BACKGROUND:Ankle coronal plane deformity represents a complex 3-dimensional problem, and comparative data are lacking to guide treatment recommendations for optimal treatment of end-stage ankle arthritis with concomitant coronal plane deformity.METHODS:In total, 224 patients treated for end-stage ankle arthritis were enrolled in an observational trial. Of 112 patients followed more than 2 years, 48 patients (19 arthrodesis, 29 arthroplasty) had coronal plane deformity and were compared to 64 patients without coronal plane deformity (18 arthrodesis, 46 arthroplasty) defined as greater than 10 degrees of varus or valgus. The arthroplasty implants used had different internal constraints to intracomponent coronal plane tilting. Patients completed Musculoskeletal Functional Assessment (MFA) and SF-36 preoperatively and at 3, 6, 12, 24, and 36 months postoperatively. Measures included change in SF-36 and MFA, as well as compared reoperation rates and pain scales.RESULTS:For the groups with coronal plane ankle deformity, the median for the arthrodesis group was 19.0 degrees and the median for the arthroplasty group was 16.9 degrees. In the deformity cohort during the follow-up period, we had 7 major reoperations: 2 in the arthrodesis group and 5 in the arthroplasty group, all with the less constrained implant design. MFA, vitality, and social function of the SF-36 improved for all groups. Patients without preoperative deformities had greater improvement with fusion or replacement at both 2 and 3 years. There was no difference in improvement between those patients with coronal deformity who received arthroplasty vs arthrodesis.CONCLUSION:Patients with and without coronal plane deformity may benefit from ankle arthroplasty and arthrodesis, although greater improvements may be expected in those without preoperative deformity. In this study, at final follow-up of 3 years, overall we found no meaningful difference in patient-reported outcomes between the patients with preoperative coronal plane deformities whether they had a fusion or a replacement as treatment for end-stage ankle arthritis.LEVEL OF EVIDENCE:Level II, comparative study.

We reviewed thirty-eight cases of open ankle fractures that had been treated with a standard protocol: alignment and splinting of the fracture at the scene of injury if possible, antibiotics administered in the emergency room and continued for forty-eight hours, admission of the patient to the operating room as quickly as possible, copious irrigation and thorough debridement of the wound, immediate rigid anatomical internal fixation, and delayed primary closure at five days. All of the fractures united, but three patients required subsequent ankle fusion because of cartilage damage noted at the initial operation. Of the thirty-five ankles with complete follow-up, the functional result was excellent in twenty-six and fair or poor in nine.

