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Background: In the setting of chronic osteomyelitis following fractures about the ankle, reconstruction through bony arthrodesis may be used as a reconstructive alternative to amputation. During these cases, surgeons often avoid using internal fixation in an attempt to avoid reinfection or premature hardware failure. In this retrospective review, we analyzed the outcomes of chronic osteomyelitic patients who had an arthrodesis of the ankle using either internal or external fixation, focusing on salvage rates, infection clearance, union rates, and functional outcomes. No device was implanted into a known active infection. Methods: We performed a retrospective chart review of adult patients undergoing arthrodesis in the setting of a previously septic ankle following a traumatic injury. In each case, multiple irrigation and debridement procedures and local and systemic antibiotics were used. Infection status was determined by clinical exam, MRI, nuclear medicine studies, and ultimately bone biopsies. No fixation device was implanted in ankles with known active infections. Patients were divided into 2 cohorts: those fused with internal devices and those fused with external fixators. Thirty patients underwent a total of 32 arthrodesis procedures. Mean follow up time was 27 months (range, 6 to 144). Results: Nineteen fusions were performed using internal fixation; only 2 required amputations, therefore limb salvage was 90%. Fifteen were able to ambulate with or without the assistance of an orthosis (79%). Four patients experienced recurrent infection (21%) and 5 developed nonunion (26%). Of the 13 fusions performed with external fixators, only 1 required an amputation, putting limb salvage at 92%. Ten patients were able to walk with or without the assistance of an orthosis as their final functional status (77%). Two patients experienced recurrent infection (15%), and 4 went on to nonunion (31%). Conclusion: When analyzing these 2 fusion methods in posttraumatic patients with previously septic ankles, with the numbers available both methods achieved similar rates of limb salvage and final functional status in these patients, as well as similar rates of infection clearance and bony union. As internal fixation is often less labor-intensive for the surgeon and more palatable for the patient postoperatively, we encourage surgeons to consider arthrodesis with internal fixation once the infection is successfully eradicated, especially in a noncompliant patient population. Level of Evidence: Level III, retrospective comparative series. [ABSTRACT FROM AUTHOR]

Background: Total hip and knee arthroplasty (THA and TKA) are accessible to patients with end-stage hip and knee arthritis in most health care systems. The availability of total ankle arthroplasty (TAA) to patients with end-stage ankle arthritis is often restricted because of prosthesis cost. Ankle fusion (AF) is often offered as the only alternative. Patients should have equal access to procedures that are equivalent in total cost. We compared total costs of TAA, AF, THA, and TKA for similar cohorts in a government-funded teaching hospital. Methods: A subset of 13 TAA and 13 AF patients were selected from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database, and 13 THA and 13 TKA patients were randomly selected from the Canadian Joint Replacement Registry. Total cost was estimated from operating room time, hospital stay, surgeon billing, and equipment used. Results: Mean total cost associated with TAA was $13,500 ± 1000 and was the same as THA ($14,500 ± 1500) and TKA ($12,500 ± 1000). Mean total cost associated with AF was significantly less at $5500 ± 500. Mean operating room time was longer, but mean hospital stay was shorter for the ankle procedures compared with THA and TKA. Conclusion: All arthroplasties had similar total costs. Total ankle arthroplasty should not be denied based on prosthetic cost alone, as total procedure cost is equivalent to THA and TKA. We believe ankle fusion is a less expensive and preferable alternative for some patient groups. Level of Evidence: Level II, comparative series. [ABSTRACT FROM AUTHOR]

The article presents a study that evaluated associations between patient expectation, satisfaction, and outcome scores for ankle fusion and total ankle replacement. The study reveals the higher expectations cores of patients undergoing TAR prior to surgery than those undergoing ankle fusion, the likelihood of meeting expectation by ankle replacement compared with ankle fusion, and the higher improved satisfaction scores gained by ankle replacement patients after surgery.

Ankle arthrodesis is commonly used in the treatment of ankle arthritis. The present study compared mesenchymal stem cell (MSC) bone allografts and proximal tibia autografts as adjuncts in performing ankle arthrodesis. A total of 109 consecutive ankle fusions performed from 2002 to 2008 were evaluated retrospectively. Of the 109 fusions, 24 were excluded from the present study, leaving 85 patients who had undergone ankle arthrodesis. Of the 85 patients, 41 had received a proximal tibia autograft and 44, an MSC bone allograft. These 2 groups were reviewed and compared retrospectively at least 2 years postoperatively for the overall fusion rate, interval to radiographic fusion, and interval to clinical fusion. A modified and adjusted American College of Foot and Ankle Surgeons ankle scale was used to measure patient satisfaction. The overall fusion rate was 84.1% in the MSC bone allograft group and 95.1% in the proximal tibia autograft group ( p = .158). The corresponding mean intervals to radiographic fusion were 13.0 ± 2.5 weeks and 11.3 ± 2.8 weeks ( p ≤ .001). The interval to clinical fusion was 13.1 ± 2.1 weeks and 11.0 ± 1.5 weeks ( p ≤ .001) in the MSC bone allograft and proximal tibia autograft group, respectively. No statistically significant difference was found in the fusion rates between the MSC bone allograft and proximal tibia autograft groups. Also, no statistically significant difference was found between the preoperative and postoperative scores using a modified and adjusted American College of Foot and Ankle Surgeons ankle scale between the 2 groups ( p = .41 and p = .44, respectively). A statistically significant delay to radiographic and clinical fusion was present in the MSC bone allograft group compared with the proximal tibia autograft group; however, no difference was found in patient satisfaction. [ABSTRACT FROM AUTHOR]

