Commentary: Important review article on the current literature and status of ankle arthroplasty in the US. It outlines all of the current FDA approved prostheses. Also reviews literature on utilization and cost comparisons to ankle fusion

Background: This study aimed to assess the preferred operative treatment for patients over the age of 60 with end-stage ankle arthritis and perspectives on total ankle replacement (TAR) among American Orthopaedic Foot & Ankle Society (AOFAS) members. Associated factors were analyzed for potential contraindications among members with different levels of experience. Method: A questionnaire containing 6 questions was designed and sent to 2056 members of the AOFAS. Responses were received from 467 orthopaedic surgeons practicing in the United States (76%), Canada (5%), and 26 other countries (20%). Participants were grouped for response comparisons according to country as well as experience level. Differences in contraindications were compared using χ2 tests or exact tests. Results: Respondents practicing in the United States and surgeons who perform 11 or more TARs per year tended to recommend operative treatments favoring TAR and displayed recognition of its increasing role (P < .05). Overall, respondents felt that 41% of typical patients over 60 years old with end-stage arthritis would be best treated with TAR. Talus avascular necrosis, morbid obesity (body mass index >40 kg/m2), and poorly controlled diabetes with neuropathy were most recognized as the absolute contraindications to TAR. Surgeon’s experience affected the consideration of these clinical factors as contraindications. Conclusions: Total ankle replacement has a substantial and increasing role in the treatment of end-stage ankle arthritis in patients over the age of 60. Absolute and potential contraindications of the procedures were indicated from a cross-sectional survey of AOFAS members. Surgeons more experienced with total ankle replacement felt more comfortable employing it in a wider range of clinical settings. Level of Evidence: Level III, therapeutic.

Category: Midfoot/Forefoot; Sports Introduction/Purpose: Patients with pathology of the sesamoids can have significant pain and disability both with activities of daily living and high impact athletic movements. Sesamoidectomy is a widely used procedure for patients who fail conservative treatment measures. Traditional dorsal or plantar approaches for sesamoidectomy have shown to successfully alleviate pain but complications are noted, including hallux varus deformity, painful plantar incision, and clawing of the hallux. Additionally, the dorsal approach is technically difficult because of poor visualization, which can lead to unnecessary disruption of important plantar ligamentous structures. An alternative medial approach using a bur provides many advantages compared to traditional approaches. Methods: This was a retrospective chart review of patients undergoing sesamoidectomy using a bur with a medial approach to the sesamoid metatarsal articulation. Data collected included patient demographics, radiographic analysis, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), Visual Analog Scale (VAS), patient satisfaction, and complications. Results: In patients (10 feet) with an average age of 36.5 (range, 13-77) years were analyzed. Six patients underwent medial sesamoidectomy, three underwent lateral sesamoidectomy, and one patient underwent excision of both medial and lateral sesamoids using a bur. The average latest follow up was 11.9 months. Scores were improved from pre-operatively to most recent follow-up for VR-12 Physical (29.43 vs 53.86), FAAM ADL (48.8 vs 94.1 points), FAAM Sports (7.8 vs 87.4 points), and VAS (57.8 vs 8.6). Patient satisfaction with the treatment was 96.4%. There were zero complications or additional procedures performed. Conclusion: In this series, sesamoidectomy utilizing a medial approach with a bur provided excellent pain relief, zero complications, and significantly improved outcome scores at early follow up. The medial approach is familiar to orthopedic foot and ankle surgeons, provides adequate exposure, and eliminates the possibility of a painful plantar incision. Furthermore, this technique allows for maintenance of the plantar plate, flexor hallucis brevis (FHB) tendon, and all other ligamentous structures that attach to the sesamoids. Larger studies with longer term follow up are needed to further our knowledge on this surgical technique.

Background: Previous Level I studies show promising results for the use of a hydrogel synthetic cartilage implant (SCI) for the treatment of hallux rigidus. A recent independent retrospective review has put those results into question, however. The purpose of this article is to report patient-reported outcomes and early complications using this implant so as to add to the paucity of data in the literature regarding this implant. Methods: This was a retrospective chart review of patients undergoing hydrogel synthetic cartilage implant for the treatment of hallux rigidus from July 2017 to November 2018. Data collected included patient demographics, radiographic grading, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS), patient satisfaction, and complications. Fifty-four patients (59 feet) with an average age of 57.6 (range, 39-78) years were analyzed. The average latest follow-up was 18.9 (range, 3-31.3) months. Body mass index was 26.7 (range, 18.7-35.2). None were diabetic and 5 were smokers. Results: The mean outcome improvements were 6.5 points (VR-12 Physical), 17.2 points (FAAM ADL), 27.4 points (FAAM Sport), and 18.4 points (VAS) (P < .01 for each). Scores were significantly improved from preoperatively to most recent follow-up for FAAM ADL (71.0 vs 88.2 points), FAAM Sports (44.6 vs 72.0 points), and VAS (49.4 vs 31.0) (P < .01). Overall, 72.5% patients would definitely or probably have the operation again. Ten patients (18.5%) went on to have revision surgery. Of these, 7 patients were revised to an arthrodesis, and 1 metal hemiarthroplasty and 2 implants were removed because of infection. Conclusion: Synthetic cartilage implantation for the treatment of hallux rigidus demonstrated improved pain and outcome scores at short-term follow-up. Reoperation and conversion to fusion rates were comparable to prior studies. Level of Evidence: Level IV, case series.

