Constantine A. Demetracopoulos

Early to Mid-Term Results of Fixed-Bearing Total Ankle Arthroplasty with a Modular Intramedullary Tibial Component

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

High Rate of Recurrence Following Proximal Medial Opening Wedge Osteotomy for Correction of Moderate Hallux Valgus

Background: The proximal medial opening wedge (PMOW) osteotomy has become more popular to treat moderate to severe hallux valgus with the recent development of specifically designed, low-profile modular plates. Despite the promising results previously reported in the literature, we have noted a high incidence of recurrence in patients treated with a PMOW. The purpose of this study was to report the clinical and radiographic outcomes of an initial cohort of patients treated with a PMOW osteotomy for moderate hallux valgus. Methods: We retrospectively analyzed prospectively gathered data on a cohort of 17 consecutive patients who were treated by the senior author using a PMOW osteotomy for moderate hallux valgus deformity. Average time to follow-up was 2.4 years (range, 1.0-3.5 years). The intermetatarsal angle (IMA), the hallux valgus angle (HVA), and the distal metatarsal articular angle (DMAA) were assessed on standard weightbearing radiographs of the foot preoperatively and at all follow-up visits. The Foot and Ankle Outcome Score (FAOS) was collected on all patients preoperatively and at final follow-up. Results: Despite demonstrating good correction of their deformity initially, 11 of the 17 patients (64.7%) had evidence of recurrence of their hallux valgus deformity at final follow-up. Patients who recurred had a greater preoperative HVA (P = .023) and DMAA (P = .049) than patients who maintained their correction. Improvement in the quality-of-life subscale of the FAOS was noted at final follow-up for all patients (P = .05). There was no significant improvement in any of the other FAOS subscales. Conclusions: There was a high rate of recurrence of the hallux valgus deformity in this cohort of patients. Recurrence was associated with greater preoperative deformity and an increased preoperative DMAA. The PMOW without a concomitant distal metatarsal osteotomy may be best reserved for patients with mild hallux valgus deformity without an increased DMAA. Level of Evidence: Level IV, retrospective case series.

Comparison of Extramedullary Versus Intramedullary Referencing for Tibial Component Alignment in Total Ankle Arthroplasty

Background: The majority of total ankle arthroplasty (TAA) systems use extramedullary alignment guides for tibial component placement. However, at least 1 system offers intramedullary referencing. In total knee arthroplasty, studies suggest that tibial component placement is more accurate with intramedullary referencing. The purpose of this study was to compare the accuracy of extramedullary referencing with intramedullary referencing for tibial component placement in total ankle arthroplasty. Methods: The coronal and sagittal tibial component alignment was evaluated on the postoperative weight-bearing anteroposterior (AP) and lateral radiographs of 236 consecutive fixed-bearing TAAs. Radiographs were measured blindly by 2 investigators. The postoperative alignment of the prosthesis was compared with the surgeon’s intended alignment in both planes. The accuracy of tibial component alignment was compared between the extramedullary and intramedullary referencing techniques using unpaired t tests. Interrater and intrarater reliabilities were assessed with intraclass correlation coefficients (ICCs). Results: Eighty-three tibial components placed with an extramedullary referencing technique were compared with 153 implants placed with an intramedullary referencing technique. The accuracy of the extramedullary referencing was within a mean of 1.5 ± 1.4 degrees and 4.1 ± 2.9 degrees in the coronal and sagittal planes, respectively. The accuracy of intramedullary referencing was within a mean of 1.4 ± 1.1 degrees and 2.5 ± 1.8 degrees in the coronal and sagittal planes, respectively. There was a significant difference (P < .001) between the 2 techniques with respect to the sagittal plane alignment. Interrater ICCs for coronal and sagittal alignment were high (0.81 and 0.94, respectively). Intrarater ICCs for coronal and sagittal alignment were high for both investigators. Conclusions: Initial sagittal plane tibial component alignment was notably more accurate when intramedullary referencing was used. Further studies are needed to determine the effect of this difference on clinical outcomes and long-term survivability of the implants. Level of Evidence: Level III, retrospective comparative study.

Management of End-Stage Ankle Arthritis: Cost-Utility Analysis Using Direct and Indirect Costs.

