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Category: Ankle; Other Introduction/Purpose: The Invision talar component was launched in 2018 as a revision total ankle arthroplasty (TAA) specific option geared towards avoiding further subsidence when poor talar bone stock is present. Due to the recency of the market- availability of the Invision, studies evaluating the efficacy of the implant, even in the short-term, are lacking. Thus, the purpose of this study was to present the early-term outcomes of a series of patients undergoing revision TAA with the use of the Invision talar component. Methods: This was a single-center, retrospective review of 28 patients undergoing revision TAA with the Invision talar component and Inbone II tibial component (Wright Medical; Memphis, Tennessee) performed between 2007 and 2022. Mean follow-up was 1.3 ± 0.93 years. Data on patient preoperative characteristics, postoperative complications, and survivorship were collected. The primary outcome measures were time to major complication, reoperation, and infection. Results: The most common concurrent procedures performed with revision TAA with the Invision talar component were gastrocnemius recession (n=14, 50%), subtalar arthrodesis (n=3, 10.7%) and cotton osteotomy (n = 1, 3.6%). The mean preoperative coronal deformity off the tibia was 4.07 ± 3.06 degrees for varus and 3.67 ± 4.36 degrees for valgus deformities, respectively, and postoperatively, was 1.67 ± 2.16 degrees for varus and 2.00 ± 3.48 degrees for valgus. The mean preoperative coronal plane deformity off the talus was 4.83 ± 6.68 degrees for varus and 4.22 ± 4.21 degrees for valgus, respectively, and postoperatively, was 1.23 ± 2.45 degrees for varus and 2.32 ± 3.93 degrees for valgus. The survivorship from any complication, major complication, reoperation, and infection is shown in Table 2. Conclusion: In a series of 28 patients undergoing revision TAA with the Invision talar component and Inbone II tibial component, we demonstrate a survivorship of 92.7% at 1-year follow up. The Invision appears to have a reasonable safety profile in this non- designer series. The implant compares favorably with others utilized in the revision TAA setting at the early-term, but further studies evaluating mid-and long-term outcomes are required to fully assess the efficacy of the Invision. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis Introduction/Purpose: As total ankle arthroplasty (TAA) rises in popularity nationwide, the incidence of major complications and need for revision TAA will continue to increase. A better understanding of the ability to durably correct deformity and improve patient reported outcomes (PROs) in the TAA revision setting is paramount for surgeons facing the impending wave of failed TAA. Thus, the purpose of this study was to present the largest single-center case series of revision TAA to date and to evaluate improvement in PROs and maintenance of correction of coronal plane deformity in patients undergoing this procedure. Methods: This was a single-center, retrospective review of 87 revision TAAs performed between 2007 and 2022. Reoperations for cyst formations only or without metallic component exchange were excluded. The two most common implants used for revision TAA were Inbone II (n=65) and Inbone I (n=14). Mean follow-up was 2.8 ± 2.9 years. Data on patient preoperative characteristics, concurrent procedures, and postoperative complications were collected. The primary outcome measures were time to major complication, reoperation, and infection. Secondary outcomes included PROs and correction of coronal plane deformity measured from both the tibial plafond and talar articulating surface from pre- to post-operatively. Cox regression analyses were performed to compute survivorship. Results: The most common concurrent procedures performed concomitantly with revision TAA were gastrocnemius recession (n=31, 35.6%), subtalar arthrodesis (n=18, 20.7%), and talonavicular arthrodesis (n=5, 5.7%). Mean preoperative coronal plane deformity measured off both the tibial plafond and talar articular surface improved after revision TAA. 1- and 5-year survivorship from major complication, reoperation, and infection is shown in Table 2. Fourteen patients underwent subsequent revision, including TAA (n= 6, 6.9%), arthrodesis (n= 4, 4.6%), below-the-knee amputation (n= 2, 2.3%), or implantation of an antibiotic spacer (n= 2, 2.3%). At one-year postoperatively, mean VAS pain score, SF36, and AOFAS Hindfoot score was 18.2 ± 16.0, 73.0 ± 13.3, and 68.8 ±:9.3, respectively, representing an improvement in PROs after revision TAA. Conclusion: In the largest single-center series of patients undergoing single or double component exchange revision TAA, we demonstrate durable improvements in coronal plane deformity measured off both the tibial plafond and talar articular surface. We also noted 63.0% survivorship with regards to reoperation and improvements in average PROs across the cohort. Overall, revision TAA is a successful procedure, but is associated with higher failure rates at 5 years than primary TAA. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis Introduction/Purpose: There is limited data evaluating the effect of obesity on outcomes following total ankle arthroplasty (TAA), especially in adequate sample sizes to detect impacts on patient reported outcomes (PROs). The purpose of this study was to assess the effect of obesity on complication rates and PROs. Methods: This was a single-institution, retrospective study of 1,093 primary TAA performed between 2001 and 2020. Minimum follow-up was 2 years. Patients were stratified by body mass index (BMI) into Control (BMI=18.5-29.9; n=615), Obesity Class I (BMI=30.0-34.9; n=285), and Obesity Class II (BMI>35.0; n=193) groups. Patient information, intraoperative variables, postoperative complications, PRO measures were compared between groups using univariable statistics. Multivariable Cox regression was performed to assess risk for implant failure. Mean follow-up was 5.6 years (sd:3.1). Results: Compared to Control and Class I, Class II patients had the lowest mean age (p=0.001), highest mean ASA score (p < 0.001), and greatest proportion of female sex (p < 0.001) and Black/African American race (p=0.005). There were no statistically significant differences in postoperative complications (infection, implant failure, or impingement) across the BMI classes (p>0.05). Preoperatively, Class II had lower (worse) mean scores for FAOS Pain and ADL subscales than Controls (posthoc pairwise p< 0.001 for both). At final follow-up, both Class II and Class I had lower (worse) mean SMFA (posthoc pairwise p< 0.001 and p=0.030, respectively) and SF36 scores (posthoc pairwise p< 0.001 and p=0.005, respectively) than Controls. Conclusion: At midterm follow-up, obesity was not associated with increased rates of complications after TAA. Patients with obesity reported worse musculoskeletal function and overall quality of life after TAA but there was no differential improvement in PROs across BMI classes. To our knowledge, this is the largest single institution study to date examining the effect of obesity on outcomes after primary TAA. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Ankle Introduction/Purpose: Younger age remains at the forefront of discussion when deciding between total ankle arthroplasty (TAA) and the ankle arthrodesis (AA) for treatment of end stage ankle arthritis. Unlike in the hip and knee, ankle arthritis is typically post-traumatic and presents at a much younger patient age. With the goal of preserving ankle motion, improving function and limiting adjacent joint degeneration, TAA has been shown to be safe and effective in patients < 55 years of age. However, it is not uncommon for debilitating ankle arthritis to occur in individuals within their fourth or even third decade of life resulting in significant patient comorbidity. The purpose of our study was to evaluate patient reported outcome measures and survivorship after primary TAA in patients < 35 years old. Methods: A retrospective chart review was conducted of patients < 35 years old who underwent primary TAA at a single institution from 2007-2020. Patient demographics, outcome measures, and complications were recorded. All patients had a minimum clinical follow up of 2 years. Patient reported outcome measures collected included VAS, SMFA dysfunction index, SF-36 and AOFAS hindfoot scores. Outcome measures were evaluated preoperative, 1 year postoperative, and at final follow up. Paired t-tests were performed to compare individual patients' changes in PRO from preoperative to postoperative timepoints. Implant survivorship was evaluated as well as complications related to the index procedure. Implant survivorship based on need for complete revision of either the tibial or talar component Results: Twelve patients were included in the study. Average age at surgery was 28.5 years. Mean follow-up was 7.2 years. Mean VAS improved from 53.8 preoperatively to 14.7 (p= 0.152) at 1-year and 12.5 (p= 0.045) at final follow up, respectively. Mean SMFA improved from 40.0 preoperatively to 27.1 (p= 0.018) at 1-year and 24.0 (p= 0.006) at final follow up, respectively. SF-36 and AOFAS hindfoot scores also improved at 1 year and final follow-up compared to preoperative values [SF-36: 45.3 to 60.2 (p=0.06) and 67.0 (p=0.016); AOFAS: 40.6 to 70 (p= 0.08) and 68.9 (p=0.068)]. One patient required talar component revision due to aseptic loosening. One patient required subsequent removal of