Background: This study aimed to assess the preferred operative treatment for patients over the age of 60 with end-stage ankle arthritis and perspectives on total ankle replacement (TAR) among American Orthopaedic Foot & Ankle Society (AOFAS) members. Associated factors were analyzed for potential contraindications among members with different levels of experience. Method: A questionnaire containing 6 questions was designed and sent to 2056 members of the AOFAS. Responses were received from 467 orthopaedic surgeons practicing in the United States (76%), Canada (5%), and 26 other countries (20%). Participants were grouped for response comparisons according to country as well as experience level. Differences in contraindications were compared using χ2 tests or exact tests. Results: Respondents practicing in the United States and surgeons who perform 11 or more TARs per year tended to recommend operative treatments favoring TAR and displayed recognition of its increasing role ( P < .05). Overall, respondents felt that 41% of typical patients over 60 years old with end-stage arthritis would be best treated with TAR. Talus avascular necrosis, morbid obesity (body mass index >40 kg/m2), and poorly controlled diabetes with neuropathy were most recognized as the absolute contraindications to TAR. Surgeon’s experience affected the consideration of these clinical factors as contraindications. Conclusions: Total ankle replacement has a substantial and increasing role in the treatment of end-stage ankle arthritis in patients over the age of 60. Absolute and potential contraindications of the procedures were indicated from a cross-sectional survey of AOFAS members. Surgeons more experienced with total ankle replacement felt more comfortable employing it in a wider range of clinical settings. Level of Evidence: Level III, therapeutic.

In addition, the basics of ankle arthritis are covered, including alternative treatment options, along with polyethylene wear and the ever-challenging deformity correction. Finally, the future of TAA is examined to provide the reader with what may lie ahead by building on current design issues. Prostheses include: The Agility Total Ankle ProsthesisThe Scandinavian Total Ankle Replacement ProsthesisThe Salto and Salto Talaris ProsthesisThe Hintegra ProsthesisThe INBONE and INBONE II ProsthesesThe Mobility ProsthesisThe Trabecular Metal ProsthesisThe Monograph Series draws on current literature to support diagnosis, initial treatment, and management decision making for specific orthopaedic conditions.

Commentary Treatment of acute rupture of the Achilles tendon is the frequent subject of investigation and innovation. The orthopaedic literature is replete with evaluations and reports of novel suture techniques, new surgical approaches, implants for both placing and holding suture, and various rehabilitation protocols. Dr. Leppilahti and his group have delivered an interesting and useful paper that stands out in this crowded field of study. In 2009, this same group reported the results of a prospective, randomized trial comparing a group of nonaugmented surgical repairs of Achilles tendon ruptures with a group of repairs augmented using a gastrocnemius fascial flap1. After one year of follow-up, they detected no advantage of the augmented repair. They now present an evaluation of fifty-five of the original sixty patients in the earlier cohort after an average duration of follow-up of fourteen years. Even though the overall number of patients is relatively small, the duration of follow-up and level of patient retention are remarkable. Patient outcomes were evaluated with multiple criteria, including tendon elongation, a nonvalidated clinical score, and strength measurements, all of which were consistent across the time points. After fourteen years of follow-up, the augmented repair again offered no clear advantage. Interestingly, there was no significant change, for either group, in the strength measurements between the twelve-month and fourteen-year follow-up evaluations, leading the authors to conclude that Achilles tendon rupture and subsequent repair result in a permanent strength deficit in the injured leg that is static by approximately one year after surgery. The weaknesses of this study are important but not fatal. The number of subjects is small, and it is possible that a larger cohort would show a difference between treatment groups. In addition, the thirteen-year interval between evaluations provided an opportunity for confounding variables, such as additional injury, courses of physical therapy, or exposure to medications, to occur and not be reported. The clinical score and strength measurements have not been validated for this injury, but they were used at both time points and the uninjured extremity was used as a control. Finally, only one specific type of augmented repair was studied and only one postoperative rehabilitation protocol was used. Therefore, it is not clear that the results are transferable to other methods of augmentation or that they would not have been affected by a change in the postoperative protocol. The results of this study suggest that more may not be better when it comes to Achilles tendon repair. Although multiple methods of augmentation of Achilles tendon repairs have demonstrated positive results in animal and biomechanical studies, randomized clinical trials comparing these methods with simple end-to-end repair have been lacking. Future trials will be necessary to determine whether augmentations such as collagen ribbons, injectable hydrogels, and xenografts lead to improvements in clinical outcomes that offset the larger incisions, increased surgical times, and/or increased cost that they require. Before we launch ourselves into that foreboding task, however, recent research suggests that we may need to consider a more fundamental question. In 2010, Willits et al. reported the results of a multicenter, randomized trial comparing operative and nonoperative treatment for acute Achilles tendon ruptures that included an accelerated functional rehabilitation protocol2. Clinical outcomes did not differ significantly between the groups, and the operative group had more than twice as many complications. Then, in 2015, Hutchison et al. reported on the treatment of more than 270 acute Achilles tendon ruptures in a dedicated management program3. Surgery was reserved for patients in whom ultrasound evaluation had demonstrated a tendon gap of >1 cm in maximum plantar flexion. Only 6% of the patients qualified for and underwent surgical repair. There was no significant difference in the rerupture rate or patient satisfaction between the surgical and nonsurgical groups. Both of these articles cast a shadow of doubt over any assumption that surgical repair should be the gold standard of treatment for acute Achilles tendon rupture in every patient. I agree with Aronow’s commentary on the Willits paper4 that we do not have enough evidence to abandon surgical repair. We do, however, have enough evidence to ask whether we truly understand which patients will benefit from surgery and should be advised to accept its inherent risks. The division between high-level athletes and the rest of us, as was often employed in the past, seems old-fashioned and unsupported. Instead, the key factor may be the characteristics of the tear, as suggested by Hutchison et al.3; the prerupture condition of the tendon; or some other variable waiting to be discovered. If further research is able to define a group that clearly benefits from surgical repair, then perhaps we can return to the questions surrounding the nature of that repair and we might find that more is in fact better in that group of patients.

