James K. DeOrio

Results of a second attempt at surgical repair of a failed initial rotator-cuff repair.

Twenty-seven patients with twenty-seven involved shoulders underwent a second attempt at repair of an initial rotator-cuff repair that had failed. Factors associated with the failure of the initial repair included a massive or large tendon tear, damage to the deltoid origin at the original surgery, and possibly inadequate postoperative external support. Seven patients required a third operation because of continuing pain or weakness. The remaining twenty patients were followed for a minimum of two years (average, forty-eight months) and seventeen of them were examined at an average of forty-six months (range, twenty-six to 118 months) after surgery. Postoperatively, although seventeen patients (63 per cent) still had moderate or severe pain, sixteen (76 per cent) of the twenty-one patients who were operated on to relieve pain reported that the pain was substantially diminished. Active abduction increased an average of 8 degrees, but only seven shoulders gained more than 30 degrees of active abduction. Nineteen shoulders remained moderately or markedly weak in abduction. Over-all, four patients (17 per cent) had a good result; six (25 per cent), a fair result; and fourteen (58 per cent), a poor result. These results suggest that the surgeon should be quite hesitant to propose a second attempt at rotator cuff repair to a patient, as although pain may be diminished, active movement is unlikely to improve.

Prospective Controlled Trial of STAR Total Ankle Replacement versus Ankle Fusion: Initial Results

Background: Mobile-bearing ankle replacements have become popular outside of the United States over the past two decades. The goal of the present study was to perform a prospective evaluation of the safety and efficacy of a mobile-bearing prosthesis to treat end stage ankle arthritis. We report the results of three separate cohorts of patients: a group of Scandanavian Total Ankle Replacement (STAR) patients and a control group of ankle fusion patients (the Pivotal Study Groups) and another group of STAR total ankle patients (Continued Access Group) whose surgery was performed following the completion of enrollment in the Pivotal Study. Materials and Methods: The Pivotal Study design was a non-inferiority study using ankle fusion as the control. A non-randomized multi-centered design with concurrent fusion controls was used. We report the initial perioperative findings up to 24 months following surgery. For an individual patient to be considered an overall success, all of the following criteria needed to be met: a) a 40-point improvement in total Buechel-Pappas ankle score, b) no device failures, revisions, or removals, c) radiographic success, and d) no major complications. In the Pivotal Study (9/00 to 12/01), 158 ankle replacement and 66 arthrodesis procedures were performed; in the Continued Access Study (4/02 to 10/06), 448 ankle replacements were performed, of which 416 were at minimum 24 months post-surgery at time of the database closure. Results: Major complications and need for secondary surgical intervention were more common in the Pivotal Study arthroplasty group than the Pivotal Study ankle fusion group. In the Continued Access Group, secondary procedures performed on these arthroplasty patients decreased by half when compared with the Pivotal Arthroplasty Group. When the Pivotal Groups were compared, treatment efficacy was higher for the ankle replacement group due to improvement in functional scores. Pain relief was equivalent between fusion and replacement patients. The hypothesis of non-inferiority of ankle replacement was met for overall patient success. Conclusion: By 24 months, ankles treated with STAR ankle replacement (in both the Pivotal and Continued Access Groups) had better function and equivalent pain relief as ankles treated with fusion. Level of Evidence: II, Prospective Controlled Comparative Surgical Trial

Results of Total Ankle Arthroplasty

Most published reports related to total ankle arthroplasty have a fair to poor-quality level of evidence. Comparative studies with a fair to good-quality level of evidence suggest that total ankle arthroplasty provides equal pain relief and possibly improved function compared with ankle arthrodesis. On the basis of the current literature, survivorship of total ankle arthroplasty implants, when measured as the retention of metal components, ranges from 70% to 98% at three to six years and from 80% to 95% at eight to twelve years. Several investigators have argued that, in the evolution of total ankle arthroplasty, some obligatory reoperation without removal of the metal implants is anticipated; examples of reoperation include relief of osseous or soft-tissue impingement, improvement of alignment or stability of the foot and ankle, bone-grafting for cystic lesions, and/or polyethylene exchange. A successful return to low-impact, recreational sporting activities is possible after total ankle arthroplasty.

Lumbar disc excision in children and adolescents.

