Gary L. Patzer

Clinical Results of the Mayo Total Ankle Arthroplasty

Two hundred and four primary Mayo total ankle arthroplasties were performed in 179 patients at the Mayo Clinic from 1974 through 1988. We evaluated the clinical result after 160 arthroplasties in 143 patients who had been followed for two years or more (mean, nine years; range, two to seventeen years). The result was good for thirty-one ankles (19 per cent), fair for fifty-five (34 per cent), and poor for seventeen (11 per cent); fifty-seven arthroplasties (36 per cent) were considered to be a failure (defined as removal of the implant). Adequate preoperative and follow-up radiographs were available for 101 ankles (eighty-nine patients). There was radiographic evidence of loosening of eight tibial components (8 per cent) and fifty-eight talar components (57 per cent), but we found no association between the clinical and radiographic results. Complications occurred after nineteen (12 per cent) of the 160 arthroplasties, and ninety-four additional reoperations were necessary after sixty-six (41 per cent). On the basis of these findings, we do not recommend ankle arthroplasty with a constrained Mayo implant for rheumatoid arthritis or osteoarthrosis of the ankle.

Survivorship analysis of the Mayo total ankle arthroplasty

From 1974 until the end of 1988, 204 primary Mayo total ankle arthroplasties were performed at the Mayo Clinic. By means of actuarial analysis, we determined the cumulative rates of survival with failure (defined as removal of the implant) as the end point. The average duration of follow-up was nine years (range, two to seventeen years). By applying the Cox proportional-hazards general linear model, we identified two independent variables that were associated with a significantly higher risk of failure: a previous operative procedure on the ipsilateral foot or ankle and an age of fifty-seven years or less. The overall cumulative rate of survival at five, ten, and fifteen years was 79, 65, and 61 per cent, respectively. The probability of an implant being in situ at ten years was 42 per cent for patients who were fifty-seven years old or less and who had had previous operative treatment of the ipsilateral ankle or foot and 73 per cent for those who were more than fifty-seven years old and who had had no such previous operative treatment. We do not recommend the use of the Mayo total ankle arthroplasty, particularly in younger patients who have had a previous operative procedure on the ipsilateral ankle or foot.

Arthrodesis for the treatment of arthrosis of the ankle and osteonecrosis of the talus.

We evaluated the results of arthrodesis that had been performed for arthrosis of the ankle and osteonecrosis of the talus in nineteen patients. Twelve patients were men, and seven were women. The mean age of the patients was thirty-four years (range, nineteen to fifty-eight years). The median interval between the injury and the index operation was twenty-one months (range, six to 408 months). The arthrodesis was performed at the level of the ankle only in three patients and in both the ankle and the subtalar joint in sixteen. External fixation was used in thirteen patients, internal fixation was used in four, and no fixation was used in two. Supplemental bone graft from the iliac crest was used in fourteen patients, and local bone graft was used in five. The mean duration of follow-up was six years (range, two to fifteen years). The clinical result was excellent in seven patients, good in six, fair in three, and poor in three. Union was achieved in sixteen ankles, but it was delayed in one of them. Complications occurred in four patients: one had a tibial stress fracture, one had an infection at the site of a non-union, and two had malalignment in plantar flexion. Overall, the arthrodesis was successful in these patients. The use of rigid fixation and bone-grafting had a rate of success approximating that reported for primary arthrodesis in patients who do not have avascular necrosis.

Analysis of Clinical Grading Scales for the Foot and Ankle

To evaluate grading methods used to report clinical results, we reviewed 1,607 articles related to the foot and ankle published in six orthopaedic journals from 1980 through July 1993. Many clinical studies use criteria such as patient satisfaction to grade results. A numeric score or grade was used in 346 articles: 238 used a grade only, 90 used a numeric score and grade, and 18 used a numeric score only. The numeric score or grade was usually, but not always, reported with details of the individual clinical factors that composed the score or grade. Twenty-three articles used a score before and after treatment. Statistics were used in 62 articles, and in 6 of those the statistics were used to compare clinical condition before and after treatment. This study demonstrated the array of grading methods used in selected orthopaedic journals and indicated the need for standardized grading techniques to allow for more meaningful interpretation of the orthopaedic literature.

