Category: Ankle Arthritis Introduction/Purpose: Addressing coronal plane deformity when performing a total ankle arthroplasty (TAA) remains a topic of controversy. While surgeons have become bolder in correcting deformity, long-term follow-up is sparse regarding maintenance of correction and viability of the prosthesis. The purpose of this study is to assess the long-term follow up of the correction of moderate to severe coronal plane deformity with the use of a mobile bearing prosthesis. Methods: Out of a consecutive series of 130 patients who underwent TAA between 2000 and 2009, 43 patients (44 ankles) had at least 100 of tibiotalar coronal plane deformity, with 25 having between 100 and 200 of deformity and 18 having greater than 200. Average age at time of the index surgery was 66 yrs (range 41-79). Initial deformity was 17.90 (range 10-290) in the entire cohort. All patients underwent intraarticular deformity correction with intraoperative soft-tissue balancing as indicated utilizing the STAR prosthesis. Patients requiring realignment osteotomies were performed in a staged fashion prior to undergoing TAA. Results: Seven patients (16%) were available for long-term follow up (avg 13 yrs; range 9-16 yrs) with retention of the original prosthesis, two of which had greater than 200 of initial deformity. Average final tibiotalar deformity was 4.90, with a mean correction of 130(p=0.0001). No additional procedures related to the prosthesis were performed. Eleven patients (12 ankles) were deceased at the time of the study due to unrelated conditions. Of the original cohort, five were deemed failures (2 converted to arthrodesis; 2 underwent component revision; 1 polyethylene fracture) and excluded from long-term follow up. The remaining 20 patients were lost to follow-up, had declined or were unable to participate due to health status. Conclusion: While the low follow-up rate limits the overall generalizability of the results, enduring correction of moderate and severe coronal plane deformity with a mobile bearing prosthesis can be achieved in a cohort of patients traditionally regarded as high-risk. One must be cautious when discussing with patients the utilization of TAA in the setting of moderate and severe coronal plane deformity given the risk of failure. However, provided a well-balanced ankle can be achieved intraoperatively, long-term mobile bearing prosthesis survivorship is achievable.

Background: Over the past decade, total ankle arthroplasty (TAA) has become a mainstay in the treatment of end-stage ankle arthritis. Currently in its fourth generation, the Scandanavian Total Ankle Replacement (STAR) is the only 3-piece mobile bearing ankle prosthesis available in the United States. Our current study reports implant survivorship at 15 years and patient outcomes for a subset of these survivors available for study. Methods: Eighty-four TAAs were performed between 1998 and 2000. Metal component survivorship at 15 years was calculated with a Kaplan-Meier curve. Twenty-four (29%) of 84 patients were available for participation with a minimum 15-year follow-up. Any radiographic changes were documented. All additional procedures and complications were recorded. Clinical findings, self-reported performance and pain evaluations, and AOFAS ankle/hindfoot scores were noted. Results: Metal implant survival was 73% at 15 years. Of the 24 patients available for clinical evaluation, 18 of 24 patients (70.7%) had no change in prosthetic alignment from the immediate postoperative radiograph. Only 1 subtalar fusion was required for symptomatic adjacent joint arthritis. Three patients sustained a broken polyethylene component. AOFAS scores improved from an average of 39.6 points preoperatively, to an average of 71.6. More than half (52.4%) of patients with retained implants required an additional surgical procedure; 3 required 2 additional procedures. The average time to subsequent procedure was 10.2 years. Conclusion: Our small cohort demonstrated STAR ankles with retention at 9 years were highly likely to survive to 15 years, and patients continued to have significant improvement in pain relief and minimal decrease in function. At 15 years from TAA, metal survivorship was 73%. As with all ankle replacements, supplementary procedures were common. Level of Evidence: Level IV, case series.