Commentary As physicians, we have always sought ways to evaluate ourselves. We strive both to know that we are providing optimum care for our patients and to satisfy ourselves that we are being the best clinicians we can be. Traditionally, a wide variety of physician-derived outcome measures have been employed to answer these questions. Unfortunately, these instruments have often failed to capture the complex relationship between success, as we define it, and satisfaction, as defined by our patients. Increasingly, patient satisfaction is assuming a more prominent position in the world of outcomes measurement. With the emergence of online rating sites such as Healthgrades, Angie’s List, and RateMDs, the public evaluation of our practice is, more than ever, a reflection of patient satisfaction. In addition, in the changing landscape of health care, patient satisfaction is becoming increasingly tied to reimbursement. Over the next year, for example, 30% of Medicare payments to hospitals will be based on a patient-satisfaction questionnaire, and patient satisfaction seems certain to play a role in pay-for-performance models. As the practice environment changes around us, we cannot dismiss the possibility that we could lose control of how our outcomes are measured. Although physician-derived instruments have, to date, failed to fully capture the factors that patients identify as important, we remain in the best position to develop the next generation of more complete measurement tools. We must apply good science to our unique knowledge and experience and take a leadership role in shaping the future of outcomes measurement. In “Age and Sex Differences Between Patient and Physician-Derived Outcome Measures in the Foot and Ankle,” Dr. Baumhauer and her colleagues demonstrate the type of important work that will begin to shape that future. Starting with an open-ended pilot question and building their survey instrument with use of the patients’ own words, they developed a survey built entirely on factors deemed important by their patients. They then administered their survey to nearly 800 patients over a three-month period to further stratify which of the factors their patients considered to be most important. They further evaluated their data by stratifying by age and sex and, finally, by comparing their rank list with two commonly used physician-derived outcome scales. I applaud Dr. Baumhauer and her colleagues for what is an important and timely contribution to the orthopaedic literature. As they would undoubtedly agree, there is further work ahead to produce a validated, widely applicable outcomes instrument. As noted in the paper, this survey was developed by, and applies most directly to, their patient population. Regional and demographic differences in the factors that patients identify as important could be substantial and, in order to best capture patient satisfaction, sex or region-specific instruments may be necessary. In addition, some work could, and should, be done to determine whether factors that foot and ankle surgeons traditionally have considered to be important may, in fact, capture factors identified by patients. As an example, this group of patients identified several factors (weakness, the need for a brace, the need for walking aids, and fear of falling) that could, at least in part, be proxies for stability, a factor that is included in physician-derived instruments. I expect that the best measurement tool, like the best surgical outcomes, will grow out of a joint effort between our patients and us. It seems certain that the demand placed on us to provide patient-satisfaction data will only increase. The face of that data and, more specifically, the collection of factors that will define patient satisfaction remain to be determined. I, and all of us in this field, will benefit greatly from the continued work of authors like Dr. Baumhauer and her colleagues, who are working to keep us at the forefront of that discussion.

Background: Open reduction and screw fixation is the current standard treatment for displaced injuries of the ankle syndesmosis. Despite reduction and stable internal fixation, however, these injuries do not uniformly have excellent outcomes. In addition, screw fixation has potential disadvantages. Materials and methods: An ongoing prospective, randomized clinical trial comparing conventional screw fixation with TightRope ® fiber wire fixation for syndesmosis injuries. The objective of this paper is also to provide an overview of the important anatomical and biomechanical issues relating to syndesmosis injuries. Results: At medium term follow-up the TightRope ® fiber wire fixation group had a statistically significant better range of motion compared to conventional screw fixation. The AOFAS ankle and hindfoot score did not show a significant difference between the two groups.