Ankle arthrodesis following failed ankle replacements is a technically challenging task because of the large defect left behind after the prosthesis is removed. The usual practice is to use bulk grafts which are either autografts or allografts to fill the defect. We report our experience with the use of a titanium foam block specifically designed for fusion of failed ankle replacements. This particular method was chosen to avoid the technical difficulties and morbidities associated with the use of bulk autografts and allografts. We describe the surgical technique and early results in the first two cases performed in our unit. The satisfactory clinical and radiologic results in the two cases demonstrate the ability of the titanium foam block to simplify an otherwise complex procedure without compromising the outcome. [ABSTRACT FROM AUTHOR]

The article presents a study which investigates the effectiveness and associated complications in using recombinant human bone morphogenetic protein-2 (rhBMP-2) augmentation in high-risk foot and ankle fusions and fracture nonunion. The researchers have described the paucity of data in evaluating the potential benefits of foot and ankle surgery. It indicates that the rhBMP-2 is a safe and effective adjunct to bony union in high-risk foot and ankle surgeries.

In persons with haemophilia (PWH), repeated ankle haemarthroses lead to pain, loss of joint range of motion (ROM), and limitations in activity and participation in society. PWH are offered ankle arthrodesis (AA) to eliminate pain. In our experience, PWH are hesitant to proceed to AA due to concerns regarding gait anomalies, functional decline and complete loss of ROM. The aim of this study was to report outcomes in ROM, assistive device (AD)/ wheelchair use, activity scale and work/school absenteeism for participants in the CDC’s Universal Data Collection surveillance project (UDC) pre- and post- AA. Males with haemophilia enrolled in the UDC with first report of AA (1998–2010) were selected. Descriptive statistics were calculated using data from the annual study visit pre-AA and the follow-up visit (~12– 24 months) post-AA. The 68 subjects who fulfilled the criteria were: mean age 36.9 years (SD = 12.9); 85.3% white; 85.3% haemophilia A; 72% severe, 20.6% moderate; and 10.3% with inhibitor once during the study period. Mean loss in total arc of ankle motion was 17.02° (SD = 21.8, P ≤ 0.01) pre- compared to post- AA. For 61.8%, there was no change in use of AD for ambulation/mobility. For 85.3%, there was no change in use of a wheelchair. On a self-reported activity scale, 11.8% improved, 8.8% worsened and 79.4% did not change. Work/school absenteeism averaged 2.7 (SD = 6.4) pre- and 1.5 (SD = 6.4, P = 0.26) days per year post-AA. While ankle ROM was significantly reduced post-AA, for most subjects, there was no change in use of AD/wheelchair for ambulation/mobility. Physical activity was maintained and work/school absenteeism remained stable. [ABSTRACT FROM AUTHOR]

Purpose: We evaluated radiographic fusion at follow-up and complication rates in patients who had either iliac crest (ICBG) or femoral reamer-irrigator-aspirator (RIA) bone graft for tibiotalar fusion. Methods: We retrospectively reviewed charts and radiographs of all patients who had a tibiotalar fusion from August 2007 to February 2011. Records were analysed for patient demographics, complications, and clinical symptoms. Radiographs were reviewed in sequential order by two fellowship-trained foot and ankle surgeons and one orthopaedic surgeon who specialises in foot and ankle surgery to determine radiographic fusion at routine follow-up. Patients were contacted to determine current visual analog scores (VAS) at their graft site. Results: Mean patient age was 49.4 ± 12.1 years in the RIA group and 49.3 ± 15.4 years in the ICBG group ( p = .97). Pre-operative characteristics showed no significant differences between groups. The ICBG group had significantly more nonunions than the RIA group (six vs. one, p = 0.04). Two patients in the ICBG had chronic pain at their graft site based on their VAS score; there were none in the RIA group. Radiographic fusion at follow-up was similar between groups, with no significant difference (12.48 ± 3.85 weeks vs.12.21 ± 3.19 weeks, p = .80). Conclusions: There was a significantly higher nonunion rate in the ICBG group, but both groups had a solid radiographic bony fusion at similar follow-up time points. Our results suggest RIA bone graft is a viable alternative to ICBG for tibiotalar fusion. [ABSTRACT FROM AUTHOR]

Background: Management of distal tibial tumours with limb salvage surgery poses a challenge for the orthopaedic surgeon. This study was done to evaluate the results of fibular centralisation as a technique to reconstruct defects that occurred after resection at this site. Materials and methods: Nine patients with a mean age of 23.2 years (range 17-34) with diagnosis of osteosarcoma in four patients, Ewing's sarcoma in two, giant cell tumour in two and chondrosarcoma in one patient underwent surgical treatment for tumour in the distal tibia. All patients had wide resection of the tumour and ankle arthrodesis with centralisation of the fibula. Patients were assessed clinico-radiologically for bone union, infection and complications. The final functional outcome was estimated according to Musculoskeletal Tumor Society (MSTS) scores. Results: The mean age at the time of surgery was 23.2 years (17-34). There were five females and four males. The mean follow-up was 37 months (range 28-54 months). One of the patients with osteosarcoma had a recurrence a year after limb salvage surgery, underwent above-knee amputation, and died 18 months later due to metastasis. One patient developed leg length discrepancy. The mean MSTS score was 22.75 (range 17-27). Conclusion: Fibular centralisation is a durable reconstruction tool for defects of the distal tibial metaphysis with an acceptable functional outcome. It is an inexpensive and simple procedure, with a low rate of late complications, and reproducible results. Level of evidence: IV Retrospective case series. [ABSTRACT FROM AUTHOR]