Category: Ankle Arthritis. Introduction/Purpose: Over the past decade, total ankle arthroplasty (TAA) has become a mainstay in the treatment of end stage ankle arthritis. Currently in its fourth generation, the Scandanavian Total Ankle Replacement (STAR™) is the only 3-piece mobile bearing design available in the United States. Current studies show 89-94% survivorship of the STAR™ at 9-12 years follow-up. We report patient outcomes at a minimum of 15 years. Methods: 24 patients from the initial U.S. STAR™ FDA trial who had undergone no metal revision at 10 year follow-up were available for participation. Radiographic examinations were performed for all patients. Changes in prosthetic position, coronal and sagittal plane alignment, osteolysis, adjacent joint arthritis, and heterotopic ossification were documented. Clinical examinations were performed for 14 patients. Clinical findings, AOFAS ankle/hindfoot scores and SF-36 scores were recorded. All secondary procedures and complications were noted. Implant failure was defined as revision or explant of either the tibial or talar component. Results: 87.5% (21/24) of participants had metal survivorship at a minimum of 15 years. Two patients required revision surgery for aseptic loosening and one required a tibiotalocalcaneal fusion for a progressive coronal plane deformity. Of the 21 patients with metal survivorship, the AOFAS ankle/hindfoot rating scale improved from an average of 39.6 points preoperatively, to an average of 71.6 points at latest follow up (range 42-89). The average SF-36 score was 49.0. Postoperative range of motion averaged 17 degrees (range 5-30°). Adjacent joint arthritis was seen radiographically in 5 patients (23.8%), one which required a subtalar fusion. Two patients required exchange for a broken polyethylene spacer. 11/21 (52.4%) of patients required an additional surgical procedure, 3 of whom required two additional procedures. Average time to subsequent procedure was 10.2 years. Conclusion: Our data shows that if the STAR™ ankle has survived for 10 years, it will likely survive for 15 years. On the whole, patients reported good subjective outcomes, maintaining a near 30 point improvement in AOFAS scores. Revisions after 10 years were seen for aseptic loosening and coronal plane deformity. Patients should be counseled that it is common to have a subsequent procedure, which averaged 10 years postoperative from our experience. Further advancement in instrumentation, polyethylene wear characteristics, and revision implants will likely be the next stage in the advancement of TAA.

Dear Editor: We recently read the article entitled “Registry Data Trends of Total Ankle Replacement Use,” by Drs. Roukis and Prissel (1), which appeared in the November/December 2013 issue of your journal. We feel the article misrepresents the history and use of the STAR Prosthesis . First, the authors failed to include all of the current and relevant data required to accurately portray the data trends of total ankle replacements. Second, they failed to distinguish between the STAR Prosthesis in the Swedish registry and the STAR Prosthesis available for use in the United States and Canada, leading to a confusing picture about the implant’s use. The most notable omission is “STAR ankle: long-term results” by Mann et al (2), published in May 2011, which reported on 10-year results of its use in the United States. We understand that Roukis and Prissel’s reviewwas based on registry data that did not include our results, but the article is not even mentioned in the discussion section. Thus, their review gives a false picture of the actual usage trends and revision rates associated with the implant. It is a gross oversight on both the part of the authors and the reviewers. Registry data is good historically, but lacks a mechanism to factor in improvements in an implant’s design. For example, some data could be based on the use of an outdated prosthesis, and does not accurately reflect current use trends. This is the case with the STAR Prosthesis , which originally had a single hydroxyapatite (HA) coating over a smooth CoCr surface. The Link Company manufactured this version of the product until 1999, and its use continued for an additional period. Hintermann’s first HINTEGRA prostheses were also HA coated on a smooth CoCr substrate, and these had similar failure rates. The loosening observed was a result of the first generation press-fit HA having an inferior surface for bone adhesion once the HA was resorbed. Link subsequently launched a second version of an HA coated press-fit implant with a rough titanium plasma spray coating under the HA for proper bone adhesion after HA resorption. This is the version of the STAR implant that is currently used in outside the United States, although is not the prosthesis available in the United States. The Norwegian Arthroplasty Registry, as referenced by Dr. Roukis in his letter demonstrated that this newer double-coated version of the STAR had better results specific to the incidence of prosthetic loosening. In the article by Hintermann et al (3), 100% of the STAR ankle revisions he performed were on the discontinued single HA coated prostheses. This was similar to the 23 of 51 HINTEGRA

Ankle fusion has long been the standard of treatment for end-stage ankle arthritis, and a successful arthroplasty has been a long sought alternative. It is a motion sparing procedure and may greatly reduce the potential for adjacent level degeneration as seen with arthrodesis. The typical candidate for arthroplasty is a healthy low demand patient, although the indications are widening as the success of the procedure has increased. Nevertheless, it is not fail-safe, technical expertise and experience are necessary to achieve a successful result. We have been treating ankle arthritis with the Scandinavian Total Ankle Replacement (STAR) ankle replacement prosthesis for over ten years. We believe that arthroplasty will surpass arthrodesis as the standard of care for severe ankle arthritis.

