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Background: Deformation of the talus and the distal tibia can be frequently observed during ankle joint osteoarthritis (OA). The aim of this study was to objectify these morphologic changes. We hypothesized that a flattening of the talus and a broadening of the distal tibia surface occurs in end-stage OA of the ankle joint. Methods: Twenty-seven computed tomography (CT) ankle joint examinations of unilateral ankle OA were matched by sex and age with 27 CT examinations of healthy ankle joints. Three-dimensional reformatting and measurements were performed with geometry analysis software. The following parameters were assessed: sagittal radius of the talus, talus height, and mediolateral and anteroposterior width of the distal tibial joint surface. Results: Medial, midsagittal, and lateral sagittal arc radii of osteoarthritic tali were significantly larger compared to tali of controls. There was a statistically significant difference in the height of the osteoarthritic talar dome in the medial and in the lateral frontal segment and in the medial central segment compared to tali of controls. The anteroposterior width and the sagittal curvature of the distal tibia was significantly larger in OA ankles than in the control group. The mediolateral measurements were comparable across both groups. Conclusion: Flattening of the talus appears to be more pronounced in the frontal aspect of the talus. The distal tibia broadens anteroposteriorly. These findings may contribute to better understanding of ankle OA development. Level of Evidence: Level III, retrospective comparative cohort study.

Osteochondral lesions of the talus, large or small, are challenging for the treating orthopaedic surgeon. These cartilage and bony defects can cause substantial pain and functional disability. Surgical treatment of small osteochondral lesions of the talus has been thoroughly explored and includes retrograde drilling, arthroscopic débridement and marrow stimulation, osteochondral autografting from cartilage/bone unit harvested from the ipsilateral knee (mosaicplasty), and autologous chondrocyte implantation. Although each of these reparative, replacement, or regenerative techniques has varying degrees of success, they may be insufficient for the treatment of large osteochondral lesions of the talus. Large-volume osteochondral lesions of the talus (1.5 cm in diameter or150 mm(2) in area) often involve a sizable portion of the weight-bearing section of the talar dome, medially or laterally. A fresh structural osteochondral allograft is a viable treatment option for large osteochondral lesions of the talus.

Background: Wound complications following total ankle replacement (TAR) may potentially lead to devastating consequences. Soft tissue coverage of the prosthesis and tendons with a flap potentially prevent a catastrophic cascade leading to infection and implant failure. The aim of this study was to investigate the success and complications of flaps following soft tissue defects as a result of total ankle arthroplasty. Methods: We retrospectively identified a consecutive series of 1001 primary TARs performed between January 1998 and December 2014 whose data were prospectively collected. We then identified patients who required a secondary surgery to treat soft tissue defects that were not amenable to split-thickness skin grafting. Clinical outcomes including secondary procedures, wound healing failure, complications, and implant failure rate were recorded. Nineteen patients had a total of 44 operative procedures to treat wound issues (1.9% of all prostheses). The follow-up time from the flap procedure is 24.1 months. Results: More than two-thirds (13/19) of patients had 1 or more previous surgeries on the ankle, for an average of 1.2 procedures. The mean time to the flap procedure was 13.1 weeks after the index TAR. The most common reason for flap coverage was a non-healing anterior wound. Thirteen of 19 patients (68.4%) underwent formal operative wound exploration and debridement prior to their definitive flap coverage. The average size of the wound was 5.4 × 3.8 cm with an average area of 24.9 cm2. The most common type of flap performed was a sural pedicle flap followed by a propeller flap. There were 4 flap failures (21.1%), with 2 subsequent below-the-knee amputations. No TAR patients developed a deep infection following a flap unless they had a preexisting infection. In patients who had a successful flap, there were significant improvements in their American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, visual analog scale (VAS), and Short Musculoskeletal Function Assessment bother index, but not their Short Form-36 scores. Conclusion: Ankle wounds that occur after TAR can result in a devastating outcome, but management with a coordinated effort with surgeons with microvascular experience can help achieve salvage of the prosthesis. A variety of flap reconstruction options are available and should be employed to improve the rate of implant survival and retention. Level of Evidence: Level IV, case series.

Background: Total ankle arthroplasty (TAA) is increasingly being recognized as an effective surgical option for end-stage ankle arthritis. Associated hindfoot arthrodesis procedures are at times needed to correct malalignment or to address adjacent joint arthritis. Results following TAA and associated hindfoot arthrodesis have at times been underwhelming and the devascularization of the talar blood supply has been postulated as a potential cause. This study explored the association between hindfoot arthrodesis fixation and talar component subsidence. Methods: The study included 81 consecutive patients who underwent a TAA with either an isolated subtalar arthrodesis or combined subtalar and talonavicular arthrodesis with a minimum of 2 years of follow-up. Radiographic and clinical evaluations including patient-reported outcomes were performed at each postoperative visit. The primary outcome measure was the presence of talar component subsidence while patient-reported outcomes were the secondary outcome measure. Results: 30.9% of patients had evidence of talar component subsidence. Subsidence was seen in 55.5% of patients with dorsal to plantar subtalar fixation compared to 11.1% of patients with plantar to dorsal screws ( P < .001) and in 44.4% of patients with screws violating the sinus tarsi compared to 3.7% of patients without screws in the sinus tarsi ( P < .001). Screws that were placed from dorsal to plantar were more likely to violate the sinus tarsi ( P < .001). Patients with evidence of talar subsidence reported higher pain scores and lower functional scores. There were 8 TAA failures, and the presence of dorsal to plantar screws was associated with failure ( P < .01). Conclusion: Screws that are placed across the subtalar joint from a dorsal to plantar approach are more likely to violate the sinus tarsi, contributing to a significantly higher rate of talar component subsidence when associated with TAA. Level of Evidence: Level II, prospective comparative series.

Background:Although advances in joint-replacement technology have made total ankle arthroplasty a viable treatment for end-stage arthritis, revision rates for ankle replacements are higher than in hip or knee replacements. The questions asked in this study were what can retrieved ankle devices demonstrate about ankle arthroplasty failures and how can understanding the causes of these failures inform clinical decisions for current and future ankle arthroplasty patients?Methods:An IRB-approved retrieval laboratory received retrieved components and surgeon-supplied reason for revision from 70 total-ankles (7 designs, including 5 currently marketed designs) from 2002 to 2018. These retrievals were rated for clinical wear and damage. Metal components were rated by method and effectiveness of fixation. Polyethylene inserts received by the laboratory 6 months or less after retrieval (n = 45) were analyzed for oxidation using Fourier transform infrared spectroscopy. Statistical analysis was performed using IBM SPSS, version 22.Results:The ankle implants were retrieved most commonly for loosening and polyethylene fracture. Loosening occurred more frequently in fixed-bearing designs (n = 18) than in the mobile-bearing designs (n = 4) and after shorter in vivo time (mean in vivo time to retrieval for loosening: fixed bearing 3.2 ± 2.1 years, mobile bearing 9.7 ± 4.5 years). Gamma-sterilized ankle inserts oxidized at a higher rate than non-gamma (EtO or gas-plasma) sterilized ankle inserts (gamma 0.29 ± 0.22/y, non-gamma 0.07 ± 0.05/y, mean difference=0.215, 95% CI 0.128-0.303, P < .001). The presence of clinical fatigue (cracking and/or delamination) of the polyethylene insert correlated with measured oxidation (Spearman rho = 0.685, P < .001). Nine inserts, all gamma-sterilized, fractured in vivo.Conclusions:This study suggests that loosening could be more of a problem in fixed-bearing devices than in mobile bearing devices. Gamma-sterilized polyethylene inserts were found to suffer fatigue damage or fracture in vivo, resulting in the need for revision. Retrieval analysis can provide insight into implant-related reasons for revision, with the goal of understanding the implant-related causes of these failures, informing future ankle design and clinical decisions for current and future ankle arthroplasty patients.Level of Evidence:Level III, comparative series.

Background: The effect of bone mineral density (BMD) on outcomes from total ankle arthroplasty (TAA) has not been studied. BMD can be estimated by measuring Hounsfield units (HU) on standard computed tomography (CT), which is frequently performed prior to TAA. We aimed to identify whether tibial and talar HU measured from preoperative CT scans were associated with periprosthetic fracture or revision risk in patients undergoing TAA. Methods: A prospectively collected database was used to retrospectively screen all patients undergoing primary TAA. Only patients with a preoperative CT within 1 year of surgery were included. Primary outcomes were periprosthetic fracture and prosthetic revision. HU were measured on axial CT cuts in the distal tibia and talus. Additional patient factors analyzed included age, sex, weight, body mass index (BMI), tobacco use, presence of rheumatoid arthritis, and preoperative deformity. A total of 198 ankles were included, with a mean 2.4 years of follow-up. Results: There were 7 intraoperative and 9 postoperative periprosthetic fractures (3.5% and 4.5%, respectively). Seven patients (3.5%) underwent prosthetic removal or revision. Lower tibial and talar HU, lower weight, and lower BMI were associated with periprosthetic fractures ( P < .05). After controlling for age, sex, and weight, only tibial HU was significantly associated with periprosthetic fracture ( P = .018). All intraoperative fractures occurred in patients with tibial HU less than 200. None of the patient factors analyzed were associated with revision. Conclusions: Lower tibial HU on preoperative CT was strongly associated with periprosthetic fracture risk with TAA. In patients with tibial HU less than 200, surgeons may consider prophylactic internal fixation of the medial malleolus. Level of Evidence: Level III, retrospective cohort study.