BACKGROUND:Newer designs and techniques of total ankle arthroplasty (TAA) have challenged the assumption of ankle arthrodesis (AA) as the primary treatment for end-stage ankle arthritis. The objective of this study was to compare physical and mental function, ankle-specific function, pain intensity, and rates of revision surgery and minor complications between these 2 procedures and to explore heterogeneous treatment effects due to age, body mass index (BMI), patient sex, comorbidities, and employment on patients treated by 1 of these 2 methods. METHODS:This was a multisite prospective cohort study comparing outcomes of surgical treatment of ankle arthritis. Subjects who presented after nonoperative management had failed received either TAA or AA using standard-of-treatment care and rehabilitation. Outcomes included the Foot and Ankle Ability Measure (FAAM), Short Form-36 (SF-36) Physical and Mental Component Summary (PCS and MCS) scores, pain, ankle-related adverse events, and treatment success. RESULTS:Five hundred and seventeen participants underwent surgery and completed a baseline assessment. At 24 months, the mean improvement in FAAM activities of daily living (ADL) and SF-36 PCS scores was significantly greater in the TAA group than in the AA group, with a difference between groups of 9 points (95% confidence interval [CI] = 3, 15) and 4 points (95% CI = 1, 7), respectively. The crude incidence risks of revision surgery and complications were greater in the AA group; however, these differences were no longer significant after adjusting for age, sex, BMI, and Functional Comorbidity Index (FCI). The treatment success rate was greater after TAA than after AA for those with an FCI of 4 (80% versus 62%) and not fully employed (81% versus 58%) but similar for those with an FCI score of 2 (81% versus 77%) and full-time employment (79% versus 78%). CONCLUSIONS:At 2-year follow-up, both AA and TAA were effective. Improvement in several patient-reported outcomes was greater after TAA than after AA, without a significant difference in the rates of revision surgery and complications. LEVEL OF EVIDENCE:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Category: Ankle Arthritis Introduction/Purpose: We used step counts as objective measures of activity as a compliment to patient self-reported outcomes in treatment of ankle arthritis to validate success or failure of treatment. Methods: 234 patients who were treated with ankle arthrodesis or ankle replacement wore step activity monitors before treatment and after treatment at 6 months, 12 months, 24 months and 36 months. Total steps taken as well as low, medium and high activity, sustained activity, and an activity index were measured in each group. In addition, step activity was compared with the subjects’ self-reported outcome using the MFA and SF-36. We measured change from baseline and compared treatment type. Linear mixed-effects regression analysis was used to test for improvement in step activity (the dependent variables) across follow-up (the fixed effect, modeled as 4 dummy variables representing differences from pre-op at 6, 12, 24 and 36 months), with fixed covariates age, sex, body mass index (BMI) and surgical treatment. Results: Both treatment groups improved significantly. Objective and PROM were not parallel. While PROM plateaued at 6 months, steps continued to increase at 36 months. Step counts increases did correlate with improving PROM however. Patients undergoing arthrodesis had slower improvement than arthroplasty patients with greater differences in the early stages of recovery (i.e., 6 and 12-month post-op) than at 36 months where improvements were similar across groups. (See table 2 for data). The trajectory of recovery was different but there were no significant differences in improvement by surgery procedure. Conclusion: Patients increase the number and the intensity of steps after treatment. Improvement after arthrodesis and ankle replacement follow different trajectories. For step totals, high intensity steps and the sustained activity metrics, arthroplasty patients showed more improvement than arthrodesis patients early in recovery. Step data are consistent with patient reported outcomes but do not parallel them. Unlike PROM which improve dramatically in the first six months then plateau, step activity demonstrated mild or no improvement at 6 months but later had improvement that increased gradually across follow-up out to three years. Objective outcome measures add value to measurement of treatment outcomes.

Background: This study summarized the frequency and functional impact of adverse events (AEs) that occur after surgery for end-stage ankle arthritis (ESAA) to inform decision making. Methods: This was a multisite prospective cohort study to compare ankle arthroplasty to ankle arthrodesis in the treatment of ESAA among 6 participating sites. We compared the risk and impact of nonankle AEs and ankle-specific AEs versus no AEs controlling for potential confounding factors, including operative procedure using multinomial logistic regression. We estimated differences in postoperative functional outcomes by AE occurrence using linear mixed effects regression. Among 517 patients who had surgery for ankle arthritis and completed the full baseline assessment, follow-up scores were available in 494 (95%) patients. Results: There were a total of 628 reported AEs (477 in the arthroplasty group and 151 in the arthrodesis group). These occurred in 261 (63%) arthroplasty patients and 67 (65%) arthrodesis patients. There were 50 (8%) ankle-specific AEs. The risk of an ankle-specific AE was slightly higher in the arthrodesis group versus the arthroplasty group, odds ratio (OR) 1.84, 95% confidence interval (CI, 0.85, 3.98). The OR for the risk of non-ankle-specific AE versus no AE was 0.96, 95% CI (0.57, 1.61) for those receiving arthrodesis compared to arthroplasty. Compared to patients with no AEs, those experiencing ankle-specific AEs had significantly less improvement in Foot and Ankle Ability Measure Sports and activities of daily living (ADL) subscores and worst pain outcomes; however, both groups improved significantly in all measures except mental health. Conclusions: Ankle-specific AEs were infrequent and only weakly associated with operative procedure. Although patients improved in all functional outcomes except mental health, regardless of AE occurrence, ankle-specific AEs negatively impacted patient improvement compared to those with no AEs or a nonankle AE. The logistical effort and cost of tracking nonankle AEs does not seem to be justified. Level of Evidence: Level II, prospective comparative study.

