Search

Background: This retrospective cohort study compared short-term complication rates following total ankle arthroplasty (TAA), alone or with concomitant procedures. Secondary independent risk factors were also examined as they related to postoperative outcomes. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology ( CPT ) codes to identify patients who underwent TAA (27702) between 2010 to 2021. Patients were divided into cohorts based on the presence or absence of ancillary procedures. Propensity score matching was employed to account for demographic differences, and statistical analyses were performed to compare short-term complication rates between matched cohorts. Results: A total of 2225 patients were identified, with 1432 (64.4%) receiving TAA alone and 793 (35.6%) with ancillary procedure(s). After matching, 793 patients were included in each cohort. The ancillary cohort had longer operative times ( P

Background: The incidence of primary total ankle arthroplasty (TAA) is rising, with a corresponding increase in revision surgeries. Despite this, research on risk factors for revision TAA following primary TAA remains limited. Radiographic soft tissue thickness has been explored as a potential predictor for outcomes in hip, knee, and shoulder arthroplasty, but its role in TAA has not been assessed. This study aimed to assess the predictive value of radiographic soft tissue thickness for identifying patients at risk of requiring revision surgery following primary TAA. Methods: A retrospective study was conducted on 323 patients who underwent primary TAA between 2003 and 2019. Radiographic measurements of soft tissue thickness were obtained from preoperative radiographs. Two novel radiographic measures of soft tissue thickness were developed and assessed (tibial tissue thickness and talus tissue thickness). Clinical variables including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, diabetes, smoking status, primary diagnosis, and implant type were recorded. Logistic regression analysis was used to assess the predictive value of soft tissue thickness and BMI for revision TAA. Results: The rate of revision surgery was 4.3% (14 of 323 patients). Patients requiring revision had significantly greater tibial tissue (3.54 vs 2.48 cm; P = .02) and talus tissue (2.79 vs 2.42 cm; P = .02) thickness compared with those not requiring revision. Both the tibial tissue thickness (odds ratio 1.16 [1.12-1.20]; P

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

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

Category: Ankle Arthritis; Ankle Introduction/Purpose: The Scandinavian Total Ankle Replacement (STAR) is a widely used ankle prosthesis, but mid- to long-term follow up remains limited. In thirteen different studies involving 939 STAR total ankle prostheses, the average duration of follow- up for recipients was 3.9 years. Thus, we sought to evaluate the STAR at the mid- to long-term interval with regards to survivorship, complications, and patient reported outcomes (PROs) in one of the largest series with the longest-term follow up to date. Methods: All patients managed with a primary STAR prosthesis at our institution from March 2002 through January 2017 were included in the analysis. Demographic characteristics including gender, race, age, diabetes status, body mass index (BMI), smoking status, American Society of Anesthesiologist (ASA) score, and surgery time were summarized. The cumulative incidence of implant failure was at 5 years and the last recorded time to event (8 years) were reported with 95% confidence intervals (CI). Paired t- tests were used to compare pre-operative and 5 year post-operative (±1 year) for PROs including Visual Analog Scale (VAS), Short Musculoskeletal Function Assessment (SMFA), Short-form-36 (SF-36), and American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot subscales. Additionally, intra- and post-operative complications were recorded. All statistical analysis were conducted in SAS 9.4 (Cary, NC). Statistical significance was assessed at α = 0.05. Results: 247 patients with a unilateral STAR procedure were included in this analysis. Demographics are listed in Table 1. The average number of years of follow-up was 5.71 ± 4.07 years. The cumulative incidence of implant failure at 5 years was 7.7% (95% CI 4.3%-12.5%). The last failure event occurred at 8 years post-implant. The cumulative incidence of implant failure at 8 years was 11.1% (95% CI 6.3%-17.3%) (Table 2, Figure 1). The most common post-operative complications were impingement (N = 39, 15.8%), ankle pain (N = 22, 8.9%), and implant failure (N = 16, 6.5%) (Table 3). With regards to PROs, patients significantly improved between baseline and 5-year follow up in all measures (all p< 0.001; Table 4). Conclusion: At mid- to long-term follow up, patients receiving the STAR prosthesis experienced a significant and durable improvement in PROs across multiple functional indices. Complication and failure rates were lower than those reported in previous series evaluating the STAR, with an observed survivorship of 88.9% at 8-year follow up.

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

Category: Ankle Arthritis Introduction/Purpose: The Vantage total ankle arthroplasty (TAA) features a design based on careful study of arthritic ankles and current ankle biomechanics, with theoretical advantages of a vertically-oriented tibial fixation and a fully congruent talar dome bone-implant interface. In this design-team, single-institution investigation, we report early-to-intermediate term clinical and radiographic outcomes, implant survivorship, and complications of the Vantage TAA. Methods: We retrospectively reviewed prospectively collected data for 278 consecutive patients undergoing Vantage fixed-bearing TAA. Ankles with coronal plane deformity > 25 degrees and suspected poor bone quality were prospectively excluded. Prospectively collected data includes: PROMIS, SF-36, SMFA, VAS and AOFAS hindfoot-ankle scores. Using previously published and commonly accepted evaluation methods, independent radiographic analysis, performed by a non-design surgeon investigator, included pre-operative, 1-year, and most recent follow-up assessments of 2-plane alignment, component position, and the bone- implant interface. A non-design surgeon investigator with dedicated training in statistics performed the statistical analysis using descriptive statistics to report PROM and radiographic measures and Kaplan-Meier survivorship analysis. Results: Mean patient age was 64.8yrs (range:33-86), 44.2% were female, and mean follow-up was 3.1yrs (2.0-5.5). Mean preoperative and postoperative PROMs were as following: PROMIS-Depression 50.3+/-4.2 and 45.6+/-9.8, PROMIS-Physical Function 39.0+/-3.4 and 45.0+/-7.8, SF-36 total score 55.8+/-15.3 and 73.2+/-20.0, SMFA-Function 29.0+/-13.5 and 15.9+/-5.4, VAS 15.8+/-24.8 and 3.1+/-10.1, and AOFAS hindfoot-ankle 46.3+/-16.5 and 81.1+/-16.3 (Table 1). Radiographic lucency at the bone- implant interface was noted in 33 (18.5%) TAAs at final follow-up; 20 (11.2%) were progressive. Lucency was almost exclusive to the tibial component. Implant survivorship was 99.6% [98.9-100.0] at 1-year and 93.3% [88.7-98.2] at the 5-year mark (Table 2, Figure 1). We identified suboptimal bone preparation, initial component alignment and/or component position in all 11 implant failures (Table 3). Conclusion: At early-to-intermediate followup, we observed favorable clinical outcomes, radiographic results and implant survivorship for the fixed-bearing Vantage TAA, especially with optimal bone preparation and component position. Tibial component lucency remains a concern and warrants further investigation. Suboptimal bone preparation, initial component alignment and/or component position was observed in all implant failures.

