Category: Ankle Introduction/Purpose: Total ankle arthroplasty (TAA) has shown durable improvements in pain, function, and quality of life. Patient factors could affect intermediate to long-term outcomes after total ankle arthroplasty, and the impact of common medical comorbidities has not been fully characterized. The purpose of this study was to determine if common preoperative patient comorbidities had an effect on patient outcomes. Methods: Patients undergoing TAA between 1/2007 and 12/2016 were enrolled into a prospective study at a single academic center. Patients completed the following outcome measures before surgery and then in follow-up: AOFAS Hindfoot score, 36-item Short Form Survey (SF-36), Foot and Ankle Disability Index (FADI), and the Short Musculoskeletal Function Assessment (SMFA) score. Patient and operative factors along with pre-operative Charlson-Deyo and Elixhauser comorbidities with at least 10% prevalence across the entire population were assessed for association with changes in outcomes from pre-operative to the patient’s most recent follow-up. A minimum of 2 years of follow-up was required. Factors that met a significance threshold of p<0.05 in univariate analyses were incorporated into multivariable outcome models. Results: A total of 538 patients with an average follow-up of 4.3 years (range, 2 to 10 years) were included. While patients had significantly improved pain and function across all outcomes, smoking was associated with smaller improvements in AOFAS hindfoot score, AOFAS hindfoot function subscale, SF-36 physical summary scale, SF-36 total scale, and SMFA function scale. Prior foot and ankle surgery was associated with smaller improvement in AOFAS hindfoot pain subscale as well as VAS pain. Rheumatoid arthritis was associated with smaller improvement in SF-36 total and physical summary subscale scores while obesity was associated with smaller improvement in the FADI. Smoking had the largest impact on results, and produced a moderate effect size. All other variables had trivial to small effect sizes. Conclusion: While patient outcomes improved significantly after TAR at intermediate duration follow-up, smoking, prior surgery, rheumatoid arthritis, and obesity were risk factors for reduced improvement in outcomes. Smoking was associated with a moderate effect size, but all other factors had only small impact on patient-reported outcomes. Active smokers should be counseled on their risk of smaller improvements in outcomes, and it may be inadvisable to perform TAR on these patients.
Context: Metatarsal stress fractures are common in cleated-sport athletes. Previous authors have shown that plantar loading varies with footwear, sex, and the athletic task. Objective: To examine the effects of shoe type and sex on plantar loading in the medial midfoot (MMF), lateral midfoot (LMF), medial forefoot (MFF), middle forefoot (MidFF), and lateral forefoot (LFF) during a jump-landing task. Design: Crossover study. Setting: Laboratory. Patients or Other Participants: Twenty-seven recreational athletes (14 men, 13 women) with no history of lower extremity injury in the last 6 months and no history of foot or ankle surgery. Main Outcome Measure(s): The athletes completed 7 jumping trials while wearing bladed-cleat, turf-cleat, and running shoes. Maximum force, contact area, contact time, and the force-time integral were analyzed in each foot region. We calculated 2 × 3 analyses of variance (α = .05) to identify shoe-condition and sex differences. Results: We found no shoe × sex interactions, but the MMF, LMF, MFF, and LFF force-time integrals were greater in men (P < .03). The MMF maximum force was less with the bladed-cleat shoes (P = .02). Total foot and MidFF maximum force was less with the running shoes (P < .01). The MFF and LFF maximum forces were different among all shoe conditions (P < .01). Total foot contact area was less in the bladed-cleat shoes (P = .01). The MMF contact area was greatest in the running shoes (P < .01). The LFF contact area was less in the running shoes (P = .03). The MFF and LFF force-time integrals were greater with the bladed-cleat shoes (P < .01). The MidFF force-time integral was less in the running shoes (P < .01). Conclusions: Independent of shoe, men and women loaded the foot differently during a jump landing. The bladed cleat increased forefoot loading, which may increase the risk for forefoot injury. The type of shoe should be considered when choosing footwear for athletes returning to activity after metatarsal stress fractures.
Category: Ankle Arthritis; Ankle Introduction/Purpose: This retrospective cohort study compared short-term complication rates following total ankle arthroplasty (TAA), either alone or with concomitant soft tissue or bony procedures. Secondary independent risk factors were also examined as they related to postoperative outcomes in these groups. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using current procedural terminology (CPT) codes to identify patients that underwent TAA (27702) between 2010 to 2021. Patients were then divided into cohorts consisting of patients who underwent TAA without concomitant procedures and patients who underwent TAA with one or more concomitant bony or soft tissue procedures. Procedures included in the development of cohorts are outlined in Table 1. Propensity score matching was then employed to account for any baseline demographic differences, and statistical analyses were performed to compare short-term complication rates between the matched cohorts. Results: A total of 2,225 patients undergoing TAA were identified, with 1,432 (64.4%) receiving TAA alone and 793 (35.6%) receiving TAA with ancillary procedure(s). After matching, 793 patients were included in each cohort. The ancillary cohort had longer operative times (172.8 vs. 144.1mins) and total length of hospital stay (LOS) (1.76 vs. 1.52 days). Rates for extended length of stay were significantly higher in the ancillary cohort compared to the simple cohort (21.2% vs 16.3%). No other complications varied significantly between cohorts, including the incidence of any adverse event (AAE). When controlling for all other variables, ASA classification of 4 was found to be an independent risk factor for development of AAE (odds ratio [OR] = 1.091, p = 0.04). Conclusion: Extended length of stay was the only variable found to be significantly different between simple and concomitant TAA cohorts. Additionally, in a subgroup analysis excluding tendon lengthening procedures, we observed greater morbidity probability in the additional procedures group. The only independent risk factor for postoperative complications was ASA class 4 status. Without significant difference in rates of any AAE other than extended LOS, the relative safety of ancillary TAA appears similar to that of simple TAA alone. Such knowledge can help inform surgical decision-making and assuage safety concerns for patients requiring TAA while having multiple foot and ankle pathologies.