Fifty patients, all of whom were sixteen years old or younger, underwent discectomy for a herniated lumbar disc at the Mayo Clinic between 1950 and 1976. Ninety-four per cent of the patients had had excellent or good initial relief of symptoms after the initial operation. Subsequently, however, twenty-eight of the thirty-seven patients who initially had undergone disc excision only required additional treatment for low-back pain or sciatica. Twelve of them required a second operation, consisting of nine discectomies (six with a concomitant spine fusion), two spine fusions alone, and one re-fusion. Of the thirty-seven patients who initially had had disc excision alone, three had a recurrent disc protrusion and five had a disc protrusion at another level. Of sixteen patients who had had multiple subtotal hemilaminectomies at the initial operation, either for involvement of multiple discs or for exploration, seven required reoperation. In the twelve patients who had had both a disc excision and a lumbar spine fusion as the initial operation, there were no recurrent disc protrusions and only one patient had a protrusion at another level. Follow-up on all patients ranged from five to thirty years (average, nineteen years). Ninety per cent of the patients stated that the condition of the back had little or no effect on their current way of life, despite the presence of continuing back complaints in some. However, we rated the results of the initial discectomy at follow-up as excellent or good in 73.5 per cent and poor in 26.5 per cent of the patients.

In Vivo Kinematics of the Tibiotalar Joint After Lateral Ankle Instability

Background Previous studies have suggested that injury to the anterior talofibular ligament (ATFL) may be linked to altered kinematics and the development of osteoarthritis of the ankle joint. However, the effects of ATFL injury on the in vivo kinematics of the ankle joint are unclear. Hypothesis Based on the orientation of the ATFL fibers, ATFL deficiency leads to increased anterior translation and increased internal rotation of the talus relative to the tibia. Study Design Descriptive laboratory study. Methods The ankles of 9 patients with unilateral ATFL injuries were compared as they stepped onto a level surface. Kinematic measurements were made as a function of increasing load. With use of magnetic resonance imaging and orthogonal fluoroscopy, the in vivo kinematics of the tibiotalar joint were measured in the ATFL-deficient and intact ankles of the same individuals. Results A statistically significant increase in internal rotation, anterior translation, and superior translation of the talus was measured in ATFL-deficient ankles, as compared with the intact contralateral controls. For example, at 100% body weight, ATFL-deficient ankles demonstrated an increase of 0.9 ± 0.5 mm in anterior translation (P = .008), an increase of 5.7° ± 3.6° in internal rotation (P = .008), and a slight increase of 0.2 ± 0.2 mm in the superior translation (P = .02) relative to the intact contralateral ankles. Conclusion Deficiency of the ATFL increases anterior translation, internal rotation, and superior translation of the talus. Clinical Relevance Altered kinematics may contribute to the degenerative changes observed with chronic lateral ankle instability. These findings might help to explain the degenerative changes frequently observed on the medial talus in patients with chronic ATFL insufficiency and so provide a baseline for improving ankle ligament reconstructions aimed at restoring normal joint motion.

Design features of current total ankle replacements: implants and instrumentation.

Abstract Development of total ankle replacements began nearly 40 years ago. The initial devices were cemented and highly constrained, and they eventually failed. These were followed by second‐generation cementless ankle implants with a fixed (two‐component design) or mobile (three‐component design) polyethylene bearing. Currently, four ankle replacements are approved by the US Food and Drug Administration. These four—Agility, INBONE, Salto‐Talaris, and Eclipse—are two‐component designs; the Scandinavian Total Ankle Replacement, a three‐part mobile‐bearing design, has been recommended for approval by the FDA. It is anticipated to arrive in the US market in late 2008. Although interest in total ankle replacements is increasing, midterm clinical results to date are few and often have not been validated by independent practitioners. In addition, no level I or II studies have been published. Therefore, the design rationale for these implants and instruments should be carefully evaluated.

Early Prospective Clinical Results of a Modern Fixed-Bearing Total Ankle Arthroplasty