Background: Although functional and morbidity outcomes following ankle arthrodesis have been widely studied, patterns of health care resource utilization remain unclear. The purpose of this study was to identify preoperative and postoperative risk factors for nonroutine discharge following ankle arthrodesis. A secondary study aim was to determine risk factors associated with prolonged hospital stay. Methods: Using the National Health Discharge Survey (NHDS) database for the years 2001 through 2007, an estimated 40 941 patients having undergone ankle arthrodesis were identified and separated into those who were discharged to home (routine discharge) and those who were discharged to rehabilitation facilities (nonroutine discharge). Factors influencing discharge disposition and hospital length of stay were determined using multivariable binary logistic regression analysis. Results: Risk factors for nonroutine discharge were increasing age, male sex, diabetes mellitus, atrial fibrillation, more than I general or surgery-related complication, additional days of care, and the 2005 to 2007 time period. Risk factors associated with prolonged hospital stay were advanced age, female sex, diabetes mellitus, more than I general or surgery-related complication, and the 2001 to 2004 time period. Conclusion: Early identification of these factors might prove useful for better allocation of resources and implementation of effective strategies aimed at preventing longer hospitalizations and nonroutine discharges in selected patients at risk. Level of Evidence: Level II, prognostic study. [ABSTRACT FROM AUTHOR]

Background: Total ankle replacement (TAR) has gained acceptance as an alternative to traditional ankle arthrodesis (AA)for end-stage ankle arthritis. Little is known about long-term trends in volume, utilization, and patient characteristics. Theobjective of this study was to use longitudinal data to examine temporal trends in TAR and AA.Methods: We identified all United States fee-for-service Medicare beneficiaries who underwent TAR and AA between1991 and 2010 (n = 5871 and 29 532, respectively). We examined changes in patient demographics and comorbidity,nationwide and hospital volume, per capita utilization, and length of stay (LOS).Results: Between 1991 and 2010, both TAR and AA patients had modest shifts in characteristics, with higher rates ofdiabetes and obesity. Overall, TAR Medicare volume increased by more than 1000% from 72 procedures in 1991 to 888in 2010, while per-capita standardized utilization increased 670.8% (P < .001). AA volume increased 35.8% from 1167procedures in 1991 to 1585 in 2010, while per-capita standardized utilization declined 15.6% (P < .001). The percentageof all US hospitals performing TAR increased nearly 4-fold from 3.1% in 1991 to 12.6% in 2010, while the proportionperforming AA remained relatively unchanged. LOS decreased dramatically from 8.7 days in 1991 to 2.3 days in 2010 inTAR and from 5.5 days to 3.2 days in AA (P < .001).Conclusion: Between 1991 and 2010, Medicare beneficiaries undergoing either TAR or AA became more medicallycomplex. Both volume and per-capita utilization of TAR increased dramatically but remained nearly constant for AA. Atthe same time, mean hospital volume for both procedures remained low. Further research should be directed towarddetermining design, surgeon, and hospital variables that relate to optimal outcomes following TAR, which has becomeincreasingly used for the treatment of ankle arthritis.Level of Evidence: Level III, comparative series. [ABSTRACT FROM AUTHOR]

Background: Total ankle replacement (TAR) and ankle fusion (AF) are the 2 major operative options for treatment of advanced ankle arthropathy; there is, however, no large epidemiologic study comparing nationwide trends of these 2 procedures. The current study used a nationwide database to compare epidemiologic profiles of TAR and AF. Methods: Data collected for the Nationwide Inpatient Sample (NIS) from 2000 to 2010 were reviewed. Procedures were identified by searching for ICD-9-CM codes 81.11 (AF) and 81.56 (TAR). Patients' demographics and comorbidities, geographic distribution, and cost of procedures were compared. Results: The NIS analysis identified 2666 TAR and 16 419 AF cases which was extrapolated to 13 145 TAR and 80 426 AF nationwide. Spearman's ρ showed an increase in the number of AF per year while the number of TAR cases remained relatively flat per year until 2006, after which there was a steady increase in the number of TAR performed. Patients receiving a TAR tended to be older, female, and white. Patients who underwent AF were more likely to be obese or diabetic than TAR patients. Both TAR and AF were performed more frequently in private urban hospitals through 2007. However, in 2010, the number of TAR procedures was greater in academic centers compared to private urban hospitals. Conclusions: Despite recent increases in the number of TAR implanted, AF was still performed more than 6 times more frequently for advanced ankle arthropathy. A trend was demonstrated toward an increasing number of TAR being implanted in academic centers, and in patients with more underlying comorbidities than was previously seen. Level of Evidence: Level II, prognostic study. [ABSTRACT FROM AUTHOR]