BACKGROUND:We analyzed self-reported outcomes in a prospective cohort of patients treated with ankle arthrodesis or total ankle replacement (TAR) during a time of transition from older to newer-generation TAR implants. METHODS:We performed a prospective cohort study comparing outcomes in 273 consecutive patients treated for ankle arthritis with arthrodesis or TAR between 2005 and 2011. Adult patients with end-stage ankle arthritis who were able to walk and willing and able to respond to surveys were included in the study. Patients were excluded when they had another lower-limb problem that might affect walking. At baseline and at 6, 12, 24, and 36-month follow-up visits, participants completed a pain score, a Musculoskeletal Function Assessment (MFA), and a Short Form-36 (SF-36) survey. RESULTS:There was significant mean improvement in most outcomes after surgery regardless of procedure. In general, the greatest improvement occurred during the first 6 months of follow-up. Linear mixed-effects regression adjusted for differences at baseline in age, body mass index (BMI), and surgery type showed that at 6 months the scores were improved by a mean (and standard error) of 12.6 ± 0.7 (33%) on the MFA, 22.0 ± 1.4 (56%) on the SF-36 Physical Functioning (PF) scale, 32.4 ± 1.6 (93%) on the SF-36 Bodily Pain (BP) scale, and 4.0 ± 0.2 (63%) on the pain rating scale. The mean improvements in the MFA and SF-36 PF scores over the 3-year follow-up period were significantly better after the TARs than after the arthrodeses, with differences between the 2 groups of 3.6 ± 1.6 (p = 0.023) and 7.5 ± 2.9 (p = 0.0098), respectively. The differences between the 2 groups were slightly greater when only the newer TAR devices were compared with the arthrodeses (MFA = 3.8 ± 1.8 [p = 0.031], SF-36 PF = 8.8 ± 3.3 [p = 0.0074], SF-36 BP = 7.3 ± 3.6 [p = 0.045], and pain score = 0.8 ± 0.4 [p = 0.038]). CONCLUSIONS:Patients reported improved comfort and function after both surgical treatments. The average improvement in the MFA and SF-36 PF scores was better after TAR than after arthrodesis, particularly when the TAR had been done with later-generation implants. Younger patients had greater functional improvements than older patients. LEVEL OF EVIDENCE:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

From the Departments of Surgery and Orthopedic Surgery, Harborview Medical Center, Seattle, Washington. Address for reprints: Kaj Johansen, MD, PhD, 600 Broadway #112, Seattle, WA 98122; email: [email protected].

Arthritis is a chronic, debilitating disease affecting one in six people in the United States annually. One of the most promising surgical treatments is total joint replacement. After decades of development, some joint replacement (arthroplasty) systems such as the hip and knee enjoy high success rates while others, particularly newer ones for the ankle, have disappointing survival rates. The goal of this study was to investigate, develop, and test a methodology to assess implant osteointegration, specifically for the talar component of a total ankle prosthesis. A vibrometry technique using Doppler ultrasound was developed to non-invasively determine osteointegration clinically. This methodology was evaluated via preliminary experimentation, along with another validation methodology, to access whether design criteria have been met in order to initiate a clinical study of the technique. Bench-top and cadaveric testing demonstrated that the Doppler ultrasound technique could distinguish the level of osteointegration between loose and fixed implant components. The laser vibrometry technique, used for the validation of the ultrasound technique intraoperatively, was also shown to be functional and indicative of the ultrasound technique's testing results. This methodology can provide a much needed tool to determine the integration of implants non-invasively in the clinical and surgical setting, thus allowing each patient's rehabilitation program to be monitored and tailored to maximize the osteointegration and survival rate of their total joint replacement.