Background: Prior studies have demonstrated a correlation between the degree of preoperative coronal plane deformity and failure following ankle replacement. We reviewed all of our patients who underwent ankle replacement utilizing the STAR™ prosthesis from 2000 to 2009 to evaluate the outcome of those with moderate (10 to 19 degrees) and severe (20 degrees or greater) coronal plane deformity. Materials and Methods: Out of 130 consecutive patients, 43 patients had at least 10 degrees of preoperative coronal plane deformity. Twenty-five ankles had 10 to 19 degrees degrees of deformity and 18 ankles had 20 degrees or greater deformity. Average age was 66 years. Average length of followup was 41 (range, 12 to 98) months. Results: Average talar preoperative deformity was 17.9 (range, 10 to 29) degrees, while average initial talar postoperative deformity was 3.5 (range, 0 to 12) degrees. Average final talar postoperative deformity was 4.7 (range, 0 to 14) degrees. Preoperative and final correction of deformity was statistically significant ( p < 0.01), but there was no significant difference between initial and final postoperative correction. Overall, recurrence of the preoperative coronal plane deformity occurred in six of 43 patients (14%). All three patients who had deformities over 25 degrees developed recurrences. Correction of the coronal plane deformities was achieved by using intraoperative soft-tissue balancing, including deltoid ligament release in 12 patients and lateral ligament reconstruction in one patient. Deltoid ligament release was found to be necessary for all patients with greater than 18 degrees of varus plane deformity. Conclusion: Correction of moderate to severe coronal plane deformity with the STAR™ prosthesis was achievable with only soft-tissue balancing procedures with predictable results especially for deformities less than 25 degrees. Level of Evidence: IV, Retrospective Case Series

Background: There has been a resurgence of interest in total ankle replacement (TAR) due to improved results with newer prostheses. However, long-term survivorship data has been limited. The STAR™ Ankle prosthesis is the first three-part prosthesis approved for use in the United States. Materials and Methods: Eighty-four total ankle replacements were performed in 80 patients using the STAR™ Ankle prosthesis and followed prospectively. Postoperatively, patients were evaluated with the AOFAS score for pain and function, and serial radiographs were evaluated for stability and alignment of the prosthesis. Implant failure, secondary procedures, and complications were recorded. Results: Ninety-one percent of prostheses remain implanted at an average followup of 9.1 years. The probability of implant survival was 96% at 5 years and 90% at 10 years. An average 39-point improvement in the AOFAS ankle-hindfoot score was noted, from a mean of 43 to a mean of 82 points. We noted a statistically significant increase in both average pain and function sub-scores. Postoperative range of motion averaged 4.5 degrees of dorsiflexion and 35 degrees of plantarflexion. Ninety-two percent of the patients were satisfied with their outcome. Ten patients (13%) developed concerning osteolytic lesions. Change in prosthetic alignment and adjacent joint arthritis were similar to previous reports. We report 21 complications, which included 14 additional surgical procedures. Conclusion: The first U.S. prospective long-term survivorship data with the STAR™ Ankle prosthesis found it to be an excellent long-term option for the treatment of ankle arthritis. Level of Evidence: IV, Case Series