Abstract: Surgical treatment of post-traumatic avascular necrosis of the talus coupled with collapse often results in limited treatment options. Of those options, the Blair tibiotalar arthrodesis has been beneficial in preserving limb length and subtalar motion. The complications associated with Blair tibiotalar arthrodesis have led to modifications to improve stability and functional outcomes with rigid internal fixation. We present the case of a 29-year-old female with a history of an open fracture dislocation of the talus 10 years previously, with subsequent development of avascular necrosis of the talus. The purpose of the present case report was to describe the surgical approach and use of an anterior compression plate to augment the modified Blair tibiotalar arthrodesis. [Copyright &y& Elsevier]

Background: Although tibiotalar fusion has historically been considered the gold standard treatment for end-stage arthritis of the ankle, the performance of total ankle replacement appears to be gaining favor as improved outcomes have been observed with new implant designs and surgical techniques. The purpose of this study was to compare trends and demographics in the performance of ankle fusion and total ankle replacement in the United States. Methods: The Current Procedural Terminology (CPT) codes of patients undergoing ankle fusion and total ankle replacement were searched using the PearlDiver Patient Record Database, a national database of orthopaedic patients. The CPT codes for open ankle arthrodesis (27870), arthroscopic ankle arthrodesis (29899), and total ankle replacement (27700, 27702) were searched for the years 2004 to 2009 to identify relative changes in the performance of ankle fusion and replacement over time. Results: The performance of ankle fusion was unchanged during the 6-year study period. In contrast, an increase in total ankle replacement was observed, from 0.63 cases per 10 000 patients searched in 2004 to 0.99 cases per 10 000 patients in 2009 (P < .05). Both ankle fusion and total ankle replacement were performed most commonly in patients aged 60 to 69 years (P < .05). Although an even gender distribution was observed in patients undergoing total ankle replacement, open and arthroscopic fusion were more commonly performed in males (P < .05). With regard to regional distribution, open and arthroscopic fusion were most commonly performed in the western region of the United States, whereas total ankle replacement was performed most frequently in the Midwest (P < .001). Conclusions: In the population studied, the performance of total ankle replacement increased 57% from 2004 to 2009 and was performed equally in male and female patients when compared to ankle fusion, which was more often performed in males and was unchanged with time. [ABSTRACT FROM AUTHOR]

Background: To reduce fusion nonunion, autogenous bone graft is often incorporated into foot and ankle fusion procedures. B2A peptide-coated ceramic granules, with encouraging results in pilot studies of transforaminal lumbar interbody fusion, were here reformulated into Amplex with a coating concentration of 225 µg B2A/cm3 ceramic granules (B2A-granule) with the goal of eliminating autogenous bone graft in foot and ankle arthrodesis. The purpose of this study was to perform a multicenter prospective randomized pilot clinical trial designed to compare the safety and effectiveness of B2A-granule to autogenous bone graft in patients undergoing foot and ankle arthrodesis surgery. Methods: This study was a multicenter, prospective, randomized, pilot clinical trial designed to compare safety and effectiveness of B2A-granule to autogenous bone graft in patients undergoing foot and ankle arthrodesis surgery. Twenty-four patients were enrolled and randomized (1:1) into 2 groups: autogenous bone graft control and B2A-granule. Primary outcome measures at 6 months (with follow-up at 9 and 12 months) included radiographic fusion assessed by computerized tomography and Ankle Osteoarthritis Scale scores for pain and disability. Results: Radiographic fusion success rates were similar in both groups (100% in the B2A-granule group, 92% autograft). Both the B2A-granule group and the autograft group had improvements in the pain and disability scores over the course of the study. Graft harvest-site pain affected only autograft-treated patients. There were no adverse events attributed to the graft material in either the B2A-granule or autograft group. Conclusion: The results of this pilot study are supportive of a larger clinical trial to assess the safety and efficacy of B2A-granule as a bone graft substitute in foot and ankle fusions. Level of Evidence: Level II, prospective comparative study. [ABSTRACT FROM AUTHOR]

Ankle fusion in patients with haemophilia is a well-accepted treatment for end-stage arthropathy. However, current published outcome data are based on small sample sizes and generally short-term follow-up. The aim of this study was to evaluate the long-term results of ankle fusion in a large group of haemophilic patients treated at a single institution. The results of 57 ankle fusions performed on 45 patients between 1971 and 2010 were reviewed retrospectively. Data were gathered for type and severity of haemophilia, HIV status, fixation technique, postoperative complications and requirement of additional surgeries. A modified American Orthopaedic Foot & Ankle Society ( AOFAS) hindfoot score was calculated for 20 ankles available for follow-up. Patients were followed for a mean of 6.6 years. There were no intra-operative or immediate postoperative complications related to fusion of the ankle. The overall non-union rate was 10.4% for tibio-talar fusion and 8.3% for sub-talar fusion. This rate was reduced to 3.7% and 5.6%, respectively, after the introduction of newer surgical techniques in 1995. None of these non-unions required revision surgery. The modified AOFAS scale demonstrated that 75% had no pain in the operated ankle a mean of 7.2 years following surgery. The remaining 25% scored their average pain as 3 of 10. The functional portion of the score suggested that patients have good alignment, minimal activity limitations or gait abnormalities, and can walk long distances. We conclude that ankle fusion successfully relieves pain and provides a good functional outcome. It is an appropriate treatment for end-stage haemophilic arthropathy of the ankle. [ABSTRACT FROM AUTHOR]

The article reports on research which was conducted to compare the outcomes of patients who underwent ankle arthrodesis (AA) with the outcomes of patients who underwent a tibiotalocalcaneal (TTC ) arthrodesis. Researchers evaluated 173 TTC patients and 100 AA patients. They found that both AA and TTC arthrodesis were associated with good functional outcomes and satisfaction and that AA patients had higher postoperative activity expectations and were less likely to meet them.