heterotopic bone due to impingement. No patients developed infection requiring surgical intervention. Conclusion: The onset of ankle arthritis typically occurs at a much younger age compared with that of the hip and knee and has a detrimental impact on patient quality of life. Despite a young age and increased activity demands, our results demonstrated that patients < 35 with end-stage ankle arthritis undergoing TAA demonstrated improved patient-reported outcomes greater than 2 years after surgery. Survivorship of TAA in our study was 91.7% at a mean follow-up of 7.2 years. We believe that TAA is a safe, effective and durable option for very young patients with high patient satisfaction at early to mid-term follow up. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Other Introduction/Purpose: Utilization rates of total ankle arthroplasty (TAA) have greatly increased in recent years. For patients with rheumatoid arthritis (RA) undergoing TAA, conflicting data have been reported regarding risk of complications and patient reported outcome (PRO) improvement when compared to patients with osteoarthritis. The purpose of this study is to compare complication rates and PROs of patients with RA to patients with osteoarthritis and posttraumatic arthritis. Methods: This was a retrospective study of 1,071 primary TAA performed at a single institution between 2001 and 2020. Minimum follow-up was two years. Patients were stratified by indication for TAA (osteoarthritis, n=372; posttraumatic arthritis, n=642; RA, n=57). Patient demographics, intraoperative variables, postoperative complications, and PRO measures were compared between groups using univariable statistics. Multivariable Cox regression was performed to assess risk for implant failure. Mean follow-up was 5.6 years (SD: 3.1). Results: Compared to the osteoarthritis and posttraumatic arthritis groups, the RA cohort had the lowest mean age (p < 0.001), lowest percentage of males (p < 0.001), and highest ASA score (p < 0.001). Univariate analysis showed no statistically significant difference for infection rates among groups (p=1.0). The RA cohort had the highest rate of heterotopic ossification postoperatively (2/57, 3.5%, p< 0.001). Multivariable regression analysis showed no increased risk of implant failure for the RA cohort (p=0.23). For the SMFA, SF-36, AOFAS-hindfoot, FAOS-symptoms, and FAOS-ADL the RA group reported the worst scores at final follow-up (p < 0.001). However, the RA cohort demonstrated the largest improvements from preoperative to postoperative scores on the FADI, SF-36, and the symptoms and ADL subscales of the FAOS (p=0.04, 0.01, 0.03, 0.03). Conclusion: In the largest single institution study to date, patients with RA had the worst PRO scores compared to the osteoarthritis and posttraumatic arthritis groups. However, they experienced significantly higher improvements in functional outcomes from their preoperative baseline. Large patient samples with mid- to long-term follow up such as a presented in this series are imperative to fully understand the risk-benefit of TAA in various patient cohorts. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis Introduction/Purpose: Total joint arthroplasty is increasingly being performed in younger individuals across the United States. While age-specific outcomes have been evaluated in total hip and knee replacements, the data are not as clear for total ankle arthroplasty (TAA). The purpose of this study was to analyze TAA outcomes and complications by age to improve shared decision-making when considering ankle replacements. Methods: A total of 1,619 primary and revision TAAs from 2012-2020 were collected and included from the National Surgical Quality Improvement Program. Patients were stratified by age into groups less than 55, between 55-70, and greater than 70 years of age. Demographics, medical comorbidities, ASA class, operative time, 30-day complications, and comorbid conditions were compared by univariable analysis. Multivariable analysis was used to analyze readmission rates, reoperation rates, operative time, and hospital length of stay. Results: By univariable analysis, patients greater than 70 have significantly more comorbidities when compared to patients younger than 55. Younger patients have a significantly longer hospital stay, with an average of 1.64 days for those younger than 55 compared to patients 55-70 (1.50 days) and patients older than 70 (1.38 days, p< 0.001). Younger patients also have a significantly longer operative time and a higher risk of still being in the hospital after 30 days (p < 0.001, p=0.034). By multivariable analysis, patients 55-70 have a statistically lower risk of readmission compared to the other two cohorts (p = 0.043). Conclusion: As the incidence of total ankle arthroplasty increases across all ages, it is important to understand specific risks for each age group. Patients younger than 55 experience higher operative times and longer lengths of stay. Patients between 55-70 have a significantly lower risk of reoperation but longer hospital stays. Patients older than 70 tend to have lower reoperation rates, lower readmission rates, and shorter operative times. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis Introduction/Purpose: End stage arthritis is a debilitating condition that significantly affects patients' quality of life. Ankle arthritis differs from arthritis of the hip and knee in that ankle arthritis is often posttraumatic in nature and affects a younger patient population. Historically, younger age was a contraindication to total ankle arthroplasty (TAA) and ankle arthrodesis was the mainstay of treatment. Advances in TAA implant design and revision implants has expanded indications and increased usage of TAA. Despite this, many surgeons remain hesitant due to the lack of long term data on patient outcomes and survivorship in these patients. The purpose of our study was to evaluate patient reported outcome measures and survivorship after primary TAA in patients < 50 years of age at the time of surgery. Methods: A retrospective chart review was conducted of patients < 50 years of age who underwent primary TAA at a single institution from 2010-2020. Patient demographics, outcome measures, and complications were recorded. All patients had a minimum clinical follow up of 5 years. Patient reported outcome (PRO) measures collected included FADI, VAS, SMFA SF-36, AOFAS hindfoot scores, and FAOS scores. Outcome measures were evaluated preoperative, 1 year postoperative, and at final clinical follow up. Paired t-tests were performed to compare individual patients' changes in PRO from preoperative to postoperative timepoints. Multiple comparisons correction was performed using the Bonferroni method. Implant survivorship was evaluated based on need for revision of either the tibial or talar component. Results: A total of 59 patients were included in the study. The average age at time of surgery was 43.2 years. All patients had a minimum follow up of 5 years with a mean follow up time of 8.8 years. Mean FADI improved from 53.3 (sd:14.1) preoperatively to 16.1 (sd:11.4) (p < 0.001) at 1-year postoperatively. Mean VAS and SMFA also improved from preoperative to 1-year postoperative timepoints [VAS: 68.2 (sd:27.0) to 10.3(sd:13.1) (p < 0.001); SMFA: 36.1 (sd:12.2) to 14.8 (sd:13.7) (p < 0.001)]. A total of 5 patients required revision of components during the follow up period. Three patients required complete revision of both tibial and talar components, 2 due to aseptic loosening and 1 due to deep infection requiring explant of components. Conclusion: Patients < 50 years undergoing TAA for end stage ankle arthritis have improved patients reported outcomes greater than 5 years after surgery. Despite the increased demands of the younger population, survivorship of total ankle implants in our study was 85% at a mean of 8.8 years postoperative. We believe that TAA is a safe and reliable option for young patients with high patient satisfaction at mid term follow up. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis Introduction/Purpose: Obesity is a well-established risk factor for complications after total hip and knee arthroplasty. The incidence of total ankle arthroplasty (TAA) continues to grow, but few studies have evaluated TAA outcomes in patients with obesity. The present study sought to measure the impact of obesity on TAA outcomes using a national database. Methods: The 2012-2020 National Surgical Quality Improvement Program (NSQIP) database was queried for primary TAA (CPT:27002). 1,610 patients were identified and stratified by preoperative body mass index (BMI): non-obese (18 5-29.9kg/m2, n=760), obesity class I (30.0-34.9kg/m2, n=455), and class II and III (>35.0kg/m2, n=395). Preoperative and perioperative patient data, operative time, hospital length of stay (LOS), and 30-day complications were compared using univariable statistics. Multivariable analyses controlling for patient characteristics were employed to measure the effect of obesity on operative time and LOS. Results: Compared to the non-obese group, obesity class II and III patients were younger (61.9 versus 65.6 years;p < 0.001), more female (57.2% versus 42.0%;p < 0.001), higher ASA class (p < 0.001) and had more comorbidities such as hypertension, diabetes, and dyspnea (p < 0.001). Mean preoperative albumin was lower (p=0.013) and white blood count was higher (p < 0.001) in the obesity class II and III group. Home discharge rate was lowest in class II and III patients (88.6%;p=0.017). Multivariable regression revealed longer hospital LOS for obesity class II and III (μ=0.21; p=0.005) relative to the non-obese group. Obesity group was not associated with operative time or 30-day readmissions and reoperations. Conclusion: Obesity class II and III patients undergoing TAA had more comorbidities and longer hospital LOS compared to lower BMI patients. Despite the well-established association between obesity and postoperative complications after hip and knee arthroplasty, the present NSQIP analysis of 1,610 TAA patients did not find a greater burden of acute complications among patients with obesity. [ABSTRACT FROM AUTHOR]