Category: Other Introduction/Purpose: The most common complications in orthopaedic surgery of the foot and ankle documented in the literature are postoperative infections with a frequency between 1 and 8%. The development of an implant-associated infection can be a potentially devastating complication following foot and ankle surgery. This leads to a high number of revision surgeries after initial fracture stabilization and potential loss of function of the joint and quality of life in the long-term follow-up. Titanium, the most commonly used alloy for foot and ankle implants, has limited strength and is notch-sensitive so repetitive stress leads to fatigue failure of implants and limits design options. Better materials with both optimized mechanical and biological properties could result in the development of superior foot and ankle implants. Methods: Several studies were performed to evaluate the biological properties of MoRe®: A study was conducted to characterize the hydrophilic properties by contact angle comparisons of the MoRe alloy compared to Titanium. A cell growth study was conducted to look at the influence of MoRe alloy on osteoblast growth and differentiation as compared to Titanium. A bone implantation study was conducted based on ISO 10993: Biological Evaluation of Medical Devices, Part 6: Tests for Local Effects after Implantation to evaluate the local tissue and bone response of MoRe® alloy test coupon compared to Titanium controls, when implanted in the mid-shaft femoral bone of rabbits for 4, 13 and 26 weeks. Biofilm formation study was conducted to quantify attachment and biofilm development of S. aureus bacteria upon MoRe® alloy in comparison to CoCr alloy in a well-controlled, reproducible, ex vivo laboratory experiment. Results: MoRe®, composed purely (99.99%) of molybdenum and rhenium, is a cofactor to the enzymes xanthine and sulfite oxidase, which are essential to bone metabolism. Rhenium is an inert metal with no biological affect. MoRe® has superior hydrophilicity (CA 37°±3°) compared to Titanium (CA 58°±3°), a key factor in cell adhesion, migration and replication. Pre-osteoblast cell seeding was found to be equivalent between MoRe° and Titanium alloy (10,000 cells/cm2). The bone implantation study demonstrated continued bone maturation over time for both MoRe® and Titanium implant sites with similar osteoconduction and bone remodeling histology of the cortical and medullary bone at 4, 13 and 26 weeks. The biofilm study found that S. aureus better colonized cobalt chrome alloy in comparison to MoRe® (p = 0.009). Conclusion: The MoRe® alloy, with its advantageous biological properties and hydrophilicity, offers great promise for the design of a new generation of bio-friendly foot and ankle implants with superior cell growth, osseointegration and biofilm resistance resulting in better outcomes for patients.

Category: Ankle Arthritis Introduction/Purpose: Tibiotalocalcaneal (TTC) fusion is a salvage operation for patients with significant arthritis and deformity of ankle and subtalar joints. Despite overall clinic success, fusion across both joints continues to be a major challenge with nonunion rates reported up to 48% [Franceschi]. Aside from certain patient comorbidities, nonunion may result when compression across the joint is lost in the setting of bone resorption. The use of a pseudoelastic intramedullary nail has been shown to maintain compression across fusion site in response to bone resorption. The purpose of this study was to evaluate the fusion rate in a high-risk population at a tertiary care center using a psuedoelastic intramedullary nail with an internal nitinol element. Methods: After obtaining IRB approval, a retrospective review of consecutive patients that underwent procedures with TTC fusion with novel intramedullary nail system with super elastic internal nickel titanium (NiTiNOL, DynaNail, Medshape Inc, Atlanta, GA) was performed at a single academic institution. From 2014 to 2016, 58 patients were identified, 55 of which had minimum one year follow up or clinical and radiographic fusion (20 months average, range 6-41 months). The primary outcome was radiographic fusion analysis which was reviewed by three authors. Fusion was determined by consensus with criteria of 3 of 4 cortices with osseous bridging in asymptomatic patients[1, 2] or CT fusion based on Glazebrook et. al. criteria for hindfoot fusion[3, 4]. Average age of this cohort was 59 (SD= 16.3) years with BMI average 33.1 (SD= 8.87). Exclusion criteria include: follow-up less than 12 months in non-fused patients, and incomplete clinical or radiologic data. Results: The fusion rate in this high-risk population was 80.0% with the use of the NiTiNOL tibiotalocalcaneal nailing system. Univariate analysis demonstrated no significant difference (p>0.05) in fusion rates with patient comorbidities that portend to non-union: current or former history of tobacco use, diabetes mellitus, rheumatoid arthritis, nor patients with chronic kidney disease. The average BMI in the fusion group was 31.97 compared to 27.4 in the non-union group (p=0.016). There were 5 deep infections requiring reoperation with a single patient requiring a below the knee amputation. Seven patients required a second operation for removal of prominent interlocking screws. Conclusion: This preliminary data demonstrates fusion rates with this novel intramedullary device are consistent with historical data. These findings are encouraging in that this nailing system shows equal rates of fusion in patients with high risk comorbidities for non-union compared to historical controls demonstrating increased non-union rates in diabetics, patients with chronic renal failure and those with a history of smoking. This Tibiotalocalcaneal nailing system is safe and offers theoretical sustained compression with up to 6 mm of resorption or settling.

Category: Ankle Arthritis Introduction/Purpose: Bone density is a modifiable factor which can be addressed prior to elective surgery if necessary. However, its role pertaining to complications of total ankle arthroplasty (TAA) has not been studied. Hounsfield units (HU) can be measured on standard computed tomography (CT) imaging, and have been shown to correlate with bone mineral density measures from dual-energy X-ray absorptiometry (DEXA). There is a precedent for these measurements in the orthopedic literature: different authors have shown that patients with higher vertebral bone density on CT are at lower risk for pedicle screw loosening. We hypothesized that patients with lower bone density, as measured by HU on preoperative CT, or with large preoperative cysts, would be at greater risk for revision and periprosthetic fractures following TAA. Methods: An existing database at the authors’ institution was used to screen all patients who underwent primary TAA. Inclusion criteria included a CT scan within one year prior to surgery. Exclusion criteria included tibial or talar hardware and nonweightbearing status at the time of the CT scan. The primary outcomes were prosthetic revision and periprosthetic fracture. HU were measured on axial CT cuts at 10 mm above the tibial plafond and at 5 mm below the talar dome to approximate the location of bone cuts. HU measurements for 30 patients were made independently by two reviewers in order to establish interrater reliability. Subchondral cysts at least 5 mm in diameter were counted. Additional patient factors analyzed included age, sex, weight, body mass index (BMI), tobacco use, presence of rheumatoid arthritis, preoperative deformity =15°, and pain visual analog scale scores. Results: 198 patients with a mean 2.4 years of follow-up met the inclusion criteria. The intraclass correlation coefficients for tibial and talar HU measurements were both 0.95. Seven patients (3.5%) underwent revision, four for infection, at a mean 1.2 years postoperatively. There were seven intraoperative and nine postoperative periprosthetic fractures (3.5% and 4.5%, respectively). Neither bone density nor cysts were associated with revision (p>.05). Lower tibial and talar HU, lower weight, and lower BMI were all associated with periprosthetic fracture (Table). After controlling for age, sex, and weight, only tibial HU was significantly associated with periprosthetic fractures (p=0.018). All intraoperative fractures occurred in patients with tibial HU Conclusion: Lower tibial and talar bone density on preoperative CT of the ankle was strongly associated with periprosthetic fracture. The low incidence of revision during the relatively short study period limited our ability to analyze effects on revision rates. In patients who have had a preoperative CT, measuring HU represents a quick, simple method of assessing bone density with excellent inter-rater reliability. In patients with tibial HU

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on “Conservative Management and Biological Treatment Strategies” developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. Results: A total of 12 statements on Conservative Management and Biological Treatment Strategies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Ten statements reached strong consensus (greater than 75% agreement), and 2 achieved consensus. Conclusions: This international consensus derived from leaders in the field will assist clinicians with conservative management and biological treatment strategies for osteochondral lesions of the talus.

Background: Treatment guidelines for cartilage lesions of the talus have been based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions on key topics regarding cartilage lesions of the talus. The purpose of this consensus article is to explain the process and delineate the consensus statements derived from this consensus meeting on the use of “osteochondral autograft” for osteochondral lesions of the talus. Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%. Results: A total of 14 statements on osteochondral autograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support, 11 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 67% agreement. Conclusions: This international consensus derived from leaders in the field will assist clinicians with osteochondral autograft as a treatment strategy for osteochondral lesions of the talus.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on “Debridement, Curettage and Bone Marrow Stimulation” developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. Results: A total of 14 statements on debridement, curettage, and bone marrow stimulation reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 12 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 72% agreement. Conclusions: This international consensus derived from leaders in the field will assist clinicians with debridement, curettage and bone marrow stimulation as a treatment strategy for osteochondral lesions of the talus.