The article discusses the correlation of fibular osteotomy in open ankle arthrodesis, the surgical procedures conducted in patients with ankle arthritis and deformity. It examines the fusion rate and clinical consequences of a novel open fibular-sparing ankle arthrodesis technique to determine the complications, patient satisfaction, and functional scoring. It notes that the technique had a high fusion rate with good patient outcome scores.

The article presents a case report of a 45-year-old woman with painful ankle arthrodesis who received bipolar fresh osteochondral allografts (BFOA) to restore ankle motion and support the midtarsal overload. The procedure which had no intra- or post-operative complications is described. The clinical and radiographic results from the 44-months followup such as range of motion are discussed.

Presently, tibiotalar fusion remains a valid treatment option in patients affected by end-stage arthritis of the ankle that is unresponsive to other treatments. Over the years, many different surgical techniques have been described to make this kind of surgery less invasive and invalidating. Consequently, the last two decades have seen arthroscopic ankle fusion gain in popularity with many studies aiming to understand its advantages compared with open surgery, indications, and contraindications. The review of literature revealed a lower rate of complication, faster recovery, and shorter time of hospitalization with arthroscopic arthrodesis, in comparison with open surgery. These characteristics, along with a reduction of costs, will probably increase the use of arthroscopic ankle arthrodesis in the near future. [ABSTRACT FROM AUTHOR]

Tibio-talo-calcaneal (TTC) arthrodesis is a procedure to treat severe ankle arthropathy by providing a pain-free and stable fusion. Intramedullary (IM) nails offer a method of internal fixation for TTC arthrodesis by providing compressive stability, as well as shear and torsional rigidity. IM nails have been developed to apply compression to the TTC complex during installation; however, current designs are highly susceptible to a loss of compression when exposed to small amounts of bone resorption and cyclic loading. Nickel titanium (NiTi) is a shape-memory alloy capable of recovering large amounts of deformation via shape-memory or pseudoelasticity. Currently, the next generation of IM nails is being developed to utilize the adaptive, pseudoelastic properties of NiTi and provide a fusion nail that is resistant to loss of compression or loosening. Specifically, the pseudoelastic IM nail contains an internal NiTi compression element that applies sustained compression during the course of fusion, analogous to external fixators. INSET: Key issues. [ABSTRACT FROM AUTHOR]

The article discusses research conducted to investigate whether one of three screws used in a common screw construct used in ankle fusion gave the greatest initial compression and should be inserted first during surgery. Researchers dissected 17 cadaver limbs. They found that there was no difference in the total contact area, percent contact area, or pressure generated between the three screws and that the mean contact area for all screws was 11% of the joint surface.

Long-term concerns about arthrodesis, including accelerated adjacent joint degenerative disease, altered gait biomechanics, nonunion rates, and activity limitations, provided an impetus for the development and refinement of total ankle arthroplasty in the treatment of end-stage ankle arthrosis. There has been a relative paucity of literature with regard to the actual impact of these surgical treatments on gait biomechanics. We present a summary of the available literature on this topic, with the goal of illuminating the differences in gait biomechanics between ankle fusion and ankle replacement. [ABSTRACT FROM AUTHOR]

Background: Both total ankle replacement (TAR) and ankle arthrodesis do show some problems in long-term studies. To choose either of these surgical options is a delicate task. There are no randomized studies reported in the literature and no previous studies in which patients constitute the own controls.Methods: Patients with a TAR and a contralateral ankle arthrodesis were identified in the Swedish Ankle Register. A self-reported foot and ankle specific questionnaire (SEFAS) was sent to these patients who also were asked to report their grade of satisfaction from 1 to 5.Results: The median SEFAS score was 32 (16-44) for the prostheses and 27 (14-47) for the arthrodeses. The median satisfaction score was 2 (1-4) for the prostheses and 2 (1-5) for the arthrodeses. There were no statistically significant difference between the prosthetic side and the fused side regarding these scores.Conclusion: Patients who had undergone ankle arthrodesis on one side and had the contralateral ankle replaced, were equally satisfied with both procedures. [ABSTRACT FROM AUTHOR]

The article presents a study that evaluates the efficacy and safety of a mobile-bearing prosthesis in the treatment of end-stage ankle arthritis. Three separate cohorts of patients including a group of Scandanavian Total Ankle Replacement (STAR) patients, a control group of ankle fusion patients and another group of STAR total ankle patients are included in the study. Treatment efficacy was higher for the ankle replacement group when the Pivotal Groups were compared and this is due to improvement in functional scores.