BACKGROUND:Reported ankle fusion healing times vary between 7 to 72 weeks. High non-union and delayed union rates have led to an increased use of bone graft and bone graft substitutes. It was our goal to see if addition of a bone slurry could accelerate the rate of healing. MATERIALS AND METHODS:We compared the radiographic healing after ankle arthrodesis in two groups of patients treated over 3 years with and without a 'bone slurry.' In group one, a slurry of bone particles was generated with a low-speed burr and left in the joint before internal fixation. Group two had similar fixation but no bone slurry. Two reviewers, blinded to the presence or absence of slurry, studied magnified digital radiographs at 6 and 12 weeks. The percentage of the joint bridged by bone was recorded for each and the groups were averaged. Groups were compared using Wilcoxon rank sum. RESULTS:There were 32 patients in group one and 22 in group two. Groups were similar in age, gender and diagnosis. At 6 weeks, group one had 94.1% bridging bone, as measured on AP radiographs. Group two had 76.4% bridging bone. (Wilcoxon rank sum test p = 0.0099). At 12 weeks, group one had 98.1% bridging bone and group two had 85.7% bridging bone (Wilcoxon rank sum test p = 0.026). CONCLUSION:Use of a low-speed burr to generate a "bone paste'' from the local bone surfaces was associated with an increased percentage of healed bone surface at 6 and 12 weeks in patients undergoing ankle arthrodesis.

Fixation for ankle arthrodesis often consists of compression screws. A technique using a mechanically sound configuration for stable fixation is presented. The spatial orientation of the screws is in the form of a tripod that provides circumferential compression across the fusion mass. The sequence of delivery of the hardware minimizes the likelihood of intraosseous screw collision. The strategic placement of the screws also prevents stress concentration that may lead to stress risers in the distal tibia.

For the past 100 years or so, the approach foot and ankle surgeons have taken too often has been to make compensating deformities or to do dysfunctional fusions. There is now a much improved understanding of the foot and attempt to restore normal anatomy, alignment, muscle balance, and function whenever possible. In a way, clinicians try to complete the evolutionary goal for the ideal foot for a biped. The first metatarsal is the key structure in this effort.

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.

Principles of Surgery in the Foot and AnkleAppendix A: Surgical Instruments Used in Foot Surgery I. ACUTE TRAUMA AND FRACTURE SURGERY 1. Functional Anatomy3. Heel Cord Injuries4. Acute Ankle Injuries5. Acute Fractures in the Foot6. Dislocations in the Foot II. RECONSTRUCTIVE SURGERY IN THE FOOT AND ANKLE7. Evaluation and Education of the Patient8. Nonunions, Malunions, and Avascular Necrosis9. Posttraumatic and Degenerative Problems in the Joints10. Posttraumatic and Degenerative Problems in the Muscles and Tendons11. Progressive Symptomatic Flatfoot (Lateral Peritalar Subluxation)12. The Cavovarus Foot (Medial Peritalar Subluxation)13. The Dysfunctional Forefoot14. Other Neuromuscular Conditions15. Rheumatoid Arthritis and Other Inflammatory Arthritides16. Diabetic Foot Problems17. Revisions of Previous Surgery18. Amputation Techniques III. ATLAS OF STANDARD OPERATIVE TECHNIQUES19. Arthrodesis Techniques20. Osteotomy Techniques21. Tendon Transfers and Muscle-Balancing Techniques22. Capsulorrhaphy and Capsulotomy Techniques23. Miscellaneous TechniquesInde

This article describes one surgeon's experience in pediatric orthopedic surgery. His experiences treating cavovarus/supinated foot deformities and external tibial torsion are described.