Background: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on “Scaffold-Based Therapies” developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. Results: A total of 9 statements on scaffold-based therapies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 8 reached strong consensus (greater than 75% agreement), and 1 was removed because of redundancy in the information provided. All statements reached at least 80% agreement. Conclusions: This international consensus derived from leaders in the field will assist clinicians with applying scaffold-based therapies as a treatment strategy for osteochondral lesions of the talus. Level of Evidence: Level V, expert opinion.

Background: The proposed benefit of total ankle replacement (TAR) over ankle fusion is preserved ankle motion, thus we hypothesized that an increase in range of motion (ROM) is positively correlated with validated patient-reported outcome measures (PROMs) in individuals receiving TAR. Methods: Patients undergoing TAR at a single academic medical center between 2007 and 2013 were evaluated in this study. In addition to a minimum of 2-year follow-up, complete preoperative and postoperative outcome measures for the Foot and Ankle Disability Index (FADI), Short Musculoskeletal Function Assessment (SMFA) Bother and Function Indices, Visual Analog Scale (VAS), and 36-Item Short Form Health Survey (SF-36) were requisite for inclusion. Standardized weightbearing maximum dorsiflexion and plantarflexion sagittal radiographs were obtained and previously described ankle and foot measurements were performed to determine ankle ROM. Results: Eighty-eight patients met inclusion criteria (33 INBONE, 18 Salto-Talaris, 37 STAR). Mean time to final ROM radiographs was 43.8 months (range 24-89 months). All aforementioned PROMs improved between preoperative evaluation and most recent follow-up ( P < .01). Final ankle ROM was significantly correlated with postoperative FADI, SF-36 Mental Component Summary (MCS), SMFA Bother and Function Indices, and VAS. Additionally, dorsiflexion was positively associated with FADI, SF-36 MCS, and SMFA Function ( P < .05) but plantarflexion had no such influence on outcomes. No differences were identified with subset stratification by prosthesis type, fixed versus mobile-bearing design or etiology. Conclusion: In this TAR cohort with prospectively collected outcomes data, radiographic sagittal plane ankle motion was positively correlated with multiple PROMs. Disease-specific and generic health-related quality of life PROMs demonstrated improvement postoperatively in all domains when evaluating final total range of motion. Patients who undergo TAR for end-stage osteoarthritis with improvement in ROM demonstrate a direct correlation with improved patient-centric metrics and outcome scores. Levels of Evidence: Level III: Retrospective comparative study

Background: The operative treatment of bone cysts after total ankle replacements (TAR) is not well described. Bone cysts may cause component migration, implant failure, and pain. Surgery is performed on cysts with the goals of reducing pain and preventing component failure. Methods: We retrospectively evaluated a consecutive series of 726 primary TARs performed between January 1998 and May 2013 and identified those who had a subsequent bone cyst grafting procedure. We identified cyst location and method of treatment. Clinical outcomes including secondary procedures, infection rate, complications, and failure rate were recorded. Thirty-one patients were treated with a total of 33 operative procedures for bone cysts after TAR. Of these patients, 22 (71.0%) were males with an average age of 62.2 and median follow-up 65.9 months. Results: Intraoperatively, 22 tibial cysts (71.0%), 20 talar cysts (64.5%), 5 fibular cysts (16.1%), and 13 multiple cysts (41.9%) were treated. Allograft was used in 25 procedures (75.8%), calcium phosphate in 4 (12.1%), cement in 3 (9.1%), and autograft in 1 (3.0%). These procedures were supplemented by calcaneus autograft, allograft mixed with mesenchymal stem cells, platelet-rich plasma, recombinant human bone morphogenic protein-2, and demineralized bone matrix. There were no infections or wound complications. Of the 27 subjects with a successful second surgery, the success rate for bone grafting of cysts was 90.9% (95% CI: 50.8, 98.7%) at 24 months and 60.6% (95% CI: 25.1%, 83.4%) at 48 months. One patient needed a repeat bone grafting. The 4 failures observed postprocedure resulted in 3 tibial and talar component revisions, and 1 tibiotalocalcaneal (TTC) fusion. Conclusions: Grafting bone cysts without revision of TAR was in general an effective and safe means for treating patients with peri-prosthetic bone cysts. Treatment with grafting and supplemental materials may improve implant survivorship and might improve the structural support surrounding the implant. Further exploration of the etiology of bone cysts may aid in the prevention and treatment of cystic formation in the TAR. Level of Evidence: Level IV, case series.

Background: The prevalence of obesity in the United States is staggering. Currently, the effect of obesity on third-generation total ankle replacement (TAR) is unknown. Methods: We prospectively identified a consecutive series of 455 primary TARs operated between May 2007 and September 2013 who had a minimum follow-up of 2 years. We identified 266 patients with a body mass index (BMI) 35 (Obese II). Clinical outcomes including wound issues, infection rate, complications, and failure rates were compared. Functional outcomes including American Orthopaedic Foot & Ankle Society hindfoot score, Short Form–36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), Foot and Ankle Disability Index (FADI), and Foot and Ankle Outcome Score (FAOS) were compared. Average patient follow-up in the Obese I group was 44.7 ± 17.3 months, Obese II was 42.7 ± 16.4 months, and 45.2 ± 17.4 months in the control group. Results: Age, race, and smoking history in the obese group were not significantly higher than the control group; however, sex was significantly related to BMI. There was no difference in complication, infection, or failure rates between the groups. Preoperatively, the Obese II group had significantly lower SF-36 scores and higher SMFA function, FADI, and FAOS Symptoms scores. For each of the Obese I, Obese II, and control groups, all functional outcome scores 1 year postoperatively and at most recent follow-up were significantly improved. However, at most recent follow-up, Obese II patients had lower FAOS Pain and SF-36 scores and higher FADI and SMFA Functional scores. Conclusion: Total ankle arthroplasty in obese patients was a relatively safe procedure. Although obese patients after TAR had lower functional outcome scores compared to their nonobese counterpart, they did experience significant functional and pain improvements at most recent follow-up. Level of Evidence: Level III, comparative series.

Background: As the incidence of diabetes mellitus (DM) grows, managing patients with diabetes and concomitant ankle arthritis poses a challenging clinical dilemma. While diabetes is known to be a risk factor for complications relating to open reduction and internal fixation of ankle fractures, it is unclear if DM is a risk factor for negative outcomes after total ankle replacement (TAR). Methods: We retrospectively identified a consecutive series of 813 primary TARs performed between 2002 and November 2013 that had a minimum follow-up of 1 year. Within that larger group, we identified 50 patients with DM and used a control group without DM for comparison (n = 55). Clinical outcomes including wound issues, infection rates, complications, and failure rates were then compared. Functional outcomes, including American Orthopaedic Foot & Ankle Society hindfoot score, Short Form–36 (SF-36), Short Musculoskeletal Function Assessment, Foot and Ankle Disability Index, and visual analog scale, were also compared. Median patient follow-up was 2.3 years in the DM group and 3.1 years in the control group ( P = .239). Results: The body mass index, age, preoperative American Society of Anesthesiologists (ASA) grading, and smoking history in the DM were significantly higher than in the control group. While 5 patients (10%) in the DM group had secondary operations related to the TAR, no patients had a superficial or deep infection. Eight patients (14.5%) in the control group had secondary operations, including 1 patient who needed a flap. There was no statistical differences in secondary operations ( P = .562), revisions ( P = .604), or failure rates ( P = .345). For both the diabetes and control groups, all functional outcome scores except SF-36 General Health significantly improved at 1 year postoperatively; these improvements were maintained at most recent follow-up. There was no statistically significant difference between the groups regarding functional outcomes except that at 1 year, the magnitude of improvement in SF-36 General Heath was significantly better in the control group. Conclusions: Total ankle arthroplasty appears to be an effective and safe means for providing pain relief and improving function in patients with diabetes and ankle arthritis. While patients with DM were heavier and had worse ASA preoperative grades, they did not have a significantly different complication or infection rate. Level of Evidence: Level III, retrospective comparative study.