Introduction/Purpose: End-stage ankle arthritis has long been managed surgically with open ankle arthrodesis (OAA). More recently, arthroscopic ankle arthrodesis (AAA) is thought to be associated with improved patient-reported outcome measures (PROMs) and fewer complications. The objective of this study was to systematically compare these two approaches in long-term PROMs, major complication rates and survivorship of the ankle fusion. Methods: In this retrospective longitudinal cohort study, all patients with an ankle fusion done at our institution and a minimum two-year follow-up were screened for inclusion. Patients demographics at baseline were collected including: age, gender, BMI, smoking status, diabetes status as well as preoperative ankle arthritis COFAS (Canadian Orthopedic Foot and Ankle Society) type. The following PROMs were completed preoperatively, at 6-months and annually thereafter to five years: AAS, AOS, SF-36, expectation, satisfaction and swelling scores. PROMs were compared at all timepoints using a mixed-effects regression model adjusted for baseline patients' demographics, COFAS type and PROMs. Major postoperative complications and survival analysis/rate of revision of the ankle fusions were also compared. Results: Of 874 patients screened for inclusion, 351 ankle fusions done between 2003 and 2019 were eligible for the study, 223 AAA and 128 OAA. The two groups were similar at baseline with respect to demographics, but COFAS type was higher in the OAA group and AAS and AOS scores were better in the AAA group. At one-year post-operatively, there was a higher mean AAS score in the AAA group, but there were no other differences in outcomes at any other timepoint. Survivorship of the ankle fusion in the arthroscopic group was lower (ie higher rate of revision) due to a higher rate of amputation or fusion. Deep infection and wound complications were more common with OAA and accounted for most ankle fusion revisions in this group. Conclusion: There were no consistent differences in PROMs of patients who underwent AAA versus OAA patients up to fiveyears postoperatively. Ankle fusions done arthroscopically had a lower survivorship rate compared to those done with the open approach due to a higher rate of major complications. Previously proposed advantages of AAA over OAA may therefore need to re-assessed and weighed against the technical challenges and associated complications of the arthroscopic technique. [ABSTRACT FROM AUTHOR]

Total extrusion of the talus is a rare and severe injury of the foot. If the talus is viable and can be repositioned, the outcome is unpredictable and mainly depends on whether infection and/or avascular necrosis ensues. If the talus is actually missing, the surgeon is faced with extensive bone loss and destruction of the ankle. In this report, we present 2 cases of total talus extrusion treated with the sandwich block tibiocalcaneal arthrodesis with structural autografts harvested from iliac crest. The surgical technique is reviewed in detail, and its application in 2 male patients who had a complete talus fracture-dislocation and a dislocation, respectively, is described. Follow-up after 18 years and 1 year, respectively, showed favorable clinical outcomes and only minor restrictions in daily activities. In light of these case reports, we believe that the sandwich block arthrodesis offers a useful alternative for the treatment of these serious lower extremity injuries. [Copyright &y& Elsevier]