BACKGROUND Several fixed-bearing total ankle arthroplasty systems are available in the United States. We report on the early clinical results of the largest known cohort of patients in the United States who received a Salto Talaris total ankle replacement for the treatment of end-stage arthritis of the ankle. METHODS We prospectively followed sixty-seven patients with a minimum clinical follow-up of two years. Patients completed standardized assessments and underwent physical examination, functional assessment, and radiographic evaluation preoperatively and at six weeks, three months, and six months postoperatively and yearly thereafter through their most recent follow-up. RESULTS Implant survival at a mean follow-up time of 2.8 years was 96% when metallic component revision, removal, or impending failure was used as the end point. Three patients developed aseptic loosening, and all instances involved the tibial component. One of the three patients underwent revision to another fixed-bearing total ankle arthroplasty system, one patient is awaiting revision surgery, and the third patient has remained minimally symptomatic and fully functional without additional surgery. Forty-five patients underwent at least one additional procedure at the time of the index surgery. The most common concurrent procedure performed was a deltoid ligament release (n = 21). Eight patients underwent additional surgery following the index arthroplasty, most commonly debridement for medial and/or lateral impingement (n = 4). As of the most recent follow-up, patients demonstrated significant improvement in pain scores, American Orthopaedic Foot & Ankle Society hindfoot score, and functional scores. CONCLUSIONS Early clinical results indicate that the Salto Talaris fixed-bearing total ankle arthroplasty system can provide significant improvement in pain, quality of life, and standard functional measures in patients with end-stage ankle arthritis. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Lesser Toe Deformities

Abstract Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various appliances. Surgical management is reserved for patients who fail nonsurgical treatment. Options include soft‐tissue correction (eg, tendon transfer) as well as bony procedures (eg, joint resection, fusion, metatarsal shortening), or a combination of techniques.

In vivo cartilage contact strains in patients with lateral ankle instability

Damage to the anterior talofibular ligament (ATFL) and cacaneofibular ligament (CFL) during an ankle sprain may be linked to the development of osteoarthritis. Although altered tibiotalar kinematics have been demonstrated, the effects of lateral ankle instability (LAI) on in vivo cartilage strains have not been described. We hypothesized that peak cartilage strains increase, and the location is shifted in patients with ATFL injuries. We used 3-D MRI models and biplanar fluoroscopy to evaluate in vivo cartilage contact strains in seven patients with unilateral LAI. Subjects had chronic unilateral ATFL injury or combined ATFL and CFL injury, and were evaluated with increasing load while stepping onto a force plate. Peak cartilage strain and the location of the peak strain were measured using the contralateral normal ankle as a control. Ankles with LAI demonstrated significantly increased peak strain when compared with ATFL-intact controls. For example, at 100% body weight, peak strain was 29+/-8% on the injured side compared to 21+/-5% on the intact side. The position of peak strain on the injured ankle also showed significant anterior translation and medial translation. At 100% body weight, the location of peak strain in the injured ankle translated anteriorly by 15.5+/-7.1mm and medially by 12.9+/-4.3mm relative to the intact ankle. These changes correspond to the region of clinically observed osteoarthritis. Chronic LAI, therefore, may contribute to the development of tibiotalar cartilage degeneration due to altered cartilage strains.

Differences in Outcomes Following Total Ankle Replacement in Patients with Neutral Alignment Compared with Tibiotalar Joint Malalignment

BACKGROUND Excessive tibiotalar malalignment in the coronal plane has been considered by some to be a contraindication to total ankle replacement. The purpose of the present study was to compare clinical outcomes and physical performance measures according to preoperative tibiotalar alignment. METHODS One hundred and three patients undergoing total ankle replacement were grouped according to coronal plane tibiotalar alignment. Seventeen patients had an excessive deformity (>15° of varus or valgus), twenty-one had moderate valgus alignment (5° to 15° of valgus), twenty-seven had moderate varus alignment (5° to 15° of varus), and thirty-eight had neutral alignment (<5° of varus or valgus). Outcome measures, including the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the Foot and Ankle Disability Index (FADI), the Short Form-36 (SF-36), the timed up and go test (TUG), the four square step test (4SST), and walking speed, were assessed preoperatively and at one and two years after total ankle replacement. RESULTS Coronal plane alignment improved following the procedure, with 36.9% of patients having neutral alignment preoperatively as compared with 95% postoperatively. To achieve this alignment, adjunctive procedures, including deltoid ligament release, lateral ligament reconstruction, and posterior soft-tissue releases, were necessary. Significant improvements were seen for the Page: 3 AOFAS pain, function, alignment, and hindfoot scores (p < 0.001) and the SF-36 subscales of body pain, physical function, and role physical (p < 0.001) following total ankle replacement. Walking speed and the FADI, TUG, and 4SST scores also improved significantly (p < 0.001). Subgroup analysis demonstrated no significant differences in clinical outcomes and physical performance measures based on preoperative coronal plane alignment. CONCLUSIONS Total ankle replacement improves clinical and functional outcomes independent of preoperative tibiotalar alignment when postoperative alignment is restored to neutral at the time of arthroplasty. LEVEL OF EVIDENCE Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.