Background: Contemporary total ankle prostheses embody design changes intended to address weaknesses in first-generation implants. Due to these changes, outcomes of the newer designs are of particular interest. We have previously published self-reported patient outcomes for the STAR (Scandinavian Total Ankle Replacement) prosthesis. The present study documents radiographic outcome measurements for the STAR prosthesis at intermediate to long-term follow-up. Methods: Of 89 consecutive ankle replacements performed between July 1998 and April 2007, 79 had a minimum follow-up of 2 years and were followed prospectively. Serial radiographs were measured by 2 of the authors, including varus, valgus, alpha, beta, and gamma angles, as well as point contact ratio. Inter- and intrarater reliability was calculated and reported. A “severe” subgroup of patients with preoperative coronal plane deformity exceeding 10 degrees was assessed separately. Preoperative and immediate postoperative measurements were compared and maintenance of correction evaluated on subsequent radiographs. Heterotopic ossification and pericomponent lucency were documented and followed, and subsequent procedures were recorded to follow survivorship. The mean follow-up was 8.0 years. Results: Of the 79 ankles, 25 underwent a secondary surgery (31.6%). Coronal correction averaged 5.1 degrees ( P < .001), and this was maintained to final follow-up. The severe subgroup (n = 21), with a mean preoperative coronal angulation of 16.1 degrees, was corrected to 4.6 degrees at final follow-up ( P < .001). The severe subgroup had a higher secondary surgery rate at 33.3%, with metallic component revision or failure occurring in 3 cases (14.3%) compared to 8 (10.1%) in the entire cohort. The heterotopic ossification rate was 100%, slightly higher than prior reports. Conclusions: STAR prosthesis survivorship was similar to that documented in prior studies of second-generation implants in European patient cohorts. Statistically significant correction in coronal alignment was achieved immediately after surgery and maintained until a final mean follow-up of 8 years, even in patients with preoperative deformity greater than 10 degrees. Level of Evidence: Level III, retrospective cohort study.

Background: This series reviews the clinical and radiographic outcomes of patients who underwent total ankle replacement (TAR) using first- and second-generations of a modern fixed-bearing prosthesis utilizing a modular intramedullary stem. Methods: A consecutive series of first- and second-generation primary TARs with modular intramedullary stems were identified. Clinical outcome data were collected prospectively—including visual analog scale for pain, American Orthopaedic Foot & Ankle Society hindfoot-ankle, Short Musculoskeletal Function Assessment, and Short Form–36 scores. Preoperative coronal plane deformity and correction of deformity after TAR were assessed. Complications, subsequent procedures, and failure rates were compared. A total of 193 first- and 56 second-generation patients were identified with a mean follow-up of 3.7 and 2.1 years, respectively. Results: Clinical outcome data reflected significant improvements at 1 year postoperatively, and improvements were maintained at 2-year follow-up for each group. Improvement in visual analog scale scores were significantly better in the second-generation group at 1 year postoperatively, but this was not maintained at 2 years. Mean coronal tibiotalar angles for ankles with preoperative varus or valgus deformities were significantly improved. Correction was maintained until final follow-up, with no significant differences in deformity improvement between groups. The rate of reoperation at 2 years postoperatively on the affected foot or ankle subsequent to the index ankle replacement for patients in the first-generation group (18.5%) was higher compared to the second-generation group (15.9%), but the time until reoperation was not statistically significant ( P = .376). The implant failure rate was higher in the first-generation group (6.0%) compared to the second-generation group (2.6%) at 2 years postoperatively, but the time until failure was not significantly different ( P = .295). Conclusion: Patients who underwent TAR with a first- or second-generation fixed-bearing prosthesis with an intramedullary tibial component demonstrated significant improvements in all measures of pain and function with sustained improvements in coronal plane alignment. The second-generation prosthesis demonstrated slightly better improvements at 1 year and was associated with lower reoperation and implant failure rates. Level of Evidence: Level II, comparative series.

Background: There has been a continuing increase in the use of total ankle arthroplasty for the treatment of end-stage ankle arthritis. Our aim was to determine the clinical, radiographic, and functional outcomes of total ankle arthroplasties done with a prosthesis with a modular intramedullary stem and intramedullary referencing to align the tibia. Methods: A consecutive series of patients who underwent total ankle arthroplasty with the INBONE Total Ankle Replacement from June 2007 to December 2010 were enrolled in this study. Pain and patient-reported function were assessed with use of a visual analog scale (VAS) for pain, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the Short Musculoskeletal Function Assessment (SMFA), and the Short Form-36 (SF-36) Health Survey. Objective function was measured with assessment of walking speed, the Timed Up and Go (TUG) test, the Sit-to-Stand (STS) test, and the Four Square Step Test (4SST). Standardized weight-bearing radiographs obtained preoperatively and after total ankle arthroplasty were evaluated. We analyzed clinical, functional, and radiographic measurements with a series of repeated-measures analyses of variance (ANOVAs) with post-hoc testing to assess differences between preoperative, one-year postoperative, and most recent follow-up data. On the basis of the number of statistical comparisons, a Bonferroni correction was completed (alpha < 0.003). Results: We identified 194 primary INBONE total ankle arthroplasties with a mean duration of clinical follow-up of 3.7 years (range, 2.2 to 5.5 years). Patients demonstrated a significant improvement (p < 0.003) in VAS pain, AOFAS, SMFA, and SF-36 scores at the time of final follow-up, compared with preoperative values, and in walking speed, STS time, TUG time, and 4SST time at two years postoperatively, compared with preoperatively. The mean coronal tibiotalar angle for varus and valgus ankles significantly improved postoperatively and was maintained until the time of final follow-up. The prevalence of unstable subsidence leading to impending failure was 5%, and the prevalence of revision was 6%. Conclusions: Patients who underwent total ankle arthroplasty with the INBONE Total Ankle Replacement demonstrated significant improvement in radiographic, functional, and patient-reported outcome scores at a mean of 3.7 years postoperatively. The overall implant survival rate was 89%. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Although medial-sided stress fractures of the foot and ankle are a relatively uncommon injury, the delay in diagnosis and improper treatment can cause long-term pain and functional loss. Evaluation of medial-sided foot and ankle pain in the athlete prompts careful consideration and merits a heightened awareness of subtle stress injuries. Once the diagnosis is made, treatment for both navicular and medial malleolus stress fractures are hotly debated—ranging from a simple reduction in sports activities to strict non–weight bearing to operative intervention. In this technique guide, we sought not only to provide techniques for treating these uncommon stress fractures, but also to supplement this with diagnostic criteria, the current state of evidence-based practice, and the clinical rationale for such treatment modalities.

Background: Structural or bulk osteochondral allograft transplantation for shoulder talar osteochondral lesions as a salvage procedure has demonstrated efficacy in several retrospective reviews. The purpose of this study was to evaluate prospectively patients who received fresh structural allograft transplantation to the talus. Methods: Prospective evaluation of a consecutive series of patients who underwent fresh structural allograft transplantation for an osteochondral lesion of the talus (OLT) was performed. Preoperative magnetic resonance imaging (MRI) and/or computed tomography (CT) and plain radiographs were obtained on all patients. The following patient-reported outcomes questionnaires were administered preoperatively and yearly after surgery: 100-mm visual analog scale (VAS) pain scale, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, Short Form 36 (SF-36), and the Short Musculoskeletal Functional Assessment (SMFA). Preoperative and postoperative radiographs were assessed for allograft incorporation and subsequent arthritis. Fourteen patients with an average age of 40 years (range, 18-69) and a mean follow-up of 55 months (range, 24-97) underwent structural fresh osteochondral allograft transplantation to the talar shoulder. Results: The average size of the OLT was 2269 mm3 (range, 813-8366) based on CT imaging and 5797 mm3 (range, 1136-12 489) based on MRI imaging. There was significant ( P < .05) improvement in the VAS pain, AOFAS scale, SF-36, and SMFA scores. Five (36%) of the patients required additional surgery for pain and stiffness. Two patients had cartilage delamination and were considered treatment failures. Therefore, the success rate was 86% (12/14). Conclusion: Significant improvement in pain and function was achieved with structural allograft transplantation for large OLTs at midterm follow-up. This was a safe and effective treatment option in this small series for large OLTs. Level of Evidence: Level IV, prospective case series.

Category: Ankle, Ankle Arthritis, Hindfoot Introduction/Purpose: A variety of operative approaches and fixation techniques have been described for tibiotalocalcaneal (TTC) arthrodesis. As a durable, load-sharing device with favorable biomechanical properties, the intramedullary (IM) nail is commonly used. Lateral, fixed-angle plating continues to be popular as well, due to ease of use and lack of significant clinical inferiority. A lateral approach with distal fibula resection allows for direct access to the tibiotalar and subtalar joints, but the posterior, Achilles tendon-splitting (PAS) approach offers a robust soft tissue envelope. The purpose of this study was to compare the results of TTC arthrodesis with either PAS approach and IM nailing or lateral, trans-fibular (LTF) approach with lateral, fixed- angle plating. Methods: Following institutional review board approval, all patients who underwent simultaneous tibiotalar and subtalar arthrodesis were identified with minimum one year clinical and radiographic follow up. A retrospective review of all clinic notes, operative details, and radiographs was performed by a fellowship-trained orthopaedic foot and ankle surgeon not associated with the procedures. Patients were excluded if they underwent TTC arthrodesis through an approach other than PAS or LTF, and received fixation without an IM nail or lateral, fixed-angle plate. Primary outcomes examined were union rate and complications. Statistical analysis was performed with student’s t-test for continuous data and Chi-square test for categorical variables. P-values less than 0.05 were considered significant. Results: 38 patients underwent TTC arthrodesis with a PAS approach and IM nailing, and 28 with a LTF approach and lateral plating. The overall union rate for the PAS/IM nail group was 76.3% (29 of 38), and 64.3% (18 of 28) for LTF/lateral plating group (p=0.41). 15.8% (6 of 38) in the PAS/IM nail group underwent revision arthrodesis versus 7.1% (2 of 28) in the LTF/lateral plating group (p=0.45). Nonunion at the subtalar joint occurred in 25.0% (7 of 28) in the LTF/lateral plating group and 5.3% (2 of 38) in the PAS/IM nail group (p=0.03), but there was not a significant difference in tibiotalar union. Patients were allowed to bear weight 3 weeks earlier in the PAS/IM nail group (11.2 vs 14.4 weeks, p=0.01). Conclusion: Despite similar overall union rates, nonunion of the subtalar joint was significantly increased in the LTF/lateral plating group. This could be due to disruption of blood supply during exposure, insufficient stability, or inadequate compression of the arthrodesis site. However, revision arthrodesis rates were similar between groups because some nonunions were not symptomatic enough to warrant correction. Patients were allowed to fully weight bear significantly earlier in the PAS/IM nail group. PAS approach and IM nailing for TTC arthrodesis may allow for quicker recovery and increased likelihood of radiographic union at the subtalar joint.