Introduction/Purpose: To aid in healing and avoid costly revision surgery, bone grafts, growth factors, and bone stimulation devices are used as adjuncts to foot/ankle arthrodesis. This study evaluated the union rates of LIPUS as an adjunct to foot/ankle arthrodesis and the corresponding factors associated with improved healing. Methods: Foot/ankle arthrodesis patients were identified retrospectively from a prospective post-market arthrodesis/fracture registry for EXOGEN (Bioventus LLC, Durham, NC). Inclusion criteria were males or non-pregnant females 18 years of age or older at time of enrollment, known date of fracture, known start and end dates of LIPUS treatment, and known treatment success outcome. Treatment success was defined by both clinical (solid and pain-free on manual stress) and radiological (at least 3 of 4 cortices bridged on x-rays) criteria. Association between union rates and surgical treatments, comorbidities, and medications was tested with Chi-square tests. Results: A total of 235 primary and 16 revision foot/ankle arthrodesis patients used EXOGEN. 41.4% used EXOGEN within 90 days of the fracture/arthrodesis. Overall union rate was 86.9% (primary: 86.4%; revision: 93.8%). Having the comorbidity of diabetes, obesity, or current smoker was not associated with a higher non-union rate (p=0.779). Other comorbidities were also not associated with increased non-union rates (e.g., Charcot disease p=0.614, NSAID p=0.862, steroids p=0.647). EXOGEN use within 90 days of the fracture/procedure date was associated with improved union rates for the overall (p=0.004, odds ratio (OR) 3.7 (95% CI: 1.5-9.3)) and primary (p=0.007, OR 3.4 (95% CI: 1.3-8.6)) groups. For the overall group, union rates were 94.2% (EXOGEN use <=90 days post-fracture/procedure), 80.6% (91 to 365 days), and 84.6% (>365 days). Conclusion: Union rates for foot/ankle arthrodesis with adjunctive LIPUS were comparable to other therapies with and without other adjuncts (Table 1). Known risk factors for non-union, such as smoking and Charcot disease, were not found to be associated with healing for the LIPUS patients. This suggests the possibility that LIPUS was able to mitigate potential patient risk factors and may offer a low risk post-operative adjunct in difficult healing scenarios. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Surgical management pilon fractures continue to be a challenge for orthopedic surgeons. Despite a staged protocol, anatomic reduction, and stable fixation, many patients will require secondary procedures including ankle arthrodesis to treat painful post-traumatic arthritis. Some investigators have correlated the absorbed energy at the time of the injury with the natural history of the pilon fracture despite the quality of the surgical reconstruction. We hypothesize that the presence of an intact fibula in association with an OTA Type C pilon fracture may be a marker for a strict axial compression mechanism resulting in more severe cartilage compression and a poor late outcome. No studies to date have correlated the presence of an intact fibula to pilon fracture outcomes. Methods: An IRB approved 7-year retrospective study was performed at three Level I Trauma Centers. Inclusion criteria included all adult patients (>=18) with isolated OTA type B or C pilon fractures from 2008 through 2014. All patients were treated in a staged fashion with initial external fixation by fellowship-trained orthopedic traumatologists. The primary outcome measurement was ankle arthrodesis. Secondary measurements included infection. Binary logistic regression models were used to evaluate the prognostic factors of arthrodesis and infection. Results: A total of 239 patients met inclusion criteria for analysis: 33-patients (13.81%) had open injuries, 155 (64.85%) had a C type pilon fracture and 157 fractures (65.69%) presented with an associated fibula fracture. Only 12 patients (5.02%) progressed to ankle arthrodesis. The incidence of fusion in the intact fibula group was 5 (6.10%) similar to that of 7 (4.46%) of patients with an associated fibula fracture. It was found that OTA Type C pilon fractures (OR (95% CI): 6.34 (0.80, 49.98), p=0.08), intact fibulas (OR (95% CI): 1.39 (0.43, 4.53), p=0.58), and open injuries (OR (95% CI): 2.19 (0.56, 8.55), p=0.26) were more likely to result in eventual arthrodesis compared to OTA Type B pilon fractures, fractured fibulas, and closed injuries, respectively. Conclusion: The results of this study suggest an adverse relationship for closed complex pilon fractures with an intact fibula. This was especially pronounced in C type injuries in comparison to type B injuries with a 6.34 odds ratio of subsequent fusion. The data approached statistical significance and may have clinical relevance in the decision making and patient counselling for managing these fractures. Pilon fractures historically have had poor outcomes and a higher rate of secondary surgeries which was surprisingly low in our current study. Further study needs to determine if this observation correlates with improved patient outcomes. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Non-union and delayed union are common complications following hindfoot arthrodesis. The failure to obtain and maintain compression at the arthrodesis site may be a causative factor. Partially threaded cannulated 'lag' screws are commonly used for fixation in hindfoot arthrodesis; however, the ability of these screws to maintain compression in the hindfoot bones has not been well-characterized. The goals of this work were to: 1) quantify the stress relaxation response of hindfoot bones when compressed with a lag screw, particularly compression change upon screw retightening, and 2) compare the results to prior studies on stress relaxation in direct bone compression. Methods: 12 pairs of calcaneus, talus and tibia bone cylinders, 25mm in diameter, were cut with a keyhole saw from fresh thawed cadaveric feet. The bone cylinders were prepared for simulated arthrodesis by removing the cartilage and flattening the subchondral surface with an oscillating saw. A Futek LTH 300 donut load cell and two metal washers were sandwiched between the two bone cylinders. An 8.0mm partially threaded cannulated lag screw (Smith and Nephew) was placed from the posteriorinferior aspect of the calcaneus cylinder to the anterior-superior aspect of the talus cylinder to simulate subtalar arthrodesis, or from the superior aspect of the tibia cylinder to the inferior aspect of the talus cylinder. Compression was recorded continuously as the screws were tightened by three-quarters of a turn and left untouched for 3 minutes. Recording continued as the screws were retightened one quarter-turn and then left untouched for 30 additional minutes. Results: Both initial and subsequent compression with a lag screw demonstrated a stress relaxation pattern, with increased maximum compression and slowed decay upon retightening. Maximum compression after three quarter-turns and retightening averaged 284 N and 351 N, respectively (n=12; t=-2.55; p=0.0136). Time to decay to 80% of maximum compression after three quarter-turns and retightening averaged 34 and 528 (n=9; t=-2.59; p=0.0159) seconds, respectively, compared to 21 seconds for direct compression. Compression loss 30 minutes after retightening averaged 25.5% (SD=8.8%), compared to 34.3% for direct compression. Conclusion: The maximum compression attained following retightening was significantly greater than the maximum compression attained after initial tightening. The time required to reach 80% of maximum compression was significantly longer after subsequent compared to initial maximum compression. These findings suggest that screw retightening before surgical wound closure may slow compression loss, which could increase the likelihood of successful arthrodesis. Lag screw compression resulted in a lower percent compression loss and loss rate compared to direct compression, which was previously used to describe bone viscoelasticity. [ABSTRACT FROM AUTHOR]

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Abstract: Our aim was to evaluate the outcome of tibiotalocalcaneal fusion in rheumatoid arthritis patients using the locked Supracondylar nail. Methods. Twenty-four patients (27 ankles) underwent this procedure. The mean follow up was 38.4 months. Seventeen cases had ankle debridement at the time of arthrodesis. This was aimed at correcting hindfoot deformity in addition to facilitating joint fusion. The Fries scoring system was used to assess the severity of rheumatoid disease. The rheumatoid ankle score (RAS) and modified American Orthopaedic Foot & Ankle Society Score were used to analyse functional outcome. Results. Patients with ankle debridement and intramedullary nailing had mean RAS of 80.5 and bony union in 87%. However, patients with in situ nailing without ankle debridement had mean RAS of 72 and no evidence of bony union. Conclusion. We recommend that, in patients with rheumatoid hindfoot arthritis intramedullary nail fusion is always performed with ankle debridement. [Copyright &y& Elsevier]