Category: Ankle Arthritis; Basic Sciences/Biologics Introduction/Purpose: From 2009-2019, there has been a 120% increase in the incidence of total ankle arthroplasty (TAA) in the United States. With the rise in primary TAA, future increases in revision TAA cases is anticipated. Aseptic loosening with periprosthetic osteolysis continues to account for a significant number of revisions. While several factors may contribute to the pathophysiology of osteolysis, an underlying inflammatory response surrounding TAA implants may play a primary role. It is well known that monosodium urate (gout) and calcium-pyrophosphate (pseudo-gout) crystals evoke a highly inflammatory response and may involve the foot and ankle joints. However, the effect of these conditions following TAA has not yet been reported. We present a small case series of patients with ballooning osteolysis following TAA with confirmed crystalline arthropathy. Methods: This is a retrospective study from a single academic institution looking at patients who underwent TAA revision surgery for periprosthetic osteolysis and concern for aseptic loosening. Revision surgeries were performed by three orthopedic foot and ankle fellowship trained surgeons. Case characteristics, including pre-operative imaging, clinical presentations, intra-operative findings and surgical treatments performed were analyzed and presented in this small case series. Results: We report 5 patients whom underwent revision surgery for ballooning periprosthetic osteolysis following TAA. Intra- operative pathology samples from periprosthetic cysts returned positive for monosodium urate (MSU) or calcium pyrophosphate (CPP) crystalline deposition (1 MSU and 4 CPP) in all 5 patients. Final intra-operative cultures were all negative for infection. Upon gross intra-operative inspection, all polyethylene liners were considered to be normal without abnormal wear characteristics. Periprosthetic cysts were isolated to the tibial component in 2 patients and involved both the tibial and talar components in 3 patients. Staged TAA revision was performed in 2 patients. Bone cyst curettage, bone grafting and polyethylene liner exchange was performed in 3 patients. Conclusion: Periprosthetic osteolysis is a known complication following TAA and often leads to implant loosening, functional disability and subsequent revision surgery. An objective strategy for management of this condition has not been agreed upon amongst orthopedic foot and ankle surgeons, as uncertainty remains surrounding the pathophysiology of osteolysis in TAA. To our knowledge, we are the first to describe a small case series of patients with crystalline arthropathy as a potential cause for periprosthetic osteolysis following TAA. Future prospective studies are warranted to better elucidate this potential cause of TAA failure.

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

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

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

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

Background: Total ankle arthroplasty (TAA) provides a surgical alternative to tibiotalar arthrodesis when treating end-stage ankle arthritis. TAA preserves range of motion at the tibiotalar joint leading to improved postoperative function. Many patients who undergo TAA wish to maintain a high level of activity, including participation in low-impact sports such as golf. There are several studies in the total hip and total knee arthroplasty literature that have looked at the effect of total joint arthroplasty on golf handicap. We hypothesized that similar to hip and knee arthroplasty research, TAA is likely to result in a postoperative increase in golf handicap. Methods: After obtaining institutional review board approval, we retrospectively identified 60 patients (from 140 consecutive TAAs performed between August 2016 and February 2017) who had undergone TAA, played golf pre- and postoperatively, and had at least 1 year of postoperative follow-up. The average postoperative follow-up for the cohort was 28.1 months. Variables including preoperative and postoperative golf handicaps, swing laterality, age, gender, surgical laterality, implant used, and operating surgeon were recorded. Results: The average preoperative and postoperative handicaps were 19.7 and 17.9, respectively, which did not represent a statistically significant difference ( P = .07). Patients who played 3 or more rounds per week had better preoperative and postoperative handicaps compared to patients who played 2 rounds or less; however, the change in their handicap following TAA and the number of rounds played per week was not affected. There was no association between the change in handicap and the follow-up period, handedness of golf shot, surgical laterality, implant used, or the operating surgeon. Conclusion: Our findings showed that golf handicap was not negatively affected following TAA in this series. Level of Evidence: Level IV, case series.

Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: The utilization of total ankle arthroplasty (TAA) has increased over the past decade to include bilateral TAAs. The risk-benefit profiles of simultaneous versus staged joint arthroplasty continues to be debated in the literature. There are limited case series reporting outcomes after bilateral TAA with no previous comparison of simultaneous versus staged TAA. It is important to study patients with bilateral pathology as they represent a unique population often with a differing arthritis etiology and an overall more debilitating condition. Thus, we aim to compare bilateral simultaneous versus staged TAAs including perioperative complications and patient reported outcome measures (PROMs). Methods: We performed a comparative cohort study of patients who underwent primary TAA from 2007 to 2019 at a single academic center. Inclusion criteria were primary bilateral TAA performed in simultaneous or staged fashion in patients over 18 years of age. Exclusion criteria were patients with less than two-years follow-up and those with previous tibiotalar arthrodesis or infection. Patient demographics, comorbidities, perioperative complications, and PROMs were collected. PROMs included preoperative and postoperative visual analog scale (VAS) for pain, the Short Form-36 (SF-36) Health Survey, the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Short Musculoskeletal Function Assessment (SMFA) bother and function sub-scores. Bivariate tests of significance were used to compare variables between the two cohorts. Results: Fifty patients were included with an average clinical follow-up was 52.2 (+-27.3; range 24-109) months. The mean time between staged TAA surgeries was 17.5 months (+-20.1, range 3-74). The mean age was 64.3 (+-10.6, range 21-76) years with 32 (64.0%) men. Many patients had primary osteoarthritis (n=28, 56.0%). Both cohorts experienced improvement in all PROMs at one year, which were maintained at final follow-up with no significant between-group differences (p >0.05). There were no differences in perioperative complication rates with similar overall complications (22.0% vs. 24.0%; p=0.7788) and reoperations (6.0% vs 5.0%; p=0.7354) between the simultaneous and staged cohorts, respectively. The two-year and five-year reoperation-free survival were 96.0% and 90.0% for the staged cohort and 94.0% and 88.0% for the simultaneous cohort, respectively (p=0.4612) Both cohorts had 100% failure-free survival up to eight-years postoperative. One patient in the simultaneous cohort required metal component revision at eight years postoperative. Conclusion: The results of bilateral simultaneous TAA, including patient reported outcomes, perioperative complications, and component survival are comparable to patients undergoing staged TAA. When performed under surgeon expertise in appropriately selected patients, we advocate that simultaneous bilateral TAA is a safe and effective method for the treatment of bilateral end-stage ankle osteoarthritis. Potential benefits of simultaneous TAA warranting further investigation include decreased anesthesia events, surgery time, tourniquet time, length of hospitalization, recovery and rehabilitation time, and overall cost. Future investigations will include dedicated analyses of radiographic outcomes and cost comparisons between these two cohorts.