The Salto Talaris total ankle replacement is a modern fixed-bearing implant used to treat symptomatic ankle arthritis with the goals of providing pain relief, restoring mechanical alignment, and allowing motion of the ankle joint. The goal of this study was to report the midterm clinical results of one of the largest cohort of patients in the United States who underwent ankle replacement with this prosthesis.This is a review of patients with a minimum of 5 years up to 10 years' follow-up. At the preoperative visit and each annual assessment, patients rated their current level of pain using the visual analog score (VAS) and reported their functional level using the American Orthopaedic FootAnkle (AOFAS) ankle-hindfoot scores, the Short Musculoskeletal Function Assessment (SMFA), and the Short Form-36 (SF-36) Health survey. These scores were analyzed to assess differences between their levels preoperatively, 1 year postoperatively, and at their most recent follow-up. Criteria for failure was defined as revision requiring exchange or removal of the metallic components for any reason. We identified 106 patients having a Salto Talaris total ankle replacement. Seventy-two patients (mean age, 61.9 years) met the minimum requirement for follow-up (range 60-115 months, mean 81.1 months).Significant improvements were seen in the VAS, SMFA, AOFAS score, and SF-36 from preoperatively to their final follow-up ( P.001). Survivorship was 95.8% for those with at least 5-year follow-up, with 2 patients undergoing revision arthroplasty for aseptic loosening and a third patient scheduled for revision for a chronic wound infection. Fourteen patients (19%) required an additional surgery for a total of 17 additional operative procedures on the ipsilateral ankle or hindfoot.Patients undergoing total ankle arthroplasty with the Salto Talaris prosthesis continued to show significant improvements in pain and functional outcomes at midterm follow-up. This prosthesis has shown to be an effective treatment option with durable results.Level IV, therapeutic, case series.

This study attempted to identify where motion occurs after total ankle replacement, the difference in range-of-motion contributions between fixed-bearing and mobile-bearing total ankle replacements, and the contribution of abnormal peritalar motion. We hypothesized that sagittal plane radiographic assessment would demonstrate that actual ankle motion through the prosthesis is less than the total arc of ankle motion that may be observed clinically secondary to contributions from adjacent joints.Patients underwent routine standardized weight-bearing maximum dorsiflexion and plantar flexion sagittal radiographs. Sagittal plane ankle and foot measurements were performed on each dorsiflexion and plantar flexion radiograph to determine the total arc of ankle motion, actual ankle motion through the prosthesis, motion through the subtalar and talonavicular joints, and midfoot motion. Motion radiographs were routinely made at 1 year postoperatively and at the time of the most recent follow-up. A minimum follow-up of 2 years was required of all patients.There were 197 patients who met the inclusion criteria (75 INBONE, 52 Salto Talaris, and 70 STAR prostheses). The mean time to the latest radiographs (and standard deviation) was 42.9 ± 18.8 months. The mean actual ankle motion through the prosthesis was 25.9° ± 12.2°, which was significantly less (p0.001) than the mean total motion arc of 37.6° ± 12.0°. The motion of the ankle accounted for 68% of total range of motion, and motion of the peritalar joints accounted for 32%. There was no significant difference (p0.05) among the 3 prostheses or when comparing fixed and mobile-bearing designs for both ranges of motion.This study demonstrates that actual ankle motion after total ankle replacement is approximately 12° less than the total arc of motion that might be observed clinically because of increased midfoot and subtalar motion.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Concomitant procedures are being performed with total ankle replacement (TAR) to improve alignment, function, and mobility. The purpose of this study was to examine the differences in outcomes between patients who had a concomitant triceps surae lengthening (gastrocnemius recession [GSR] or triple hemisection [TAL]) versus a group that underwent TAR alone preoperatively and 1 year after TAR. Methods: For this prospective, nonrandomized study, 229 patients (37 GSR, 22 TAL, and 170 TAR alone) were examined. Patient-reported outcomes, physical performance, and lower extremity gait mechanics were completed preoperatively and 1 year postoperatively. A series of repeated measures ANOVAs were used to determine significant differences ( P < .05), and Tukey’s post hoc testing was used to follow any significant ANOVA results. Results: No difference existed in BMI, age, gender, or dorsiflexion (DF) angle at heel strike between the triceps surae lengthening groups or between preoperative and 1 year following TAR. Walking speed, the physical performance measures, the AOFAS Hindfoot Score, SF-36, peak plantar flexion angle, and the peak plantar flexion moment were significantly improved ( P < .001) postoperatively with no differences between the triceps surae lengthening groups. The peak DF angle ( P = .006) and the ankle range of motion ( P = .014) demonstrated a greater improvement from preoperative to 1 year postoperatively in the triceps surae lengthening groups in comparison to the TAR alone group. Conclusion: Significant improvements existed between preoperative and 1 year postoperatively for most of the variables of interest independent of the triceps surae lengthening group. This study demonstrated that the use of a concomitant triceps surae lengthening procedure (GSR or TAL) resulted in equivalent outcomes when compared with a group undergoing TAR alone. Level of Evidence: Level II, prospective comparative study.

Background: The popularity of total ankle replacement as a treatment for end-stage arthritis continues to grow. The purpose of this study was to assess changes in ankle kinetics and kinematics from a preoperative time point through two years postoperatively in patients who had received either a fixed-bearing or a mobile-bearing implant. Methods: Ninety patients who received a primary total ankle replacement (forty-nine mobile-bearing and forty-one fixed-bearing) were examined. Three-dimensional joint mechanics and ground reaction forces were measured during level walking preoperatively and one and two years postoperatively. Patient-reported and functional outcomes were also collected. Data were analyzed with use of a 3 × 2 repeated-measures analysis of variance (ANOVA) to determine significant differences between implant types and across time (α = 0.05). Results: No significant difference was observed in the ankle motion or step time between implant types or across time. However, there was a greater increase in the peak plantar flexion moment and the Short Form-36 (SF-36) total score across time in the fixed-bearing group than in the mobile-bearing group. Conversely, visual analog scale (VAS) pain scores exhibited greater improvement in the mobile-bearing group than in the fixed-bearing group. Independent of implant type, a significant improvement was observed in walking speed, results of the functional tests, spatiotemporal variables, patient-reported outcomes, and vertical ground reaction forces. Independent of time, the fixed-bearing group demonstrated a significant increase in both the weight-acceptance and the propulsion ground reaction forces compared with the mobile-bearing group. The mobile-bearing group completed the Sit-to-Stand test significantly faster. Conclusions: All of the observed changes suggest improved or maintenance of function following total ankle replacement. In general, the group with a fixed-bearing implant demonstrated improvements in ankle moment and ground reaction forces, while the mobile-bearing-implant group demonstrated improvements in patient-reported pain outcome. There were few significant changes between the two implant types. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Following total ankle replacement (TAR) patients demonstrate improvements in gait. The purpose of this study was to assess the changes in gait symmetry from a pre-operative assessment through two years following TAR.Seventy-eight patients who received a primary TAR and had no contralateral pain were examined. Three-dimensional joint mechanics and ground reaction forces were collected during seven walking trials pre-operatively, and 1 and 2-years post-operatively. Data was analyzed using a 2×3 repeated measures ANOVA to determine significant differences between limbs and across time points (α=0.05).Walking speed improved from pre-operative to each post-operative time point (P.001; ES=1.5). Peak dorsiflexion was not changed across time or between sides, however, the dorsiflexion angle at heel strike was increased on the nonsurgical side (P=0.049; ES=0.32). Peak plantar flexion moment (P.001; ES=.80), stance (P.001; ES=.29) and step time (P.001; ES=.41) were improved from pre-op to 1year post-surgery on the surgical side. Step (P.001; ES=1.2) and stride length (P.001; ES=1.2) demonstrated improvements across all time points, while the weight acceptance (P.001; ES=.27) and propulsion ground reaction forces (P.001; ES=.22) showed improvements between pre-op and 1year post-op.The results of the study indicate that the patients are able to walk faster and demonstrate an improvement in gait symmetry; however, this improvement does not return the patient to a symmetric walking pattern by 2years post-TAR.