Background: Mobile-bearing ankle replacements have become popular outside of the United States over the past two decades. The goal of the present study was to perform a prospective evaluation of the safety and efficacy of a mobile-bearing prosthesis to treat end stage ankle arthritis. We report the results of three separate cohorts of patients: a group of Scandanavian Total Ankle Replacement (STAR) patients and a control group of ankle fusion patients (the Pivotal Study Groups) and another group of STAR total ankle patients (Continued Access Group) whose surgery was performed following the completion of enrollment in the Pivotal Study. Materials and Methods: The Pivotal Study design was a non-inferiority study using ankle fusion as the control. A non-randomized multi-centered design with concurrent fusion controls was used. We report the initial perioperative findings up to 24 months following surgery. For an individual patient to be considered an overall success, all of the following criteria needed to be met: a) a 40-point improvement in total Buechel-Pappas ankle score, b) no device failures, revisions, or removals, c) radiographic success, and d) no major complications. In the Pivotal Study (9/00 to 12/01), 158 ankle replacement and 66 arthrodesis procedures were performed; in the Continued Access Study (4/02 to 10/06), 448 ankle replacements were performed, of which 416 were at minimum 24 months post-surgery at time of the database closure. Results: Major complications and need for secondary surgical intervention were more common in the Pivotal Study arthroplasty group than the Pivotal Study ankle fusion group. In the Continued Access Group, secondary procedures performed on these arthroplasty patients decreased by half when compared with the Pivotal Arthroplasty Group. When the Pivotal Groups were compared, treatment efficacy was higher for the ankle replacement group due to improvement in functional scores. Pain relief was equivalent between fusion and replacement patients. The hypothesis of non-inferiority of ankle replacement was met for overall patient success. Conclusion: By 24 months, ankles treated with STAR ankle replacement (in both the Pivotal and Continued Access Groups) had better function and equivalent pain relief as ankles treated with fusion. Level of Evidence: II, Prospective Controlled Comparative Surgical Trial

Total ankle arthroplasty was developed to reduce pain and retain motion of the ankle joint in patients with osteoarthritis. The ankle joint has unique, complex anatomic and biomechanical characteristics that must be considered in a successful total ankle arthroplasty prosthesis. Initial designs from the 1960s to the 1970s had many failures. Current designs use two or three components, and recent reports on total ankle arthroplasty show consistent good to excellent intermediate clinical results, with up to 90% decreased pain and high patient satisfaction. The follow-up time of these studies is limited, however, and long-term studies with 10- to 15- year follow-ups are needed. Also, a wide variety of complications has been reported, including osteomyelitis and osteolysis. To limit the number of complications and improve clinical outcome of total ankle arthroplasty, careful patient selection and surgeon experience are important.

Background: Autogenous bone graft from the distal tibia provides cancellous bone graft for foot and ankle operations, and it has osteogenic and osteoconductive properties. The site is in close proximity to the foot and ankle, and published retrospective studies show low morbidity from the procedure. Methods: One-hundred autografts were obtained from the distal tibia between 2000 and 2003. In four cases the distal tibial bone graft harvest resulted in a stress fracture. There were three women and one man. Results: The average time of diagnosis of the stress fracture from the operation was 1.8 months. All stress fractures healed with a short course (average 2.4 months) of cast immobilization. Conclusions: This study demonstrated that a stress fracture from the donor site of autogenous bone graft of the distal tibia occurs and can be successfully treated nonoperatively.

Introduction and Aims: Many patients having total ankle replacement require correction of a coronal plane deformity. This study examines the pre-operative characteristics and short-term results of patients with a coronal plane deformity having total ankle replacement. It tests the hypotheses that the pre-operative deformity will be corrected and maintained at two years. Method: Eighteen of 86 patients who underwent Scandinavian Total Ankle Replacement between February 1998 and April 2001 had a pre-operative coronal plane deformity ≥ 10° and at least two-year follow-up. The goal of intraoperative alignment was to place all components perpendicular to the plumb line of the body, and to have this position maintained by appropriate ligament balancing. The mean patient age was 62.2±13.2 years. The etiology of arthrosis included eight post-traumatic, five idiopathic, one rheumatoid, and four other. There were 10 men and eight women. Valgus measurements are > 90°. Congruent ankles have pre-operative talar and tibial alignment within 10 degrees. Results: Ligament balancing consisting of lateral ligament reconstruction was performed in six patients and superficial deltoid release was performed in three patients. The eight ankles with pre-operative varus-congruent alignment improved both the talar and tibial alignment immediately post-operatively and at two-year follow-up (p Ankles with an incongruent pre-operative deformity had a greater loss of correction of the talus between the immediate pre-operative period and two-year follow-up than patients with a congruent pre-operative deformity (3.9±2.8 degrees vs. 1.3±1.0 degrees loss of correction, p Conclusion: In patients with a pre-operative coronal plane deformity ≥ 10 degrees, alignment after ankle replacement improves toward a neutral axis in the postoperative period and at two-year follow-up. Ankles with incongruent pre-operative deformities have a greater loss of correction over the first two years than ankles with congruent pre-operative deformities.