Category: Ankle; Sports Introduction/Purpose: A growing body of evidence favors the use of dynamic fixation techniques such as suture endo button over rigid screw fixation for syndesmotic injuries. However, specific dynamic fixation techniques have been poorly evaluated. The purpose of this study was to compare single suture-endobutton fixation (single) to double fixation with suture-endobuttons placed one centimeter (cm) apart (double 1 cm) and double fixation with suture-endobuttons placed three cm apart (double 3 cm). Methods: Twenty-four lower leg specimens from twelve cadavers were tested using a custom biaxial apparatus. Internal rotation, external rotation, and anterior and posterior translation of the tibia and fibula were examined using motion tracking systems after transection of deltoid and syndesmotic ligaments to compare three syndesmotic repair techniques: 1) a single suture-endobutton placed 1 cm above the joint line, 2) two suture suture-endobuttons placed 2 and 3 cm above the joint line, and 3) two suture- endobuttons placed 1 and 4 cm above the joint line. Results: All three endobutton constructs improved the stability of the syndesmosis by reducing aberrant motion after transection. There was no clear superiority of either single suture-endobutton (SEB), double suture-endobuttons placed 2 and 3 cm above the joint line (DSEB 1), or double suture-endobuttons placed 1 and 4 cm above the joint line (DSEB 3). DSEB 3 and DSEB 1 showed equal median laxity for tibia internal rotation (2.7 degrees, DSEB 1 (2.0 – 3.2) degrees, DSEB 3 (2.3 – 2.8) degrees), tibia external rotation (-0.2 degrees, DSEB 1 (-0.4 - 0.4) degrees, DSEB 3 (-0.4 - 0.3) degrees), and fibula external rotation (-0.3 degrees, DSEB 1 (-0.7 - 0.3) degrees, DSEB 3 (-0.7 - 0.7) degrees). Conclusion: Cadaveric biomechanical studies are critical to evaluate various suture-endobutton constructs prior to widespread use in patients. Our results demonstrate that the added cost of a second suture-endobutton may not confer substantial additional stability to the syndesmosis. Likewise, increased spread between suture-endobuttons appears to have minimal impact of syndesmotic stability. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Ankle Introduction/Purpose: Although many patients with postraumatic ankle arthritis are of a younger age, studies evaluating the impact of age on outcomes of primary total ankle arthroplasty (TAA) reveal heterogenous results. The purpose of this study is to determine the effect of age on complication rates and patient reported outcomes after TAA. Methods: This was a retrospective study of 1,185 primary TAA divided into 3 age cohorts (Age < 55, n=219; Age55-70, n=688; Age>70, n=278). Patient demographics, intraoperative variables, postoperative complications, and patient reported outcome measures were compared among groups using univariable analyses. Multivariable Cox regression was performed to assess risk for implant failure by age group. Mean follow-up was 5.7 years. Results: Compared to Age55-70 and Age>70 groups, Age < 55 patients had the lowest mean ASA score (2.2 vs 2.4 vs 2.5; p< 0.001) and highest rates of all complications (33.8% vs 23.1% vs 19.8%; p=0.001), implant failure (9.1% vs 6.0% vs 3.2%; p=0.022), and component removal (5.0% vs 2.8% vs 1.1%; p=0.030). Univariable and multivariable cox regression analysis revealed decreased risk for implant failure for Age>70 compared to Age < 55 patients (HR: 0.43 [95%CI: 0.19-0.94], p=0.034; and HR: 0.42 [95%CI: 0.18-0.95], p=0.038, respectively). Across the AOFAS Hindfoot and all FAOS subscales, Age < 55 group reported the lowest (worst) mean pre and postoperative scores (p < 0.001). The age < 55 group had the highest mean VAS score at final follow-up (22 vs 14 vs 14; p< 0.001). Conclusion: Studies involving large sample sizes with mid-to long-term follow up are critical to reveal age-related impacts on outcomes after TAA. Younger patients had higher rates of complications and implant failure and fared worse on patient reported outcome measures in the largest single-institution series to date evaluating the effect of age on outcomes in TAA. [ABSTRACT FROM AUTHOR]