Fifth metatarsal stress fractures are common in sports and often result in delayed and non-union. The purpose of this study was to examine the effect of a rigid carbon graphite footplate (CGF) on plantar loading during take-off and landing from a jump. Nineteen recreational male athletes with no history of lower extremity injury in the past 6 months and no foot or ankle surgery in the past 3 years participated in this study. Subjects completed 7 jumping tasks while wearing a standard running shoe and then the shoe plus the CGF while plantar loading data was recorded. A series of paired t-tests were used to examine differences between the two footwear conditions independently for both takeoff and landing (a = 0.05). The contact area in the medial midfoot (p < .001) and forefoot (p = .010) statistically decreased when wearing the CGFP. The force–time integral was significantly greater when wearing the CGFP in the middle (p < .001) and lateral forefoot (p = .019). Maximum force was significantly greater beneath the middle (p < .001) and lateral forefoot (p < .001) when wearing the CGFP, while it was decreased beneath the medial midfoot (p < .001). During landing, the contact area beneath the medial (p = .017) and lateral midfoot (p = .004) were significantly decreased when wearing the CGFP. The force– time integral was significantly decrease beneath the medial midfoot (p < .001) when wearing the CGFP. The maximum force was significantly greater beneath the medial (p = .047) and middle forefoot (p = .001) when the subject was wearing the CGFP. The maximum force beneath the medial midfoot (p < .001) was significantly reduced when wearing the carbon graphite footplate. The results of the study indicate that the CGF is ineffective at reducing plantar loading during jumping and landing.

Background: Peroneal tendon tears are relatively common; however, there are few reports on the long-term success of operative treatment. The purpose of this study was to review the long-term clinical and patient-reported outcomes of a cohort of patients with peroneal tendon tears treated with debridement and primary repair. Methods: Patients who underwent debridement and primary repair of tears of the peroneus longus and brevis from 1994 to 2008 were included in the study. A chart review was performed to determine patient demographics, postoperative complications, and return to sport. Clinical outcomes scores used to assess patients preoperatively and at most recent follow-up included a visual analog scale (VAS) for pain, the SF-12 Health Survey, and the Lower Extremity Functional Scale (LEFS) questionnaire. Results: We identified 34 patients with a tear of one or both peroneal tendons treated operatively by a single surgeon. Eighteen patients participated in the follow-up survey with an average follow-up time of 6.5 years (range, 2-14 years). There was significant improvement in mean VAS pain scores at the time of final follow-up ( P < .001) from a mean of 39 (range, 0-80) preoperatively to a mean of 10 (range, 0-52) postoperatively. In addition, there was a significant increase in the LEFS score from a mean of 45 (range, 23-70) preoperatively to a mean of 71 (range, 24-80) postoperatively ( P < .001). Of the 18 patients who responded, 17 returned to full sporting activity without limitation. There were no reoperations or operative failures during this time interval. Conclusions: Our study found excellent long-term functional outcomes for patients with tears of the peroneal tendons treated with debridement and primary operative repair. Moreover, we observed that the majority of patients returned to their previous level of activity without the need for reoperation or revision of the repair. Level of Evidence: Level IV, case series.

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.

Background: Irreparable peroneal tendon tears are uncommon and require complex surgical decision making. Intercalary segment allograft reconstruction has been previously described as a treatment option; however, there are no reports of the outcomes of this technique in the literature. We describe our technique and present our results using this method. Methods: A retrospective chart review was conducted to identify all patients who underwent intercalary allograft reconstruction of the peroneal tendons. Mechanism of injury, concomitant operative procedures, pertinent radiographic findings, pre- and postoperative physical examination, intercalary graft length, medical history, visual analog scale (VAS) score for pain, Short Form-12 (SF-12) physical health survey, Lower Extremity Functional Score (LEFS), and complications were reviewed. Results: Fourteen patients with peroneal tendon ruptures requiring reconstruction were identified. Mean follow-up was 17 months (range, 7-47 months; median, 12 months). The average length of the intercalary segment reconstructed was 10.8 ± 3.8 cm (range, 6-20 cm). The average postoperative VAS score decreased to 1.0 ± 1.4 ( P = .0005). No patient had a higher postoperative pain score than preoperative pain score. Average postoperative eversion strength as categorized by the Medical Research Council grading scale improved to 4.8 ± 0.5 ( P = .001). The average SF-12 score improved to 48.8 ± 7.8 ( P = .02). The average LEFS improved to 86.4. ± 14.9 ( P = .00001). Four patients experienced sensory numbness in the sural nerve distribution, and 2 of these were transient. There were no postoperative wound healing complications, infections, tendon reruptures, or reoperations. No allograft associated complications were encountered. All patients returned to their preinjury activity levels. Conclusion: Allograft reconstruction of the peroneal tendons can improve strength, decrease pain, and yield satisfactory patient-reported outcomes. It can be performed without incurring the deleterious effects associated with tendon transfer procedures. We believe that allograft reconstruction is a safe and useful alternative in the treatment of irreparable peroneal tendon ruptures. Level of Evidence: Level IV, retrospective case series.

Background: Adult-acquired flatfoot deformity is usually secondary to failure of the tibialis posterior tendon, with secondary injury to the surrounding osseous-ligamentous complex. Rarely, patients may present with a normal tibialis posterior tendon and an isolated injury of the plantar calcaneonavicular, or spring, ligament. The current study describes the clinical presentation and operative management of 6 patients with isolated spring ligament ruptures who presented with symptomatic flexible flatfoot deformities. Methods: Six consecutive patients with unilateral flatfoot deformities secondary to spring ligament failure were operatively treated at one institution between 2003 and 2010. All patients presented with symptomatic flatfoot deformities recalcitrant to conservative management. No patients had previous flatfoot reconstructive surgery, but all had undergone some combination of orthotic use, immobilization, or activity modifications prior to operative treatment. In each case, intraoperative findings demonstrated a tear of the spring ligament complex with a normal tibialis posterior tendon. To address the deformities, spring ligament repairs and adjunctive flatfoot reconstructions were performed. A retrospective chart study was performed to document patient presentation, demographics, and outcomes. Results: Average patient age was 42 years. All 6 patients were female. All patients presented with medial foot pain for a mean of 27 months prior to presentation. Spring ligament abnormality was demonstrated in all 5 patients who received preoperative magnetic resonance imaging. Intraoperatively, all 6 patients demonstrated spring ligament tears and no significant tibialis posterior tendon abnormality. All 6 patients underwent spring ligament repairs with or without adjunctive flatfoot reconstructions. At mean follow-up of 13 months, all but 1 patient were pain-free without orthotics, and all patients were without residual deformity. There was a single patient with delayed bone graft healing and no other minor or major complications in this series. Conclusions: Adult-acquired flatfoot deformity is usually secondary to tibialis posterior tendon failure but in rare cases may be secondary to isolated spring ligament injury without tibialis posterior tendon abnormality. This unique clinical entity should be considered in patients who present with flatfoot deformities. In this study, although preoperative magnetic resonance imaging was not required, it identified a suspected spring ligament tear in all cases in which it was used. Thorough intraoperative exploration can identify an injury to the spring ligament and a normal tibialis posterior tendon. Failure to recognize an isolated spring ligament injury as the primary cause of a flatfoot deformity could lead to inappropriate operative management. Level of Evidence: Level IV, retrospective study.

Background: An increasingly popular ankle fusion method uses plates and screws positioned on the anterior aspect of the tibiotalar joint. This study compared the mechanical properties of 2 contemporary plate systems for ankle arthrodesis, one based on a single anterior plate and the other comprising paired anteromedial and anterolateral plates. Methods: Ten matched pairs of fresh-frozen cadaver ankle joints underwent arthrodesis with a single anatomically contoured anterior plate or 2 anatomic plates applied anteromedially and anterolaterally. Each arthrodesed specimen was subjected to controlled sagittal and coronal plane bending and internal and external rotation. Tibiotalar joint bending stiffness, bending angulation, torsional stiffness, and joint rotation were documented. Results: Bending stiffness of the 2-plate system was 1.5 to 5 times greater than that of the single-plate system in plantarflexion, dorsiflexion, eversion, and inversion ( P = .005-.050). Angulation in each bending direction was several-fold greater than for the single plate ( P = .005-.014) at the peak applied moment. Torsional stiffness of the 2-plate system nearly doubled that of the single plate in both rotation directions ( P = .014, P = .005). Approximately half as much arthrodesis site rotation occurred with 2-plate fixation at the peak applied torque ( P = .005, P = .007). Conclusion: The tested 2-plate arthrodesis system has the potential to optimize arthrodesis site stiffness compared with fixation with a contemporary single plate. Clinical Relevance: Use of the stiffer 2-plate system could improve the clinical fusion rate, especially in patients with suboptimal bone quality.