Nonoperative treatment of plantar interdigital neuroma with a single corticosteroid injection

Patients who received a single corticosteroid injection for treatment of third webspace plantar interdigital neuroma were studied retrospectively. Forty-three patients (51 feet) were available for followup study (followup mean, 4 years; range, 2 to 6 years). Mean age of patients was 53 years. Pain initially was relieved in 36 patients (41 feet [80%]). Twenty-four feet (47%) ultimately required surgical excision, while most of the remaining 27 feet (53%), which had not been treated surgically, were the source of residual symptoms in patients. A single corticosteroid injection cannot be recommended as a cure for symptoms of third webspace neuroma, but it can be offered as a temporizing measure or as nonoperative treatment. A single corticosteroid injection does not preclude a successful surgical result.

Salvage Treatment of Failed Hallux Valgus Operations with Proximal First Metatarsal Osteotomy and Distal Soft-Tissue Reconstruction

We reviewed the results of 15 patients (16 feet) in whom a hallux valgus procedure had failed. Salvage was by proximal crescentic first metatarsal osteotomy with distal soft-tissue reconstruction. Results based on a clinical scale considering the level of pain, activity limitations, support requirement, footwear limitations, and alignment were good in 11, fair in two, and poor in three. Patients were satisfied with the results in 10 feet, satisfied with reservations in four feet, and dissatisfied in two feet. Complications were: transfer metatarsalgia in three, hallux varus in one, and osteotomy nonunion in one. One of the patients required reoperation to bone graft a proximal osteotomy. Metatarsal osteotomy was helpful in the salvage treatment of recurrent, symptomatic hallux valgus when the first metatarsophalangeal joint was functional and painless.

Arthrodesis versus resection arthroplasty for failed hallux valgus operations.

The results for 18 patients (20 feet) in whom a hallux valgus procedure had failed were reviewed. Ten patients (11 feet), with a mean age of 63 years, had correction with Keller resection arthroplasty and were observed for an average of 10 years (range, 3–15 years). The hallux valgus angle improved an average of 11° ± 3°, and the intermetatarsal angle improved an average of 2°± 1.7°. Results were good in six feet, fair in four, and poor in one. Eight patients (nine feet), with a mean age of 63 years, had correction with arthrodesis and were observed for an average of 5 years (range, 2–8 years). The hallux valgus angle improved an average of 23°± 6.9°, and the intermetatarsal angle improved an average of 2°± 3°. Results were good in six feet, fair in two, and poor in one. There were differences between the two operations in terms of patient satisfaction, pain relief, appearance, and footwear. The incidence of metatarsalgia was similar for the two groups. Complications, particularly malalignment, were more common in the resection group. None of the patients required additional revision operation. Resection arthroplasty is a simple procedure and does not require cast immobilization. Resection arthroplasty and arthrodesis are reasonable options for salvage treatment of failed hallux valgus operations in older patients because good results were achieved in six of nine (67%) feet after arthrodesis and in six of 11 (54%) feet after resection.

Oblique Metatarsal Osteotomy for Intractable Plantar Keratosis: 10-Year Follow-up:

Twenty patients (14 women and 6 men) (23 feet) had a single oblique osteotomy operation of the 2nd, 3rd, or 4th metatarsal without fixation during an 8-year period. The mean age was 46 years (range, 21–64 years). Each patient had a painful intractable plantar keratosis preoperatively. The average follow-up was 10 years (range, 3–14 years). Postoperatively, reoperation was performed in four feet because of painful callosities. For 13 of the 19 feet that did not have reoperation, patients were limited in footwear or required a shoe insert. Overall results were good for 10 feet, fair for 7 feet, and poor for 6 feet. The only complication was a deep infection that occurred in one foot (good result). Nonunion occurred in one foot and delayed union in one. The average decrease in metatarsal length after osteotomy was 6 ± 6 mm. The single oblique lesser metatarsal osteotomy may be successful, but one half of the patients continued to have some degree of pain and most patients had limitations in footwear. Overall results were disappointing, and patients who are offered this procedure should be advised of its limitations.