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Hallux valgus (HV) is recognized as a triplanar deformity comprising axial abduction, sagittal hypermobility, and coronal pronation of the first metatarsal. A first tarsometatarsal (TMT) arthrodesis may be used to address all three planes of deformity. The Lapiplasty system (Treace Medical Concepts, Inc., Ponte Vedra, FL) was developed to reproducibly address triplanar deformity. However, the Lapiplasty system is costlier than other fixation constructs. Because healthcare is increasingly value-focused, we sought to determine if the more expensive Lapiplasty system improved radiographic outcomes or decreased complication rates over standard cross-screw fixation. We hypothesized that HV patients undergoing first TMT arthrodesis with the Lapiplasty system would have equivalent radiographic correction and similar complication rates when compared to patients treated with cross-screw fixation. Methods: In this multi-center, IRB-approved retrospective study, consecutive series of patients who underwent 1st TMT arthrodesis for HV, either with cross-screw fixation at Institution A, or Lapiplasty at Institution B, were identified by registry search. Inclusion criteria included age over 18 and preoperative and minimum 6-month postoperative weight-bearing AP and lateral radiographs. Exclusion criteria included primary conditions other than hallux valgus and previous first ray surgeries or ipsilateral arthrodeses. Hallux valgus angle (HVA), intermetatarsal angle (IMA), and tibial sesamoid position (TSP) were measured preoperatively and at final follow-up, and clinic notes were reviewed to identify complications and reoperations. To compare cohorts, Mann-Whitney U tests and Fisher's Exact tests were applied for continuous and discrete variables, respectively. To examine preoperative-postoperative changes, Wilcoxon signed rank tests were used. Multivariable regressions tested the effect of fixation constructs on postoperative radiographic parameters, adjusted for preoperative radiographic measurements, age, sex, and BMI. Results: 65 patients were included in each group, with 121 (93.8%) female patients, mean (SD) age 54.7 (14.8), BMI 25.8 (5.2), and radiographic follow-up time 8.9 (6.7) months. The Lapiplasty cohort had greater BMI (26.8 vs. 24.7, P = .048), and there were no significant differences between groups in age, sex distribution, and radiographic follow-up time. Radiographic measurement data is displayed in Table 1. After adjusting for age, sex, BMI, preoperative HVA, and preoperative IMA, fixation with Lapiplasty was significantly associated with lower postoperative IMA (b=-2.03, 95% CI = [-2.78, -1.37], P < .001) and lower postoperative HVA (b= -7.48; 95% CI = [-9.69, -5.26]; P < .001), but not postoperative sesamoid position. There were no significant differences between cohorts in the incidence of complications or reoperations. Conclusion: We found that use of the Lapiplasty system was associated with better radiographic hallux valgus correction, as evidenced by lower postoperative HVAs and IMAs, compared to standard technique with crossing screws. The clinical significance of these findings is unclear, as complication and reoperation rates were similar between groups. Future research assessing longer- term outcomes, patient-reported outcome data, and cost-benefit analysis will be necessary to further compare techniques and fixation systems.

Category: Ankle; Hindfoot Introduction/Purpose: End-stage ankle osteoarthritis is a debilitating condition that often results in limited tibiotalar range of motion. Total ankle replacement (TAR) preserves ankle range of motion and improves the patient's functionality. Tendo-Achilles lengthening (TAL) and gastrocnemius recession (GR) are concomitant procedures often performed with TAR to improve tibiotalar dorsiflexion. The purpose of this study is to determine the effect of a TAL and GR during TAR on radiographic range of motion compared to a control group without a lengthening procedure. Methods: A retrospective review of a prospectively maintained TAR database was conducted from November 2015 - June 2020 at a single academic institution. All surgeries were performed by fellowship-trained foot and ankle surgeons. Inclusion criteria included greater than18 years of age and a minimum of one-year radiographic follow-up with both preoperative and postoperative weight-bearing, range of motion radiographs. Exclusion criteria included concomitant 1) calcaneal osteotomies, 2) hindfoot or midfoot arthrodesis, 3) prior ankle arthrodesis, or 4) revision total ankle arthroplasty. A total of seventy-five patients (TAL, n = 40; GR, n = 35) were included with a control group of seventy-five consecutive patients who underwent TAR without a lengthening procedure. Demographic and clinical data were extracted from the TAR database. Preoperative and postoperative radiographic assessment included a measurement of dorsiflexion and plantarflexion. All measurements were performed by two members of the research team. Results: A total of 150 patients were included in this study: TAL: n = 35, GR: n = 40, Control: n = 75. Dorsiflexion significantly improved by 3.4° (p=0.0053) and by 6.7° (p < 0.0001) in the TAL and GR cohorts respectively with no significant difference in the control group (+1.3°, p=0.0857). Plantarflexion was significantly decreased by 3.6° (p=0.0378) and by 6.6° (p=0.0002) in the TAL and GR cohorts respectively with no significant difference in the control group (+0.3°, p=0.7863). The total arc of motion did not change significantly for any of the three groups postoperative (control 1.63°, GR 0.05°, TAL -0.20°; all p>0.05). There were no significant between-group differences in the change in overall arc of motion between the groups (p=0.3913). Compared to TAL group, GR resulted in a greater increase in dorsiflexion (6.7° versus 3.4°; p=0.0459) with a reciprocal, albeit non-significant, greater decrease in plantarflexion (6.8° versus 3.6°; p=0.1598). Conclusion: Both TAL and GR significantly increased postoperative dorsiflexion; however, this was accompanied by a reciprocal significant loss in plantarflexion. GR resulted in double the improvement in dorsiflexion and loss in plantarflexion compared to TAL. The total arc of motion did not significantly change for the control, GR, or TAL cohorts. Patients should be counselled that their preoperative range of motion (ROM) will dictate their postoperative ROM, and that concomitant procedures performed to achieve an increase in dorsiflexion will do so at the expense of plantarflexion.

Category: Ankle; Ankle Arthritis Introduction/Purpose: The indications for both total talus replacement (TTR) and total ankle replacement (TAR) are expanding. Combined total ankle-total talus (combined TAR) is a novel treatment option for patients with end-stage ankle arthritis and talar avascular necrosis (AVN) and patients with a prior TAR and talar component collapse. End-stage talar AVN with subchondral collapse is a challenging entity to treat. Historically, an alternative treatment option was tibiotalocalcaneal arthrodesis with structural allograft which results in fair outcomes including nonunion rates up to 40%. Combined TAR is a treatment option that theoretically maintains joint range of motion and restores anatomic alignment. The purpose of this study is to evaluate the short-term outcomes for combined TAR including pain, functional outcomes, radiographic outcomes, and complications. Methods: Consecutive patients who underwent combined TAR from 2016-2020 were retrospectively reviewed. All surgeries were performed by one of four fellowship-trained foot and ankle orthopaedic surgeons at a single academic institution. All talus implants were custom 3D printed total tali (Additive Orthopaedics, Little Silver, NJ), composed of an alloy primarily made of cobalt chrome. The implants were sized based on computed tomography scans of the contralateral talus and created to articulate with multiple TAR systems. Patient demographics, comorbidities, and surgical data were collected. Outcomes included the Visual Analog Scale (VAS) scores, radiographic alignment, range of motion, and complications. Data analysis was performed with paired t- tests and a significance level of p