The treatment of coronal plane deformity during total ankle arthroplasty is understood poorly. This study tests the hypotheses that preoperative coronal plane malalignment and incongruence of the ankle can be corrected and maintained for 2 years with total ankle replacement, and that factors can be identified that place ankles at risk of having progressive edge-loading develop. Of 86 consecutive patients who had total ankle replacement, 35 had preoperative coronal plane alignment > or =10 degrees. Lateral ligament reconstruction was done in seven patients and superficial deltoid release was done in four patients at the time of ankle replacement. Ankles with talar and tibial deformities improved talar and tibial alignment toward a neutral weightbearing axis postoperatively. Ankles with only a talar deformity improved the talar alignment toward a neutral weightbearing axis postoperatively. No changes in alignment were shown during the subsequent 2 years. Postoperative ankle articulations were congruent. Patients with preoperative incongruent joints are 10 times more likely to have progressive edge-loading develop than patients with congruent joints. Surgeons must be attentive to coronal plane alignment during and after ankle replacement. Longer followup is needed to assess the longevity of the correction and the impact of minor malalignment on implant wear.

The bunionette deformity results in pain about the lateral and/or the plantar aspect of the fifth metatarsal head. It is important to carefully assess the deformity anatomically in order to select the proper surgical procedure to correct this painful affliction. Knowledge of pathoanatomy and certain surgical procedures can be used to correct the deformity.

Background:Recent studies suggest the perioperative complication rate of total ankle arthroplasty decreases as a surgeon becomes familiar with the procedure. This study tests the hypothesis that the number of perioperative adverse events will decrease as surgeon experience with total ankle replacement increases.Methods:Ten surgeons completed retrospective chart and radiographic reviews of their first 10 cases as well as 10 subsequent cases of the Scandinavian Total Ankle Replacement (STAR). Not all surgeons completed 10 cases within the allotted time periods, and two patients were excluded for less than 3-month follow-up, resulting in 187 cases for review. The surgeons performed an average of 12.8 (range, 0–61) STARs between these two time periods. Cases were divided into Early Group if they were among the first five STARs a surgeon performed and Late Group if they were after the first five.Results:The average patient age was 60.4 ± 12.8 years. The etiology of arthrosis included 96 (51%) of 187 posttraumatic, 49 (26%) idiopathic, and 33 (18%) rheumatoid. Patients in Early Group had a 3.1 times greater chance of having a perioperative adverse event (95% CI 1.6–6.1, p < .001), and a 3.2 times greater chance of having a perioperative wound problem (95% CI 1.5–6.8, p = .002) than patients in Late Group. Patients in Early Group took 1 week longer to heal their wounds than patients in Late Group (4.5 vs. 3.5 weeks, p = .046).Conclusions:This study shows a decrease in the perioperative adverse event rate commensurate with surgeon experience with STAR. In contrast to other reports, this study was unable to show a decrease in the number of perioperative fractures with increasing surgeon experience. This information is important for planning how best to train surgeons new to total ankle replacement and for patient counseling regarding the potential risks of the procedure.

Rheumatoid arthritis is a systemic disease that often affects the foot and ankle. Approximately 20% of patients with rheumatoid arthritis present initially with foot and ankle symptoms, and most patients will eventually develop foot and ankle symptoms. Although early intervention includes conservative measures, operative treatment often is needed to adequately treat rheumatoid patients. Treatment of foot and ankle problems in patients with rheumatoid arthritis is directed to maintaining ambulatory capacity. This article reviews the clinical presentation, evaluation, and treatment of rheumatoid arthritis affecting the foot and ankle.

Keratotic lesions on the plantar aspect of the foot develop beneath an osseous prominence and can result in substantial disability. This occurs because, during normal gait, the metatarsal head area is subjected to more prolonged stress than any other area on the plantar aspect of the foot. In the treatment of this disorder, it is imperative to establish the etiology, among many possibilities, and then address the specific pathology accordingly.