis was relatively more common in the AAA group. In addition, the Ankle Osteoarthritis Scale (AOS) score and Ankle Arthritis Score (AAS) were better in the AAA group. In the mixed-effects model analysis, the differences in postoperative outcome scores between the groups were not significant. The risk of revision due to malunion or nonunion was similar in both groups (6% in the AAA group, compared with 4% in the OAA group). Deep infection and wound complications did not occur in the arthroscopic group but occurred in 4% of the patients in the OAA group. Conclusions: After adjustment for baseline patient characteristics, there were no differences in PROMs between the 2 techniques. Ankle arthrodeses done arthroscopically had a similar revision rate but lower infection rate compared with those done with the open technique. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

In end-stage ankle arthritis, little is known about the impact of concomitant knee pathology, including the impact of ipsilateral knee pain on total ankle arthroplasty (TAA) outcomes. The aim of this study was to determine the prevalence of ipsilateral preoperative knee pain in patients undergoing TAA and analyze its impact on patient-reported functional outcome measures (PROMs). A retrospective review was performed on the Vancouver End Stage Ankle Arthritis Database at a single institution. In total, 114 patients were studied, with patient demographics collected preoperatively, including the presence or absence of knee pain. Postoperative follow-up was performed at 5 years, primarily analyzing disease-specific PROMs, including the Ankle Osteoarthritis Score (AOS) and Ankle Arthritis Score (AAS). Multivariate mixed-effects linear regression models compared the scores between the groups. In total, 31 patients (27.2%) presented with concomitant ipsilateral knee pain. Despite more females in the knee pain group (64.5% vs 36.1%) there were no other significant differences at baseline between the knee pain and no knee pain groups in terms of demographics or baseline primary disease specific PROMs. At 5 years, the patients with knee pain had significantly worse AAS (37.9 ± 23.8 vs 21.2 ± 16.3, P = .004) and AOS total scores (38.1 ± 24.1 vs 21.9 ± 15.5, P = .005) compared with the no-knee pain group. Both groups improved significantly from baseline across all outcome measures; however, the magnitude of improvement was less in the knee pain group. Our study demonstrated that over one-quarter of patients with end-stage ankle arthritis undergoing TAA present with ipsilateral concomitant knee pain. If present, it is associated with worse functional outcomes at the 5-year mark. Further studies are needed to evaluate if knee pain influences complications, implant failure rates, and survival.Levels of Evidence: Level III.

BACKGROUND:We investigated the influence of sex on patient-reported outcomes preoperatively and following total ankle replacement and ankle arthrodesis. METHODS:Patients who had undergone total ankle replacement or ankle arthrodesis for the treatment of end-stage ankle arthritis and who had ≥2 years of follow-up were identified from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database. Standard surgical techniques and implantation methods were followed, and STAR, Hintegra, Mobility, and Agility prostheses were used. Data were collected on patient demographics, revisions, secondary procedures, complications, Ankle Osteoarthritis Scale (AOS) scores, Short Form-36 (SF-36) scores, and expectations and satisfaction. Statistical analyses included 3-way repeated-measures analysis of variance (ANOVA) and multiple linear regression models controlling for inflammatory arthritis, age, preoperative scores, and surgery type. RESULTS:The study included 872 patients: 629 who had undergone total ankle replacement (316 men, 313 women) and 243 who had undergone ankle arthrodesis (154 men, 89 women). The mean duration of follow-up (and standard deviation) was 4.9 ± 2.4 and 4.0 ± 1.9 years for the total ankle replacement and ankle arthrodesis groups, respectively. Men were older than women (p ≤ 0.001). In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS pain scores (i.e., more pain) than men preoperatively (p < 0.05). Pain was reduced significantly in both sexes postoperatively (p < 0.05), with no significant difference between sexes. In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS disability scores (i.e., more disability) and lower SF-36 Physical Component Summary (PCS) scores (i.e., worse function) than men both preoperatively and postoperatively (p < 0.001). Postoperatively, AOS disability and SF-36 PCS scores improved significantly from baseline in both sexes (p < 0.001). After controlling for covariates, sex was not a significant predictor of postoperative SF-36 MCS (Mental Component Summary), AOS pain, or AOS disability scores (p > 0.05) but explained 0.5% of variance in SF-36 PCS scores (p = 0.03). Sex did not significantly influence preoperative expectations or postoperative satisfaction. When patients with inflammatory arthritis were excluded, preoperative and postoperative outcome measures, expectations, and satisfaction were similar. CONCLUSIONS:Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. Small differences in pain and function between men and women undergoing total ankle replacement and ankle arthrodesis mostly disappeared when controlling for potential confounding variables. Both total ankle replacement and ankle arthrodesis remain good options for men and women with end-stage ankle arthritis. LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.