Category: Ankle Introduction/Purpose: The management of large osteochondral lesions of the talar shoulder remains a clinical challenge. Their size, three-dimensional geometry, and subchondral cystic degeneration often preclude treatment with traditional measures such as microfracture and osteochondral autograft transplantation. Structural or bulk osteochondral allograft transplantation has demonstrated efficacy in several retrospective reviews. The purpose of this study was to prospectively evaluate patients who received fresh structural allograft transplantation to the talus. Methods: A prospective evaluation of consecutive patients who underwent fresh structural allograft transplantation for an OLT form 2010 to 2019 was performed under Institutional Review Board approval. All patients failed a minimum of 6 months of conservative management. Preoperative MRI and/or CT, as well as plain radiographs were obtained on all patients. The following patient reported outcomes questionnaires were administered preoperatively and yearly after surgery: 100mm VAS pain scale, AOFAS Ankle-Hindfoot Scale, SF-36, and the Short Musculoskeletal Functional Assessment (SMFA). Pre- and postoperative radiographs were assessed for allograft incorporation and the development of arthritis. Results: 27 patients underwent fresh osteochondral allograft transplantation and were followed for a minimum of 2 years. The mean follow-up was 5 years (range 2-11). The average size of the OLT was 2,269 mm 3 (range 813-8,366) based on CT imaging and 5,797 mm 3 (range 1,136-12,489) based on MRI imaging. There was significant improvement in the VAS pain score, AOFAS Ankle- Hindfoot Scale score, the SF-36 total score, and the SMFA functional and bother indices (Figure 1). Thirteen (48%) of the patients required subsequent surgery. Twelve underwent removal of hardware and joint debridement and one patient underwent isolated joint debridement. At the time of these surgeries, two grafts demonstrated cartilage delamination. One of these patients had continued pain and progression of arthritis without additional surgery and one was converted to an ankle replacement. Therefore, the failure rate was 7%. Conclusion: Significant improvement in pain and function can be achieved with structural allograft transplantation for large OLTs. However, it is important to council patients that painful hardware and stiffness can occur in approximately one-half of patients. An unstable graft and cartilage delamination are indicators of subsequent failure. The use of a structural allograft does not preclude subsequent ankle arthrodesis or arthroplasty.

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: The utilization of total ankle replacement (TAR) for end-stage ankle osteoarthritis continues to increase in the United States. From 2011-2012, 47.5% of all TAR were covered by Medicare insurance, which represents a large insurance market share for inpatient ankle surgeries. However, there is a growing trend in orthopedics toward performing outpatient surgery. There have been studies that demonstrate the cost benefits and safety of outpatient TAR surgery. However, previous cost studies involve a single implant, small sample size, and lack clinical outcomes. Thus, we aim to compare the costs and clinical outcomes associated with TAR in the outpatient versus inpatient settings. Methods: We performed a retrospective study on 178 consecutive patients undergoing primary inpatient versus short-stay designation TAR during the 2016 and 2017 fiscal years. Patient demographics, concomitant procedures, perioperative complications, patient reported outcomes, and perioperative costs were collected. Results: The mean age of our cohort was 62.5 yo. The implant types were: Infinity (39.3%), Salto (38.2%), INBONE (15.2%), Vantage (7.3%), and STAR (3.4%). 47.8% of patients were covered under managed care and 42.1% under Medicare. There were no significant differences in medical comorbidities (p > 0.05) or concomitant surgeries (p=0.4574) between inpatient and outpatient groups. There was no difference in complications between inpatient and outpatient groups (p= 0.9652). Inpatients had a greater improvement in their SMFA function score compared to outpatients (p=0.0442). Both inpatient and outpatient cohorts significantly improved in all other reported patient reported outcomes at final follow-up (0.05). The total direct cost was higher for the inpatient group ($15,340.1) versus outpatient group ($13,002.6) (p

Category: Ankle; Ankle Arthritis Introduction/Purpose: The utilization of total ankle arthroplasty has increased over the past decade, including bilateral TARs. The risk-benefit profiles of staged versus simultaneous joint arthroplasty continues to be debated in the literature. Previous studies of the hip and knee have demonstrated simultaneous bilateral surgery is associated with shorter hospitalization, shorter recovery and rehabilitation time, and decreased cost without increasing perioperative morbidity or mortality. There are limited case series reporting outcomes after bilateral TAR with no previous comparison of simultaneous versus staged TAR. Thus, we aim to compare our experience with bilateral simultaneous versus staged TARs including perioperative complications and patient reported outcomes. Methods: We performed a retrospective study on 62 patients (124 ankles) undergoing primary TAA (CPT 27702) from 2008 at a single academic center. Inclusion criteria were primary bilateral TAA performed in staged or simultaneous fashion in patients over the age of 18 years-old. Exclusion criteria were patients with less than one-year follow-up. Patient demographics, comorbidities, concomitant procedures, perioperative complications, and patient reported outcomes were also collected. Patient reported outcomes included preoperative and postoperative visual analog scale (VAS) for pain, the Short Form-36 (SF-36) Health Survey, the American Orthopaedic Foot & Ankle Society (AOFAS) score, the Foot and Ankle disability Index (FADI) score, and the Short Musculoskeletal Function Assessment (SMFA) bother and function sub-scores. Every patient had separate outcome scores available for each ankle. Univariate and multivariable tests of significance were used to relate patient and operative characteristics to outcomes. Separate subgroup analyses were performed comparing stages versus simultaneous surgeries. Results: The mean age was 63.7 years-old with a mean duration of 40.5 months of clinical follow-up. There were no significant pre-operative differences between simultaneous and staged groups in terms of age, gender, BMI, ASA classification, or arthritis etiology (p>0.05). The majority (54.5%) of patients had primary or secondary arthritis. Comorbidities were similar between the two groups with the exception of the simultaneous cohort having a higher proportion of previous smokers (56.3 vs 26.1, p=0.0020) and coronary artery disease (19.8 vs 6.5, 0.0447). There was no difference in perioperative complications between the groups(p= 0.4652). Both cohorts significantly improved in all reported patient reported outcomes at final follow-up (0.05) (Table 1). Conclusion: The prevalence of osteoarthritis (primary arthritis) and inflammatory arthritis (secondary arthritis) was higher in patients with bilateral end-stage arthritis necessitating a TAR than previous reports of unilateral TAR. The results of bilateral simultaneous TAA, including perioperative complications and patient reported outcomes, are comparable to patients undergoing staged TAA. We advocate that simultaneous bilateral TAA is a safe and effective method the treatment of bilateral end-stage ankle osteoarthritis in a setting where experienced surgeons are available. Potential benefits of simultaneous TAR for further investigation include decreased: anesthesia events, surgery time, length of hospitalization, recovery and rehabilitation time, and overall cost.

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) use has increased with newer generation implants. Current reports in the literature regarding complications use data extracted from high-volume centers. The types of complications experienced by less experienced centers may not be reflected in these reports. The purpose of this study was to determine a comprehensive TAA adverse event profile from a mandatory-reporting regulatory database. Methods: The US Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2015-2018 to determine reported adverse events for approved implants. We recorded the type of adverse event and excluded duplicate reports and those extracted from already published literature. We categorized the adverse events into infection, intraoperative guide/jig error, component loosening (tibia or talus), cyst formation, component fracture, gutter impingement/heterotopic ossification, iatrogenic fracture, polyethylene wear, component dissociation, malalignment, malalignment recurrence, direct surgeon error, and miscellaneous. The overall percentage distribution of each of the adverse events failure causes was calculated as was the percentage distribution for each total ankle device. Results: Among 408 unique TAA device failures, the modes of failure listed by commonality were component loosening (17.9% [9.6% tibia, 8.3% talus]), intraoperative guide or jig error (15.4%), infection (13.7%), cyst formation (12.7%), gutter impingement/heterotopic ossification (10.3%), component fracture (9.6%), iatrogenic fracture (5.4%), poly wear (3.7%), component dissociation (3.2%), malalignment (2.5%), miscellaneous (2.9%), malalignment recurrence (2.2%), and direct surgeon error (0.5%). These were consistent with some systematic reviews of the literature but in disagreement with others which found high rates of iatrogenic fracture. In addition, the percentage distribution of adverse event failure types differed among implants. Conclusion: The MAUDE database is a publicly available method which requires mandatory reporting of approved device adverse events. Using this report, we found general agreement in types of complications reported in the literature, although there were some differences. In addition, intraoperative guide or jig errors were very common and may not have been previously appreciated. This data may more accurately reflect a comprehensive profile of TAA complications as data was taken from a database of all device users rather than only high-volume centers.