We report a series of patients who presented with post-traumatic osteonecrosis of the lateral tibial plafond. Nine patients were identified with evidence of osteonecrosis limited to the lateral tibial plafond. All of them were seriously impaired with a mean valgus collapse of the ankle joint of 15.3°. Seven patients had a Weber C open medial fracture-dislocation, and two had a closed Weber C fracture-dislocation. This series confirms that post-traumatic osteonerosis of the lateral tibial plafond is associated with Weber C fracture-dislocation. It evolves into a valgus deformity of the ankle due to collapse of the lateral tibial plafond. The prognosis is poor and required further reconstructive surgery in all cases.

The modified Jones procedure is the standard surgical procedure for clawed hallux, although the deformity may be caused by overpull of 1 of 3 different muscles. In this technique article we describe the technique of an alternative procedure for the surgical correction of clawed hallux: the flexor hallucis longus (FHL) tendon transfer. The transfer is performed by drawing two thirds of the FHL tendon up through a drill hole in the proximal phalanx and then suturing it medially back to the remaining third of the FHL tendon. Patients are placed in a splint for 2 weeks, followed by weight bearing as tolerated in a camboot (CAM walker boot) for 4 weeks. In a review of 19 patients (22 feet) following the procedure, all were fully or somewhat satisfied. No patients were dissatisfied. All preoperative ulcers healed. It has been shown that clawed hallux can result from excessive motor function in 1 of 3 muscles: FHL, peroneus longus (PL), and extensor hallucis longus (EHL). We suggest that transfer of the FHL tendon is an effective alternative surgical procedure for correction of clawed hallux with good patient satisfaction.

BACKGROUND Primary tarsometatarsal arthrosis is relatively uncommon. The etiology of osteoarthritis in the foot is poorly understood, and it is possible that mechanical or anatomic factors play a role. METHODS We compared the relative length of the metatarsals in patients with idiopathic arthrosis of the midfoot with that in a group of controls without arthrosis. We analyzed the radiographs of all patients who had had an arthrodesis of the first, second, and third tarsometatarsal joints to treat arthrosis during a three-year period at a tertiary teaching hospital. We excluded patients with a history of inflammatory arthritis, trauma, or Charcot arthropathy. Nine patients (fifteen feet), seven women and two men with an average age of 64.2 years, met the inclusion criteria. We compared them with a control group consisting of the uninjured feet of patients with an acute traumatic injury to the hindfoot and the feet of volunteers with no foot problems. We measured the first, second, and fourth metatarsal lengths and the intermetatarsal angles on weight-bearing anteroposterior radiographs. We also measured the length of the first metatarsal relative to the long axis of the second metatarsal to define the functional first metatarsal length. The ratios of metatarsal lengths and the ratios of functional lengths were used for analysis to minimize differences in foot size and differences caused by radiographic magnification. Statistical comparisons between groups were then carried out. RESULTS In the study group, the length of the first metatarsal was, on the average, 77.0% of the length of the second metatarsal, whereas, in the control group, the first metatarsal length was an average of 82.0% of the second metatarsal length. The functional length of the second metatarsal was, on the average, 18.6% greater than that of the first metatarsal in the study group and only an average of 4.1% greater than that of the first metatarsal in the control group. Both differences were significant (p < 0.0004 and p < 0.0001, respectively). CONCLUSIONS Patients with midfoot arthrosis had a different ratio of the first to the second metatarsal length than did a similarly aged cohort without midfoot arthrosis. The patients had a relatively short first metatarsal or a relatively long second metatarsal, or both. Midfoot arthrosis may have a mechanical etiology. Recognition of risk factors is the first step in developing prevention strategies.

Gastrocnemius tightness is commonly found in patients with foot/ankle dysfunction. Gastrocnemius lengthening or recession is commonly performed as part of the treatment for plantar fasciitis, hallux valgus, symptomatic adult acquired flatfoot, metatarsalgia, and/or diabetic foot ulcers. We describe a technique using a vaginal speculum that allows safe completion of the procedure through a very limited incision.