BACKGROUND Total ankle replacement and ankle fusion are costly but clinically effective treatments for ankle arthritis. Prior cost-effectiveness analyses for the management of ankle arthritis have been limited by a lack of consideration of indirect costs and nonoperative management. The purpose of this study was to compare the cost-effectiveness of operative and nonoperative treatments for ankle arthritis with inclusion of direct and indirect costs in the analysis. METHODS Markov model analysis was conducted from a health-systems perspective with use of direct costs and from a societal perspective with use of direct and indirect costs. Costs were derived from the 2012 Nationwide Inpatient Sample (NIS) and expressed in 2013 U.S. dollars; effectiveness was expressed in quality-adjusted life years (QALYs). Model transition probabilities were derived from the available literature. The principal outcome measure was the incremental cost-effectiveness ratio (ICER). RESULTS In the direct-cost analysis for the base case, total ankle replacement was associated with an ICER of

Long-Term Results of Debridement and Primary Repair of Peroneal Tendon Tears

14,500/QALY compared with nonoperative management. When indirect costs were included, total ankle replacement was both more effective and resulted in

Effect of Age on Outcomes in Total Ankle Arthroplasty

5900 and

Arthroscopic Particulated Juvenile Cartilage Allograft Transplantation for the Treatment of Osteochondral Lesions of the Talus.

800 in lifetime cost savings compared with the lifetime costs following nonoperative management and ankle fusion, respectively. At a

Limited-Open Achilles Tendon Repair Using Locking Sutures Versus Nonlocking Sutures An In Vitro Model

100,000/QALY threshold, surgical management of ankle arthritis was preferred for patients younger than ninety-six years and total ankle replacement was increasingly more cost-effective in younger patients. Total ankle replacement, ankle fusion, and nonoperative management were the preferred strategy in 83%, 12%, and 5% of the analyses, respectively; however, our model was sensitive to patient age, the direct costs of total ankle replacement, the failure rate of total ankle replacement, and the probability of arthritis after ankle fusion. CONCLUSIONS Compared with nonoperative treatment for the management of end-stage ankle arthritis, total ankle replacement is preferred over ankle fusion; total ankle replacement is cost-saving when indirect costs are considered and demonstrates increasing cost-effectiveness in younger patients. As indications for and utilization of total ankle replacement increase, continued research is needed to define appropriate subgroups of patients who would likely derive the greatest clinical benefit from that procedure. LEVEL OF EVIDENCE Economic and decision analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of a Stepcut Lengthening Calcaneal Osteotomy for Adult-Acquired Flatfoot Deformity.

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

Lateral Column Lengthening Corrects Hindfoot Valgus in a Cadaveric Flatfoot Model

Background: Little is known about the efficacy and durability of total ankle arthroplasty (TAA) in younger patients. The purpose of this study was to determine the effect of age on the clinical, radiographic, and patient-reported outcomes of patients with end-stage ankle arthritis treated with TAA using modern prostheses. Methods: Patients who underwent primary TAA from June 2007 to July 2011 were prospectively enrolled in the study. Three hundred and ninety-five consecutive patients were reviewed with a mean follow-up of 3.5 years (range, 2-5.4 years). Patients were divided into 3 groups based on age at the time of surgery (<55, 55-70, and >70 years). Patient-reported outcome scores, physical performance scores, and weight-bearing radiographs were used to assess patients preoperatively and at yearly postoperative office visits. Revision was defined as failure of either the tibial or talar components requiring removal of the metallic implants. A repeated-measures analysis of variance with post hoc testing and the Pearson chi-square test were used to assess differences between the 3 groups. Statistical significance was set at an alpha level of .05. Results: Patients under the age of 55 had a greater improvement in Short-Form 36 (SF-36) Vitality (P = .026) and American Orthopaedic Foot & Ankle Society (AOFAS) Function scores (P < .001) compared with patients over the age of 70 at most recent follow-up. There were no differences in the Visual Analog Scale (VAS) pain score or the physical performance outcomes between the age groups. The incidence of wound complications, need for reoperation, and revision were not different between groups. Conclusions: Outcomes of TAA in younger patients were similar to outcomes in older patients at early follow-up. This study establishes a cohort of patients that will be followed to determine the effect of age on the long-term outcomes of TAA with an emphasis on the need for reoperation and revision. Level of Evidence: Level II, prospective comparative study.