Category: Ankle; Ankle Arthritis; Trauma Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is generally considered a salvage operation for either complex deformity or arthritis about the hindfoot. Several methods can be used to achieve a TTC arthrodesis, including: intramedullary nail fixation, screws, plates, and a fine wire frame. We hypothesized that fibula sparing TTC arthrodesis would improve the union rate and decrease complications in TTC arthrodeses. To best of our knowledge, this is the largest study of TTCs in current literature and no comparative studies have been performed to investigate whether fibular resection influences union and complication rate. Methods: After obtaining approval from the IRB, a retrospective review of the TTC fusions performed at a single academic institution was performed. Orthopaedic surgeons specializing in foot and ankle surgery performed all operations. Eligible patients included those whom underwent a TTC fusion either with or without fibular resection constructs from 2005 to 2017, were 18 years or older at the time of surgery, and had at least two-year follow-up. Patients were excluded if their clinical or radiographic data were unavailable for review. Preoperative diagnosis and indications, fixation methods, clinical success, and complications were obtained from the patient chart and operative reports. 152 patients (155 ankles) underwent TTC arthrodesis, mean age 57.5 years. 94 ankles comprised the fibula-sparing group and 61 comprised the fibular resection group. Statistical analysis was performed using t-Student and Chi-squared test with a p-value of 0.05 defining significance. Results: Common diagnoses included: arthritis (n=66), prior non-union of the ankle or subtalar joint (42), Charcot neuro- arthropathy (25), failed total ankle arthroplasty (TAA) (21) and avascular necrosis of the talus (36). Pre-operative diagnosis of failed TAA was associated with post-operative nonunion (47.6%, p=0.029). In 108 ankles (70%), hindfoot intramedullary arthrodesis nailing was performed, with supplemental plating or screw augmentation in 39 cases. Plating was used in 46 patients (30%). There was no difference in complications (p=0.62) or nonunion (p=0.11) between plating vs nail arthrodesis. There was no difference in non-union rate (26% fibula-resection vs 29% fibula-sparing, p=0.74) or complication rate (49% in fibula-resection vs 53% fibula-sparing, p=0.63) in the fibula-resection compared to the fibula-sparing groups. Most common complications included: non-unions, hardware irritation/failure (17.4%), infection (16.1%), and tibial stress fractures (8.4%). Conclusion: Tibiotalocalcaneal arthrodesis is used primarily as a salvage operation for severe deformity, arthritis of both the ankle and subtalar joints, and situations in which bone loss necessitates a larger fusion procedure. There appears to be no difference in the union rate or complication rates in fibula-sparing or fibula resection during the approach for these fusion operations.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty is considered one of the most common treatments for end stage osteoarthritis of the ankle. This procedure results in significant long-term improvements in pain and function while preserving pre-operative range of motion. Patients also demonstrate improvements in patient reported outcome measures (PROMs) - a modality that quantifies patient’s subjective well-being. Understanding the time to maximal subjective medical improvement (MMI) following total ankle arthroplasty can help guide resource allocation and manage patient expectations. The purpose of this investigation is to establish when patients perceive MMI according to PROMs following total ankle arthroplasty. Methods: A systematic review was conducted on the PubMed database to identify studies on total ankle arthroplasty which reported consecutive PROMs for at least two years postoperatively. Pooled analysis was done at 3-months, 6-months, 12-months, and 24-months postoperatively. The minimal clinically important difference (MCID) was established by a distribution-based method, which is one-half of the standard deviation of outcome score change for a given instrument. Clinically significant improvement was determined between pairs of intervals that exceeded the MCID. Results: A total of 12 studies and 1514 patients met the inclusion criteria for this review. Clinically significant improvement was seen up to 6 months postoperatively in both the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score (AOFAS) and Visual Analog Scale (VAS) scoring systems but was not demonstrated at later intervals. The Short Musculoskeletal Function Assessment (SMFA) Function and Bother subsections were scored individually and both demonstrated clinically significant improvement until 1 year postoperatively. Conclusion: After total ankle arthroplasty, the maximal subjective medical improvement based on PROMs is seen until one year postoperatively, with clinically insignificant improvement beyond one year. The SMFA scoring system may offer greater sensitivity to subjective improvements compared to the AOFAS or VAS scales. This trajectory may help guide patients in managing their expectations in their functional outcomes during preoperative patient education.

Category: Ankle Arthritis; Ankle Introduction/Purpose: The purpose of this study was to report on the radiographic outcomes, clinical outcomes, and implant survivorship following extramedullary-referenced (EMr) versus intramedullary-referenced (IMr) total ankle replacement (TAR). Methods: From May 2007 to February 2018, a consecutive series of patients with end-stage tibiotalar osteoarthritis undergoing TAR for primary arthritis, post-traumatic arthritis, and inflammatory arthritis was enrolled in this study. Analyses were performed comparing IMr versus EMr components for patient-reported outcomes data, pre and postoperative radiographic ankle alignment, concomitant procedures, and complications. Kaplan-Meier survivorship analyses served to determine implant reoperation and revision surgery. Data was prospectively collected and retrospectively analyzed. A p-value of < 0.05 was considered significant for all statistical analyses. Results: A total of 340 TARs were included with 105 IMr TAR and 235 EMr TAR. The mean follow-up was 5.3 years ( +- 2.5, range 2-12). The absolute value for preoperative coronal alignment was significantly greater for IMr compared to EMr TAR (13.0 vs 6.4 degrees; p < 0.0001), but both groups achieved near neutral alignment postoperatively (1.4 vs 1.5 degrees; p=0.6655). The odds of having a concomitant procedure was 2.7 times higher in patients with an IMr TAR (OR 2.7, CI 1.7-4.4; p-value 0.05). The 5-year implant survivorship was 98.6.% for IMr versus 97.5% for EMr at final follow-up. Conclusion: Despite the IMr TAR group having more severe preoperative coronal and sagittal malalignment, both IMr and EMr TAR components had comparable postoperative alignment, patient-reported outcome scores, and complications. Among the patients with preoperative varus, valgus, or anterior distal tibial slope, the IMr patients achieved greater correction than the EMr patients. Although the 5-year implant survivorship was similar between the two cohorts with 98.6% survival for IMr TAR and 97.5% for EMr TAR, impending failures were greater for the mobile-bearing EMr TAR.