Background: Triple arthrodesis through a 2-incision approach has been the primary salvage procedure for rigid hindfoot malalignment resulting from posterior tibialis dysfunction. However, complications like calcaneocuboid joint nonunion, lateral wound dehiscence, and adjacent joint arthritis have been reported after triple arthrodesis. Hence we adopted single-incision medial approach arthrodesis of subtalar and talonavicular joints, sparing the uninvolved calcaneocuboid joint and lateral skin. Method: We report the results of a series of 18 feet with posterior tibialis dysfunction that had correction of malalignment by this approach. Mean age at surgery was 65 years. The mean follow-up was 24 months. Results: There was statistically significant improvement in all the radiological parameters measured. There were no wound-related complications. The union rate was 89%. There were 2 malunions, and 2 feet developed valgus ankle deformity. The overall satisfaction rate among patients was 78%. Conclusion: We present a case series of treatment of posterior tibialis tendon dysfunction by arthrodesis of the subtalar and talonavicular joints through an isolated medial approach. The results were not encouraging enough to recommend adopting this approach as an alternative to triple arthrodesis. Level of Evidence: Level IV, retrospective case series.

Background Peroneal tendon injuries represent a significant but underappreciated source of lateral ankle pain. Partial thickness tears of the peroneus brevis amenable to direct repair techniques are common. Irreparable tears are uncommon and require more complex surgical decision-making. Intercalary segment allograft reconstruction has been previously described as a treatment option; however, there are no reports of the outcomes of this technique in the literature. We present our results utilizing this technique. Materials and methods A retrospective chart review was conducted to identify all patients who underwent intercalary allograft reconstruction of the peroneus brevis. Mechanism of injury, concomitant operative procedures, pertinent radiographic findings, pre- and postoperative physical examination, intercalary graft length, medical history, visual analog scores (VAS) for pain, short form-12 (SF-12) physical health survey, lower extremity functional scores (LEFS), and complications were reviewed. Results Eight patients with eight peroneus brevis tendon ruptures requiring reconstruction were indentified. Mean follow-up was 15 months (range, 10-31). The average length of the intercalary segment reconstructed was 12 cm ± 3.9 (range, 8-20). The average postoperative VAS decreased to 1.0 ± 1.6 from 4.0 ± 2.2 (p = 0.01). No patient had a higher postoperative pain score than preoperative pain score. Average postoperative eversion strength improved from 3.5 ± 1.2 to 4.81 ± 0.37 (p = 0.03). The average SF-12 survey improved from 41.1 ± 12.3 to 50.2 ± 9.31 (p = 0.06). The average LEFS improved from 53.3 ± 17.0 to 95.25 ± 10.0 (p = 0.02). Four patients experienced sensory numbness in the sural nerve distribution, and two of these were transient. There were no postoperative wound healing complications, infections, tendon reruptures or reoperations. No allograft associated complications were encountered. All patients returned to their preoperative activity levels. Conclusion Allograft reconstruction of the peroneus brevis can improve strength, decrease pain, and yield satisfactory patientreported outcomes. Importantly, this can be successfully performed without incurring the deleterious effects associated with tendon transfer procedures. Our results suggest that allograft reconstruction may be a safe and reasonable alternative in the treatment of irreparable peroneal tendon ruptures. Level of evidence Therapeutic level IV. Mook WR, Nunley JA. Allograft Reconstruction of Irreparable Peroneal Tendon Tears: A Preliminary Report. The Duke Orthop J 2013;3(1):1-7. I

Background Posterior tibial tendon insufficiency plays a large role in the pathogenesis of adult acquired flatfoot deformity (AAFD) in select patients. Transfer of the flexor digitorum longus is indicated to compensate for the loss of posterior tibial tendon function; however the role of resection of the degenerated posterior tibial tendon remains unclear. The aim of this study was to determine the effect of posterior tibial tendon resection on pain relief following surgical treatment of stage II AAFD. Methods All patients who underwent surgical treatment for stage II AAFD and posterior tibial tendon insufficiency were retrospectively reviewed. Patients were divided into two groups based on whether the degenerated posterior tibial tendon was resected or left in situ. Twenty-seven patients with a mean follow-up of 13.3 months were included in the study. A visual analog scale (VAS) score for pain was recorded for each patient pre-operatively and at final follow-up. Concomitant surgical procedures and the incidence of postoperative medial arch pain were also reported. Preoperative deformity and postoperative deformity correction were assessed by measuring the anteroposterior talar-first metatarsal angle, the talonavicular (TN) coverage angle, the lateral talar-first metatarsal angle, and the calcaneal pitch onstandard weight bearing radiographs. Results Eleven patients underwent FDL transfer and resection of the posterior tibial tendon (PTT resection group), and 16 patients underwent FDL transfer without resection of the posterior tibial tendon (PTT in situ group). A greater percentage of patients in the PTT resection group underwent lateral column lengthening (100 vs 18.8%, p < 0.001), and a greater percentage of patients in the PTT in situ group had a medial displacement calcaneal osteotomy performed (93.8 vs 18.2%, p < 0.001). There was no difference in preoperative VAS pain scores between groups, and all patients demonstrated excellent pain relief postoperatively. No patient in either group reported medial arch pain postoperatively. Radiographic assessment revealed similar deformity preoperatively in both groups, and patients in the PTT resection group demonstrated a greater correction of the TN coverage angle (9.8 ± 4.6 vs 6.0 ± 4.1 degrees, p = 0.041). Conclusion Resection of the PTT did not significantly affect postoperative VAS scores at final follow-up. It did however, correlate with a slightly greater correction of the TN coverage angle. There were no instances of pain along the medial ankle or medial arch of the foot in either group postoperatively. Future prospective studies are needed to determine whether resection of the PTT is necessary at the time of surgery for stage II AAFD. Demetracopoulos CA, DeOrio JK, Nunley JA II. Posterior Tibial Tendon Excision and Postoperative Pain in Adult Flatfoot Reconstruction: A Preliminary Report. The Duke Orthop J 2013;3(1):20-24.

Purpose A loss of active shoulder abduction due to axillary nerve dysfunction may be caused by brachial plexus or isolated axillary nerve injury and is often associated with a severe functional deficit. The purpose of this study was to evaluate retrospectively the restoration of deltoid strength and shoulder abduction after transfer of a branch of the radial nerve to the axillary nerve for patients who had sustained an axillary nerve injury. Materials and methods We retrospectively reviewed all patients who underwent transfer of a branch of the radial nerve to the anterior branch of the axillary nerve at our institution, either alone or in combination with other nerve transfers, between 2004 and 2011. We identified, by chart review, 12 patients with an average follow-up of 16.7 months (6-36 months) who met inclusion criteria. Results Active shoulder abduction significantly improved from an average of 9.6° (0-60°) to 84.5° (0-160°) (p < 0.005). Average initial deltoid strength significantly improved from 0.3 (0-2) on the M scale to an average postoperative deltoid strength of 2.8 (0-5) (p < 0.005). Five of 12 (41.7%) achieved at least M4 strength and eight of 12 (66.7%) achieved at least M3 strength. No statistically significant difference was seen when subgroup analysis was performed for isolated nerve transfer vs multiple nerve transfer, mechanism of injury with MVC vs shoulder arthroplasty, age, branch of radial nerve transferred, or time from injury to surgery. No significant change in triceps strength was observed with an average of 4.9 (4-5) strength preoperatively and 4.8 (4-5) postoperatively (p = 0.34). There were three patients who achieved no significant gain in shoulder abduction or deltoid strength for unknown reasons. Conclusion Transfer of a branch of the radial nerve to the anterior branch of the axillary nerve is successful in improving deltoid strength and shoulder abduction in most patients. Our series, the largest North American series to our knowledge, has not shown outcomes as favorable as other series. Larger multicenter trials are needed. Type of study/Level of evidence This is a retrospective case series representing a level IV study. Funding No outside funding was received and the authors have no conflicts of interest to disclose. Wray WH III, Aldridge JM III, Nunley JA II, Ruch DS, Leversedge FJ. Restoration of Shoulder Abduction after Radial to Axillary Nerve Transfer following Trauma or Shoulder Arthroplasty. The Duke Orthop J 2013;3(1):99-103.

Background: Irreparable peroneus brevis tendon tears are uncommon, and there is scant evidence on which to base operative treatment. Options include tendon transfer, segmental resection with tenodesis to the peroneus longus tendon, and allograft reconstruction. However, the relative effectiveness of the latter 2 procedures in restoring peroneus brevis function has not been established. Methods: Custom-made strain gage–based tension transducers were implanted into the peroneus longus and brevis tendons near their distal insertions in 10 fresh-frozen cadaver feet. Axial load was applied to the foot, and the peroneal tendons and antagonistic tibialis anterior and posterior tendons were tensioned to 50% and 100% of physiologic load. Distal tendon tension was recorded in this normal condition and after sequential peroneus brevis-to-longus tenodesis and peroneus brevis allograft reconstruction. Measurements were made in 5 foot inversion/eversion and plantarflexion/dorsiflexion positions. Results: Distal peroneus brevis tendon tension after allograft reconstruction significantly exceeded that measured after tenodesis in all tested loading conditions ( P ≤ 0.022). With 50% of physiologic load applied, peroneus brevis tension was 1% to 28% of normal (depending on foot position) after tenodesis and 73% to 101% of normal after allograft reconstruction. Under the 100% loading condition, peroneus brevis tension was 6% to 43% of normal after tenodesis and 88% to 99% of normal after reconstruction with allograft. Distal peroneus longus tension remained within 20% of normal under all operative and loading conditions. Conclusion: Allograft reconstruction of a peroneus brevis tendon tear in this model substantially restored distal tension when the peroneal tendons and their antagonists were loaded to 50% and 100% of physiologic load. Tenodesis to the peroneus longus tendon did not effectively restore peroneus brevis tension under the tested conditions. Clinical Relevance: Because tenodesis was demonstrated to be ineffective for restoration of peroneus brevis function, this procedure may result in an imbalanced foot clinically.