Impingement may be an underreported problem following modern total ankle replacements (TARs). The etiology of impingement is unclear and likely multifactorial. Because of the lack of conservative treatment options for symptomatic impingement after TAR, surgery is often necessary.We retrospectively identified a consecutive series of 1001 primary TARs performed between January 1998 and December 2014. We identified patients who required a secondary surgery to treat soft-tissue and bony impingement by either an open or arthroscopic procedure. Functional and clinical outcomes, including secondary procedures, infections, complications, and failure rates, were recorded.In all, 75 patients (7.5%) required either open (n = 49) or arthroscopic debridement for impingement after TAR; 44 patients had >12 months of follow-up, with a follow-up of 26.5 months after their debridement procedure. The mean time to the debridement procedure for all prostheses was 29.3 months, with an average of 38.7 months in STAR, 21.8 months in INBONE, and 10.5 months in Salto Talaris patients. Of the patients with more than 1 year's follow-up from their debridement, 84.1% were asymptomatic; 9 patients (20.4%) had repeat operations after their debridement procedure. Of these, 5 patients required a repeat debridement of their medial or lateral gutters for a failure rate of 11.4%.Both arthroscopic and open treatment of impingement after total ankle arthroplasty are safe and effective in improving function and pain. Although the rates for revision impingement surgery are higher in arthroscopic compared with open procedures, they are not significantly so. Therefore, we recommend arthroscopic surgery whenever possible because of earlier time to weight bearing and mobility.Level IV.
The most common first-line treatment of osteochondral lesions of the talus (OLTs) is microfracture. Although many patients do well with this procedure, a number fail and require reoperation. The mechanism of failure of microfracture is unknown, and to our knowledge there has been no research characterizing failed microfracture regarding histological and inflammatory makeup of these lesions that may contribute to failure.To characterize the structural and biochemical makeup of failed microfracture lesions.Case series; Level of evidence, 4.Specimens from 8 consecutive patients with symptomatic OLTs after microfracture who later underwent fresh osteochondral allograft transplantation were analyzed. For each patient, the failed microfracture specimen and a portion of the fresh allograft replacement tissue were collected. The allograft served as a control. Histology of the failed microfracture and the allograft replacement was scored using the Osteoarthritis Research Society International (OARSI) system. Surface roughness was also compared. In addition, tissue culture supernatants were analyzed for 16 secreted cytokines and matrix metalloproteinases (MMPs) responsible for inflammation, pain, cartilage damage, and chondrocyte death.The OARSI grade, stage, and total score as well as surface smoothness were significantly worse in the failed microfracture sample, indicating better cartilage and bone morphology for the allografts compared with the failed microfracture lesions. Analyzed cytokines and MMPs were significantly elevated in the microfracture tissue culture supernatants when compared with fresh osteochondral tissue supernatants.These data demonstrate a significantly rougher cartilage surface, cartilage and subchondral bone histology that more closely resembles osteoarthritis, and elevated inflammatory cytokines and MMPs responsible for pain, inflammation, cartilage damage, and chondrocyte death when compared with fresh osteochondral allografts used as controls.
From 1965 to 1981, eleven patients with compression of the sensory portion of the musculocutaneous nerve by the biceps aponeurosis and tendon were seen at Duke University Medical Center and followed until the completion of treatment. Four patients responded to non-operative management. Compression of the nerve by the biceps aponeurosis and tendon against the fascia of the brachialis muscle accounted for the characteristic finding of nerve-flattening and loss of vascular markings in the seven patients who required surgery. Surgical decompression relieved the symptoms in all seven of them.
Two cases of lengthening of metatarsals by distraction osteogenesis are reported. One of these cases is an acquired deformity of the first metatarsal; the other is a congenital short fourth metatarsal. By following the principles set forth by llizarov, it was possible to lengthen the metatarsal bones and surrounding soft tissues without open lengthening of tendons or secondary bone grafting of the distraction gap. We believe this method is an improvement over previously described methods of metatarsal lengthening.
Background: Ultrasonography is an emerging imaging modality which affords dynamic, real-time, cost-effective and surgeon controlled visualization of the foot and ankle. The purpose of this study was to evaluate the accuracy of ultrasound guided injections for common injection sites in the foot and ankle. Materials and Methods: In 10 fresh cadaver feet, ultrasound guidance was utilized to inject a methylene blue-saline mixture into (1) the first MTP joint, (2) the second MTP joint, (3) the tibiotalar joint, (4) the Achilles peritendinous space, (5) the flexor hallucis longus sheath, (6) the posterior tibial tendon sheath, and (7) the subtalar joint. Dissection was then undertaken to assess injection accuracy. Results: Ultrasound guidance allowed the avoidance of intervening neurovascular and tendinous structures. Ultrasound guided MTP, ankle, Achilles, PTT and FHL peritendinous injections were 100% accurate. Ultrasound guided subtalar injection was 90% accurate. Conclusion: Ultrasound appears to be a highly accurate method of localizing injections into a variety of locations in the foot and ankle. Clinical Relevance: Ultrasound's ability to display soft-tissue structures may be an advantage over blind injection and fluoroscopic injection techniques.