Category: Ankle, Ankle Arthritis Introduction/Purpose: The literature for total ankle arthroplasty (TAA) demonstrates significant improvements in patient- reported outcomes. While these reports focus on the overall study population, it is clear that some patients do not have a successful outcome. In regards to total hip and knee arthroplasty there is literature helping to define responders, or those who achieve a clinical improvement above the level of a minimally clinically important difference. However, characteristics of responders versus non-responders to TAA have not been defined. The purpose of this study was to determine patient comorbidities and characteristics that help distinguish responders from non-responders after TAA. Methods: Patients undergoing TAA between 1/2007 and 12/2016 were enrolled into a prospective study at a single academic center. Patients completed multiple patient reported outcome measures before surgery and in follow-up including the Short Musculoskeletal Function Assessment (SMFA). Patients were characterized as responders if their 2-year follow-up SMFA function score increased by 50% or more compared to preoperatively and were characterized as non-responders if their SMFA score increased by less than 50% at 2-year follow-up, consistent with OMERACT–OARSI responder criteria. Patient and operative factors along with prevalent pre-operative comorbidities were then associated with responder or non-responder status. Comorbidities that met a significance threshold of p

Category: Ankle Arthritis Introduction/Purpose: The Scandinavian Total Ankle Replacement(STAR) system and Salto Talaris(ST) total ankle system are two of the more commonly studied total ankle implants. As the STAR is one of the oldest total ankle arthroplasty (TAA) implants still in use today, most studies focus on longevity and survivorship. Reported rates of cyst formation for these two prosthesis in most series vary from 11-22% but no large study has focused on surgical management of these cysts or included patient reported outcomes after surgery. In this series, we aimed to investigate rates of cyst formation between mobile(MB) and fixed-bearing(FB) TAA and examine clinical and patient reported outcomes of bone grafting or cementing of large cysts surrounding the STAR and ST implants. Methods: A prospectively collected database at a high volume total ankle replacement center was retrospectively reviewed to identify patients who underwent TAA with either the STAR or the ST total ankle system between 2007 and 2015. Cysts were identified and measured on standard weight bearing radiographs and confirmed on computed tomography(CT) when available. Visual analog scale (VAS) score, Short Form-36 (SF-36) physical and mental component scores, Short Musculoskeletal Function Assessment(SMFA), and AOFAS hindfoot scores were collected from all patients preoperatively and then at 6 months, 1 year and annually postoperatively. Patients with a minimum 2 years follow-up who underwent revision TAA secondary to catastrophic bone cysts or who were managed with either curettage and bone grafting or curettage and cementing of bone cysts surrounding the TAA prosthesis were included in the patient reported outcomes (PRO) analysis Results: Excluding 53 patients for inadequate follow-up, 232 patients (29% female, 71% male; follow-up 6.7 years) who underwent STAR-TAA and 147 patients (26.6% female, 73.5% male; follow-up 7 years) who underwent ST-TAA were identified. Cysts 10 mm were identified in 95/232 (41%) STAR and 24/147 (16%) ST ankles. In the STAR group, 24 patients underwent cyst bone grafting (13), cementing (6) or both (8) at a mean 4.8 years. In the ST group, 14 patients underwent cyst bone grafting (6), cementing (4), or both (4) at a mean of 2.7 years. PRO data improved significantly for both the STAR and ST group in all questionnaires (p10mm 95(41%) 24 (16%) Patients Requiring Cyst Surgery 24/95 (25%) 14/24 (58%) Age (years) 61.8 63.3 Sex Male 165(71%) 107(73%) Female 67(29%) 40(27%) Time Until Cysts Visible (years) 1.82 1.63 Cysts 20mm Diameter Tibia 28 patients 4 patients Talus 4 patients 2 patients Both 0 Patients 2 patients Reoperation for Cyst n=24 n=14 Management mean 4.8 years post-op mean 2.7 years post-op Bone Grafting 13 6 Cementing 6 4 Both 8 4 SF-36 Before Cyst Surgery Physical Function 23.8 19.9 Mental Health 75.1 77.9 SF-36 After Cyst Surgery Physical Function 68.3 67.6 Mental Health 89.4 88.8 VAS Before Cyst Surgery 62.7 59.4 VAS After Cyst Surgery 4.1 3.7

Background: Metal component failure in total ankle arthroplasty (TAA) is difficult to treat. Traditionally, conversion to an arthrodesis has been advocated. Revision TAA surgery has become more common with availability of revision implants and refinement of bone-conserving primary implants. The goal of this study was to analyze the clinical results and patient-reported outcomes for patients undergoing revision total ankle arthroplasty. Methods: We retrospectively reviewed prospectively collected data on 52 patients with a mean age of 63.5 ± 9.6 years who had developed loosening or collapse of major metal components following primary TAA. These patients were compared to a case-matched control group of 52 primary TAAs performed at the host institution with a minimum of 2 years’ follow-up. Cases of isolated polyethylene exchange, infection, or extra-articular realignment procedures were excluded. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), and pain scores were prospectively collected. Clinical data was collected through review of the electronic medical record to identify reasons for clinical failure, where clinical failure was defined as second revision or conversion to arthrodesis or amputation. Results: The identified causes of failure of primary TAA were aseptic loosening of both components (42%), talar component subsidence/loosening (36%), coronal talar subluxation (12%), tibial loosening (8%), and talar malrotation (2%). Thirty-one patients (59.5%) underwent revision of all components, 20 (38.5%) just the talar and polyethylene components, and one (2%) the tibial and polyethylene components. The average time to revision was 5.5 years ± 5.4 with a follow-up of 3.1 years ± 1.5 after revision. Eleven (21.2%) revision arthroplasties required further surgery: 6 required conversion to arthrodesis and 5 required second revision TAA. Pain scores, SF-36 scores, SMFA scores, and AOFAS Hindfoot scores all improved after revision surgery but never reached the same degree of improvement seen after primary TAA. Conclusions: Clinical and patient-reported outcomes of revision ankle arthroplasty after metal component failure significantly improved after surgery, although the recovery time was longer. In this series, 21.2% of revision TAAs required a second revision TAA or arthrodesis surgery. Various prostheses performed similarly when used for revision surgery. Revision TAA can offer significant improvements postoperatively. Level of Evidence: Level III, therapeutic.

Background: Total ankle arthroplasty (TAA) provides a surgical alternative to tibiotalar arthrodesis when treating end-stage ankle arthritis. TAA preserves range of motion at the tibiotalar joint leading to improved postoperative function. Many patients who undergo TAA wish to maintain a high level of activity, including participation in low-impact sports such as golf. There are several studies in the total hip and total knee arthroplasty literature that have looked at the effect of total joint arthroplasty on golf handicap. We hypothesized that similar to hip and knee arthroplasty research, TAA is likely to result in a postoperative increase in golf handicap. Methods: After obtaining institutional review board approval, we retrospectively identified 60 patients (from 140 consecutive TAAs performed between August 2016 and February 2017) who had undergone TAA, played golf pre- and postoperatively, and had at least 1 year of postoperative follow-up. The average postoperative follow-up for the cohort was 28.1 months. Variables including preoperative and postoperative golf handicaps, swing laterality, age, gender, surgical laterality, implant used, and operating surgeon were recorded. Results: The average preoperative and postoperative handicaps were 19.7 and 17.9, respectively, which did not represent a statistically significant difference ( P = .07). Patients who played 3 or more rounds per week had better preoperative and postoperative handicaps compared to patients who played 2 rounds or less; however, the change in their handicap following TAA and the number of rounds played per week was not affected. There was no association between the change in handicap and the follow-up period, handedness of golf shot, surgical laterality, implant used, or the operating surgeon. Conclusion: Our findings showed that golf handicap was not negatively affected following TAA in this series. Level of Evidence: Level IV, case series.