Background. We present a patient with a subtotal traumatic supramalleolar amputation of the leg, which was initially treated by a vascular reconstruction with deliberate bone and soft-tissue shortening. Methods. To correct the ensuing complex deformity, which consisted of a varus hindfoot, leg length discrepancy and equinus, a staged reconstruction was planned. Initially, the hindfoot varus, in presence of a stiff ankle, was corrected by a supramalleolar osteotomy, followed by a Wagner distraction and finally a correction of the equinus. Results. After a relatively long period of normal functioning, she regained painful minimal ankle function, which necessitated ankle fusion and correction of a pronation deformity. At the most recent follow-up 13 years after the injury, the patient is fully functional and has near normal leg length. Conclusion. Although a mangled lower extremity is often a candidate for primary amputation allowing early rehabilitation, in certain cases a good result can be obtained by a creative strategy. [ABSTRACT FROM AUTHOR]

Arthrodesis of the ankle and/or tibiotalocalcaneal joints is a reliable treatment of arthritic conditions of the ankle and hindfoot. It may be complicated by infection, nonunion, malunion, fracture, wound complications, nerve injury, and adjacent joint degeneration. These complications may be addressed with a variety of techniques but should be done so carefully so as not to lead to more complex problems. A thorough work-up and discussion should take place prior to any surgical intervention and treatment. Several cases are presented to illustrate revision arthrodesis techniques and the management of these complications., Competing Interests: Disclosure M.E. Brage, Bespa Global, Stryker (Wright Medical, Inc), Paragon 28, and Kinos; C.S. Mathews, no disclosures to report., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The correction of the deformed arthritic foot and ankle is a complicated and somewhat controversial topic. After conservative methods fail, there is a wide range of possible bony procedures and arthrodesis that maybe performed. The appropriate work up and understanding of the pathomechanics is vital to the correct choice of procedures to correct these deformities. Once the work up and procedure selection is done, the operation must also be technically performed well and with efficiency, as most often the condition is corrected with a variety of procedures. This article discusses some of the most common procedures necessary to fully correct deformity of the midfoot, hindfoot, and ankle. This article will also discuss the authors' technique and pearls., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Charcot neuroarthropathy (CN) is an inflammatory arthropathy associated with bony destruction, dislocation, and deformity in patients with neuropathy. Surgical procedures involving foot and ankle in CN for deformity correction have been shown to result in high rate of complications. The purpose of this study was to compare post-operative outcomes and assess odds of complication after ankle arthrodesis among patients with diabetes-related Charcot neuroarthropathy, non-Charcot patients with diabetes, and non-Charcot patients without diabetes.Methods: The PearlDiver Patient Records Database was queried for patients who underwent ankle fusion and maintained at least one year of post-operative follow-up. The following post-operative complications were assessed among groups: overall nonunion and amputation, one-year nonunion, amputation, and hardware removal, 90-day and 30-day surgical site infection, dehiscence, acute kidney injury, and pneumonia, and 90-day myocardial infarction and deep vein thrombosis. The odds and prevalence of each complication for each group were assessed and compared.Results: Higher rates of amputation (OR 3.43, CI 2.89-4.06), hardware removal (OR 1.63, CI 1.45-1.83), wound dehiscence (OR 1.75, CI 1.44-2.13), acute kidney injury (OR 2.87, CI 2.32-3.54), pneumonia (OR 1.53, CI 1.13-2.07), and surgical site infection (OR 2.46, CI 2.12-2.85), were observed in patients with diabetes-related CN compared to non-Charcot patients with diabetes. In patients without CN, higher rates of nonunion (OR 1.38, CI 1.19-1.61), amputation (OR 2.26, CI 1.74-2.93), surgical site infection (OR 1.57, CI 1.30-1.90), and acute kidney injury (OR 1.57, CI 1.18-2.09) were observed in patients with diabetes compared to patients without diabetes. Time to hardware removal was significantly shorter in diabetes-related Charcot patients compared to non-Charcot patients without diabetes (368.0 ± 446.7 vs 438.5 ± 487.5 days, P < 0.001).Conclusion: Patients with diabetes demonstrated increased odds of nonunion, amputation, surgical site infection, and acute kidney injury compared to patients without diabetes. In the population of patients with diabetes, odds of most of these complications were further increased with the addition of Charcot diagnosis compared to patients without diabetes. Other local and multisystemic medical conditions, including pneumonia and wound dehiscence, also demonstrated increased odds in patients of CN.Level Of Evidence: Cohort study; Level of evidence, 3. [ABSTRACT FROM AUTHOR]

End-stage ankle arthritis typically affects an active younger patient population as compared with hip and knee arthritis. The optimal surgical treatment depends on several patient-specific factors. Open ankle arthrodesis has achieved reliable outcomes for this condition over years; however, arthroscopic techniques seem to be advantageous and feasible even in cases with significant intraarticular deformity. This article describes the surgical technique of arthroscopic ankle arthrodesis and discusses the outcome compared with that of open ankle fusion and total ankle replacement., Competing Interests: Disclosure A-K. Leucht has nothing to disclose. A. Veljkovic has nothing to disclose pertaining this topic., (Copyright © 2021 Elsevier Inc. All rights reserved.)