Category: Ankle Arthritis Introduction/Purpose: Patients with ankle arthrodesis exhibit hypermobility of adjacent joints that is hypothesized to result in accelerated arthritis. One theoretical advantage of total ankle replacement (TAR) over arthrodesis is preserved ankle motion and reduced stress on adjacent joints. We hypothesized that sagittal plane radiographic assessment will demonstrate “true” ankle motion of the prosthesis is less than the total arc of hindfoot motion secondary to contributions from adjacent joints. We aimed to compare fixed versus mobile-bearing prostheses for: (1) true ankle motion after TAR, (2) contribution of adjacent joint and midfoot motion that can lead to artificially inflated observed ankle motion (3) progression of subtalar and talonavicular joint arthritis. Previously described radiographic parameters were measured to allow for comparison of TAR motion to published ankle arthrodesis values. Methods: Patients underwent standardized weightbearing maximum dorsiflexion and plantar flexion sagittal radiographs. Previously described ankle and foot measurements were performed on each dorsiflexion and plantar flexion radiograph to determine the maximum observed ankle motion, true ankle motion through the prosthesis, motion through the subtalar joint, motion through the talonavicular joint, and talo-first metatarsal (midfoot) motion. Pre- and post-operative modified Kellgren- Lawrence grades of subtalar and talonavicular osteoarthritis were assigned to each patient preoperatively and latest follow-up. A minimum of two years of follow-up was needed. Results: Three prostheses were evaluated and 197 patients met inclusion criteria (75 INBONE, 52 Salto-Talaris, 70 STAR). Mean time to final ROM radiographs was 42.9 months. Mean true ankle motion through the prosthesis (25.9°) was less than the mean hindfoot motion arc (37.4°) that would be observed during clinical assessment. Mean subtalar motion was 8.6° and mean change in Meary’s angle was 16.5°. No significant difference was identified between prosthesis or fixed versus mobile-bearing design for the above parameters. The mobile-bearing STAR demonstrated more talonavicular joint motion (7.2°) than both fixed-bearing prostheses (INBONE 5.0°, p=0.02; Salto-Talaris 4.8°, p=0.02). There was no identifiable progression of modified Kellgren- Lawrence grade of subtalar or talonavicular arthritis when stratified by prosthesis or bearing type and adjusted for time to final follow-up. Conclusion: This study demonstrated that true ankle motion after TAR is approximately 10 degrees less than the total arc of clinical hindfoot motion—a difference that can be attributed to adjacent joint and midfoot motion. Additionally, no difference in true ankle motion or total arc of hindfoot motion was identified between fixed versus mobile-bearing designs. Counterintuitively, the mobile-bearing STAR prosthesis demonstrated significantly more adjacent joint talonavicular motion than its fixed-bearing counterparts. Progression of subtalar or talonavicular arthritis was not correlated with prosthesis or bearing type in this study and subtalar motion (8.6°) appears similar between TAR and historical arthrodesis controls (9.3°).

Category: Ankle Arthritis Introduction/Purpose: Cost containment is increasingly important in health care. Currently, Medicare does not reimburse for total ankle replacement (TAR) in the outpatient, ambulatory setting. Therefore, TAR in Medicare patients must be performed in the inpatient setting. The purpose of this study was to investigate if ambulatory surgery centers (ASC) can deliver lower-cost care and to identify sources of those cost savings in total ankle replacement (TAR). We hypothesize that total ankle arthroplasties cost significantly less than when performed in an inpatient setting. Methods: We performed a cost identification analysis of primary TAR at a single academic medical center. Multiple costs and time measures were taken from 574 consecutive patients over 4 years at either an inpatient facility or ASC. The relationships between total cost and operative time and multiple variables, including patient age, gender, comorbidities, type of implant used, and concurrent procedures performed were examined, using multivariate analysis and regression modeling to identify cost drivers or explanatory variables. Results: The mean operative cost over 4 years was significantly greater at the inpatient facility ($50,460) than at the outpatient facility ($46,283) (p < 0.0001, CI $3,752-$4,685). Significant cost drivers of this difference were in-patient ($1,759), physical/occupational therapy ($346), pharmacy ($233), and operating room costs ($2,752). If we were to perform all total ankle replacements in the four-year period at the ASC, the hospital system would have saved $1,445,242.00. Conclusion: The most significant predictor of cost was facility type. This study supports the use of ASC facilities to achieve efficient resource utilization in the operative treatment of total ankle arthroplasties. We also identified several specific costs and time measurements that can serve as potential targets to improve utilization.

Category: Ankle Introduction/Purpose: Tobacco use is a known risk factor for increased perioperative complications rates and having worse functional outcomes in many orthopaedic procedures. To date, no study has elucidated the effect of cigarette smoking on complications or functional outcomes scores after total ankle arthroplasty (TAA). The purpose of this study is to compare the rate of perioperative complications and outcome scores in nonsmokers, former smokers, and current smokers. Methods: We retrospectively reviewed the records of 642 patients who had TAA between June 2007 and February 2014 with a known smoking status. These patients were separated into three groups based on their smoking status: 34 current smokers, 249 former smokers, and 359 nonsmokers. Outcome scores and perioperative complications which included wound complications, talar component subsidence, periprosthetic infection, and periprosthetic bone cyst were compared between the groups. Results: When compared to nonsmokers, active smokers had a statistically significant increased risk of wound complications (Hazard ratio [HR] 3.5; p=0.03). Although the active smokers had an increased rate of talar component subsidence (HR 1.6; p=0.66) and persistent pain (HR 1.4; p=0.35), these findings were not statistically significant. Although all groups demonstrated improvement in outcome scores at 1 year and 2 year follow up compared to their preoperative scores, the active smokers showed statistically significant less improvement in their outcome scores than the nonsmokers and former smokers at 1 and 2 year follow up. Furthermore, there was no significant difference in the outcome scores or complications when comparing the nonsmokers to the former smokers. Conclusion: Patients with tobacco use undergoing TAA have a higher rate of perioperative complications and worse outcome scores compared to nonsmokers and former smokers. Furthermore, tobacco cessation appears to reverse the effects of smoking which allows TAA to be an effective and safe procedure for providing pain relief and improving function in former smokers as they have perioperative complication rates and outcomes similar to nonsmokers.

Category: Ankle Arthritis Introduction/Purpose: While it is thought that stresses through the subtalar and talonavicular joints will be decreased in total ankle replacement (TAR) relative to ankle fusion, progressive arthritis or deformity of these joints may require a fusion after a successful TAR. However, after ankle replacement, it is unknown how hindfoot biomechanics and blood supply may have been affected. Consequently, subsequent hindfoot joint fusion may be adversely affected. We hypothesize that fusion rates are not significantly affected following a TAR. Methods: We retrospectively identified a consecutive series of 1001 primary TARs performed between January 1998 and December 2014. We identified patients who underwent a secondary triple, subtalar or talonavicular arthrodesis to treat progressive arthritis or pes planus deformity. Clinical outcomes including pain and functional outcome scores, revision procedures, delayed union, nonunion, complications, and failure rates were recorded. We then compared these patients to patients who had a subtalar fusion after an ankle arthrodesis (13). Results: 26 patients required a subtalar (18), talonavicular (3), talonavicular and subtalar (3), or triple arthrodesis (2) with a mean 70.9 months follow-up. The mean time between TAR and secondary fusion was 37.5 months. 92.7% of the patients went successfully fused. Two patients (7.7%) had a delayed union. Two patients had a nonunion who had one revision talonavicular and one revision subtalar fusion. The mean time to radiographic and clinical fusion was 26.5 weeks. Pain and functional outcome scores improved significantly. There were no differences in the rates of subsequent fusions among implant choices. Compared to thirteen patients with prior ipsilateral ankle arthrodeses and subtalar fusions, patients who had TAR had a higher fusion rate (p=0.03), but did not have a longer time to fusion. Conclusion: Hindfoot arthrodesis following a TAR is safe and effective in improving function and pain. Additionally, arthrodesis following a TAR is more successful than a subtalar fusion following an ankle arthrodesis. While the time to healing is relatively long, various hindfoot fusions can be used to treat progressive arthritis and deformity with high fusion rates.