Category: Ankle. Introduction/Purpose: The management of large osteochondral lesions of the talar shoulder remains a clinical challenge. Their size, three-dimensional geometry, and subchondral cystic degeneration often preclude treatment with traditional measures such as microfracture and osteochondral autograft transplantation. Structural or bulk osteochondral allograft transplantation has demonstrated efficacy in several retrospective reviews. The purpose of this study was to prospectively evaluate patients who received fresh structural allograft transplantation to the talus. Methods: A prospective evaluation of consecutive patients who underwent fresh structural allograft transplantation for an OLT form 2010 to 2013 was performed under Institutional Review Board approval. All patients failed a minimum of 6 months of conservative management. Preoperative MRI and/or CT, as well as plain radiographs were obtained on all patients. The following patient reported outcomes questionnaires were administered preoperatively and yearly after surgery: 100 mm VAS pain scale, AOFAS Ankle-Hindfoot Scale, SF-36, and the Short Musculoskeletal Functional Assessment (SMFA). Pre- and postoperative radiographs were assessed for allograft incorporation and the development of arthritis. Results: Fourteen patients underwent fresh osteochondral allograft transplantation. The mean follow-up was 47 months (range 24-73). The average size of the OLT was 2,269 mm3 (range 813-8,366) based on CT imaging and 5,797 mm3 (range 1,136-12,489) based on MRI imaging. There was significant improvement in the VAS pain score, AOFAS Ankle-Hindfoot Scale score, the SF-36 total score, and the SMFA functional and bother indices. Five (36%) of the patients required subsequent arthroscopy and removal of the screw(s) used to secure the graft. Three of these second-look patients had stable grafts without chondral damage. Two grafts demonstrated cartilage delamination. One of these patients had continued pain and progression of arthritis without additional surgery and one was converted to an ankle replacement. Therefore, the failure rate was 14%. Conclusion: Significant improvement in pain and function can be achieved with structural allograft transplantation for large OLTs. However, it is important to council patients that painful hardware and stiffness can occur in approximately one-third of patients. An unstable graft and cartilage delamination are indicators of subsequent failure. The use of a structural allograft does not preclude subsequent ankle arthrodesis or arthroplasty.

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.

Category: Sports. Introduction/Purpose: Irreparable peroneal tendon tears are rare and there is scant evidence to guide surgeons on the appropriate treatment. In general, if more than 50% of the tendon is affected, segmental resection of the tendon and tenodesis to the remaining healthy tendon is recommended. We hypothesized that normal tension at the insertions of the peroneal tendons after an irreparable tear cannot be reestablished by tenodesis to the remaining tendon and can only be restored by allograft reconstruction. Methods: To assess tendon loading at their insertions, custom-made strain gage-based tension transducers were implanted into the peroneus longus (PL) and brevis (PB) tendons adjacent to their insertions on the 1st and 5th metatarsal bases in 12 fresh- frozen cadaver feet. Axial load was applied to the foot, and the peroneal tendons, tibialis anterior and posterior tendons were tensioned to 50% and 100% of physiologic load. Transducer outputs were recorded in this normal tendon condition and after sequential PB to PL tenodesis and peroneus brevis allograft reconstruction. The tendon force transmission was quantified in five different foot inversion/eversion and plantarflexion/dorsiflexion positions. The distal peroneal tendons and 1st and 5th metatarsals were then excised along with the implanted transducers, and calibration was performed by applying incremental tendon loads in a materials testing machine. Insertion site tensile loading in each surgical condition was then expressed as a percentage of normal. Results of the allograft and tenodesis procedures were compared using paired t tests. Results: Under 50% of physiologic load, tendon tension at the PB insertion ranged from 3% to 28% of normal after tenodesis. After allograft reconstruction, PB insertion tension increased to 73% to 101% of normal. Tension at the PL insertion site was 102% to 117% of normal after tenodesis, and 84% to 93% of normal after allograft reconstruction. The treatment outcomes differed significantly, with p-values < 0.02. Under the 100% loading condition, tension at the PB site ranged from 6% to 43% of normal after tenodesis and 88% to 99% of normal after repair with allograft. Tension at the PL insertion site was 101% to 120% and 94% to 101% after tenodesis and PB allograft reconstruction, respectively. The treatments differed significantly, with p-values < 0.02, in all comparisons except for PL tension in inverted and neutral foot positions. Conclusion: Allograft reconstruction of a peroneus brevis tendon tear substantially restored tension at both the PB and PL insertion sites when the tendons and their antagonists were loaded to 50% and 100% of physiologic load. In comparison, peroneus brevis tenodesis to PL did not effectively restore tendon tension under most of the tested conditions, suggesting that this procedure may result in an imbalanced foot when applied clinically. Clinical comparative studies are necessary to determine if the results of this cadaveric, biomechanical study have similar in-vivo consequences.

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: 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: Other Introduction/Purpose: There is a growing demand for orthopaedic surgeons trained in management of foot and ankle conditions, yet there remains wide variation in the process of fellowship training and a dearth of outcomes assessment. The 2016- 2017 American Orthopaedic Foot & Ankle Society (AOFAS) Fellowship Match consisted of 75 available positions—a 44% increase over that a decade prior. Of the 48 programs offering positions, 6 offer standardization and oversight by the Accreditation Council for Graduate Medical Education (ACGME). We aimed to assess the educational curriculum, research production and career paths of 25 years of graduates from the longest running ACGME accredited foot and ankle fellowship program in the United States. Methods: A database of graduates from a single foot and ankle fellowship program was utilized to identify practice types and locations as well as tabulate PubMed indexed articles authored by fellows while in the program. The educational curriculum corresponding to their training is described. Additionally, historical data from the AOFAS Match Program was evaluated for trends. Results: Between 2005-2015, there were 515 graduates of AOFAS sponsored foot & ankle fellowship programs in the U.S. (Figure 1). Successful match rates for fellowship applicants ranged from 80-96% and program fill rates varied between 61-93%. Our fellowship program has graduated 50 fellows in the past 25 years of whom 37 (74%) practice in the U.S. and 13 (26%) practice abroad. When accounting for international, military and academic practitioners, 54% of our graduates entered practice types with a teaching component. Research articles for each fellow were examined and on average 1.9 PubMed indexed articles (range 0-12) were published by fellows during their tenure in the program. Graduates going into military, international and U.S. academic practices published 2.5, 2.8 and 3.7 articles during training, respectively. Conclusion: As technical and cognitive demands of foot and ankle surgeons increase, the need for optimized fellowship training has become paramount. Assessment of educational curriculum, research production and graduate practice type may help fellowships identify areas for improvement in order to meet program and trainee goals.

Category: Hindfoot Introduction/Purpose: Avascular necrosis (AVN) of the talus can lead to subtalar arthritis, pain, and decreased function. Isolated subtalar arthrodesis has been attempted in these patients, potentially allowing re-vascularization of the talus from calcaneal bone ingrowth while preserving the tibiotalar joint. The purpose of this study is to determine the union rate and complications of subtalar arthrodesis in patients with AVN of the talus. Methods: After obtaining IRB approval, a retrospective review of subtalar arthrodeses performed at a single academic institution, from 2000 to 2014, was conducted. Patients were included if they had a preoperative diagnosis of avascular necrosis of the talus, underwent subtalar arthrodesis and had a minimum follow up of 12 months. Exclusion criteria include: age younger of 18 years, incomplete clinical and radiological data or those whom underwent a concomitant tibiotalar arthrodesis. Results: Twelve patients with a mean age of 46.6 ± 13.9 years were included in the study. The fusion rate was 58% with a mean time to fuse of 35 weeks (range, 14-146). Seventeen percent of the patients had diabetes or vascular disease and an additional 17% had a positive history for tobacco use. The overall complication rate was 67% (8 patients). Five patients progressed to non-union (42%) and three of them underwent revision to tibiotalocalcaneal arthrodesis. Two patients (17%) had progression of AVN, one of which necessitated a tibiotalocalcaneal arthrodesis. Two patients (17%) developed a wound dehiscence that healed uneventfully with local wound care and oral antibiotics administration. One patient (8%) underwent hardware removal. Conclusion: With a fusion rate as low as 58% and a 67% complication rate, caution should be exhibited when considering an isolated subtalar arthrodesis in the setting of AVN of the talus. In selected cases, consideration should be given to extending the arthrodesis site to include the tibiotalar or talonavicular joint or revascularization procedures such as concomitant vascularized bone grafts.

Category: Ankle Arthritis. Introduction/Purpose: Wound complications following total ankle replacement (TAR) potentially lead to devastating consequences. The aim of this study is to compare the surgical and demographic differences in those with and without wounds which require operative management. We hypothesize that increased tourniquet and surgical time negatively influences wound healing. Methods: We retrospectively identified a consecutive series of 760 primary TARs performed between January 1998 and December 2014 whose data was prospectively collected. We then identified patients who required a secondary surgery to treat wound complications (ie operative debridement, split-thickness skin grafting, soft tissue reconstruction). All patients had operative wound debridement. We then compared demographics, surgical characteristics, and functional scores to see if there were any differences between the two groups. Clinical outcomes including secondary procedures and implant failure rate were recorded. Results: Twenty-seven patients (3.6%) had a total of 50 procedures to treat wound issues. 18 patients had flaps and 13 had split- thickness skin grafts. The mean time to operatively treating the wound was 12.6 weeks after the index TAR. The follow-up time from wound procedure was 28 months. Compared to the control group, patients with major wounds had a significantly longer surgery (215.6 vs. 189.2 min, p=.028) and tourniquet time (150.9 vs. 140 min, p=.0037). The control patients were more likely to have post-traumatic arthritis, whereas those with wound complications were more likely to have osteoarthritis (p=.002). Post- operatively, only the FAOS pain score was worse in patients with wounds (p=.047). There were seven failures in the major wound complication cohort (25.9%), including 2 BKAs. Conclusion: Ankle wounds which require operative management have high failure rates and may result in devastating outcomes. Given our data, we recommend limiting tourniquet time.

Category: Midfoot/Forefoot Introduction/Purpose: Combined arthrodesis of the talonavicular (TN) and 1st tarsometatarsal (TMT) joints is a treatment option for the patient with both a rigid flatfoot and hallux valgus deformity or 1st TMT joint arthritis. In these cases, the naviculocuneiform (NC) joint is spared, as long as no evidence of joint collapse or instability is present. The purpose of this study was to assess the effect of this medial column stabilization construct on the spared NC joint over time and its ability to improve the radiographic parameters in the flatfoot deformity. Methods: Patients who underwent concomitant TN and 1st TMT joint arthrodesis, while sparing the NC joint, in the setting of a rigid flatfoot deformity, between January 2006 and December 2014, were identified. The medical records, including preoperative and postoperative radiographs were retrospectively reviewed. Outcomes included radiographic correction gained by surgery (AP and lateral talo-first metatarsal angles), union rate, complications, and need for subsequent surgery. Specific radiographic attention was paid to development of subsequent collapse and/or arthritis at the NC joint at the time of final follow-up. Results: 21 consecutive combined TN and 1st TMT joint arthrodeses were performed. Average age at time of surgery was 61 (range, 23-82) years. 17 patients had a mean follow-up of 35 (range, 12-88) months. Union was achieved at both arthrodesis sites in 16/17 patients (94.1%). One patient (5.9%) had a nonunion at the TN joint, requiring revision arthrodesis. The mean lateral talo- first metatarsal angle correction was 24.5 (range, 12-36) degrees. The mean AP talo-first metatarsal angle correction was 11.6 (range, 0-33) degrees. One patient (5.9%) developed NC joint collapse and underwent subsequent arthrodesis at that level. There was radiographic evidence of NC joint arthritis to varying degrees in all cases by the time of final follow-up, however, none were symptomatic to warrant arthrodesis. Conclusion: Simultaneous arthrodesis of the TN and 1st TMT joints, while sparing the NC joint, is a reliable treatment in the carefully selected patient who presents with both a rigid flatfoot and hallux valgus deformity or 1st TMT joint arthritis. Good results in terms of union rate and radiographic correction, as well as a low complication rate were found in this study. Subsequent joint collapse and symptomatic arthritis at the spared NC joint was rare. Longer term follow-up and inclusion of functional outcomes are warranted in future studies on this topic.

Category: Ankle Arthritis Introduction/Purpose: As surgeons have become more comfortable with performing more complex total ankle replacements (TAR) with larger amounts of deformity, it is unclear whether or not to address additional pathology at the time of surgery. Currently, we address all foot and ankle pathology at time of the index arthroplasty. It is unclear however, how often and for what reasons secondary surgery is performed after TAR. We hypothesize that there were no differences in the type or rate of secondary surgeries performed. Methods: We identified a consecutive series of 761 primary TARs performed between January 1998 and December 2014. We identified patients who required a secondary surgery to treat foot and ankle pathology following a STAR, INBONE I/II, or Salto- Talaris. We then analyzed if there were differences between the implants in terms of time to secondary surgery or types of procedures performed. Results: 193 patients (25.3%) required a secondary procedure with an average time to a secondary procedure of 24.5 months. The rate of second surgery in both the Salto (25/113, HR=0.64 with 95%CI=0.408-0.996; p=0.048) and STAR (81/333, HR=0.694 with 95%CI=0.507-0.949; p=0.022) is less when compared to the INBONE group (87/315). The STAR had a significantly longer time to secondary procedure (33.8 months) versus a Salto-Talaris (12.8 months) or an INBONE (19.2 months, p=001). The number of secondary procedures (p< .001), polyethylene exchanges (p< .001), cyst grafting (p=.036) were similar in INBONE and STAR, but significantly more than the Salto. The INBONE prosthesis had a significantly higher talar component failure rate (p=.038), but similar rate of subtalar, ankle, and TTC fusion. Conclusion: Knowledge of the rates and types of secondary surgeries is useful information on the natural history of third generation ankle implants. While there are differences in the rate of failure or revisions between implants, no implant has proven superior to one another.