Malik Siddique

Role of abrasion of the femoral component in revision knee arthroplasty

We carried out 60 revision procedures for failed porous coated anatomic total knee replacements in 54 patients, which were divided into two groups. The 14 knees in group I had a well-fixed femoral component at surgery which was retained, and in the 46 knees in group II both tibial and femoral components were loose and were revised using a variety of implants. Our review comprised clinical and radiological assessment. A total of 13 knees required a second revision. Six (42%) in group I failed very early (mean 2.1 years) when compared with seven (15%) in group II (mean 6.8 years). Failure was due to wear of the polyethylene insert by the abraded, retained femoral component (crude odds ratio 4.07; 95% CI 1.07 to 15.5). We recommend a complete change of primary bearing surfaces at the time of revision of an uncemented total knee replacement in order to prevent early wear of polyethylene.

The results of revision knee arthroplasty with and without retention of secure cemented femoral components

We have compared the survival of 67 revision arthroplasties of the knee undertaken for aseptic loosening with and without the retention of a secure, cemented femoral component. All the patients had undergone a single primary procedure at a mean of nine years previously. In group I (25 knees) the original femoral component was secure and was retained. There were no abrasions or osteolysis. The knees were stable, normally aligned, with minimal bone loss. In group 1142 knees did not fulfil these criteria and underwent revision of both components. The mean follow-up was four years. Re-revision for loosening was required in seven knees (28%) in group I and three (7%) in group II (p < 0.01). The remaining knees function well with Knee Society scores averaging 84/69 and no radiological evidence of osteolysis. When revising cemented implants, retention of a secure femoral component cannot be recommended even when conditions appear to be suitable.

Two-year outcomes of MOBILITY Total Ankle Replacement

BACKGROUND There is little literature on patient-reported outcomes following total ankle replacement in patients with osteoarthritis, posttraumatic osteoarthritis, and rheumatoid arthritis. We compared the differences in demographic data and clinical and patient-reported outcomes among patients with those types of arthritis who underwent total ankle replacement performed with use of the MOBILITY Total Ankle System. METHODS Patients were divided into three groups based on the preoperative diagnosis of type of arthritis. We analyzed patient demographic data, American Orthopaedic Foot & Ankle Society (AOFAS) scores, and patient-reported outcomes as measured with use of the Foot and Ankle Outcome Score (FAOS), the 36-item Short-Form (SF-36) Health Survey, and patient-satisfaction scores, collected preoperatively and at one and two years postoperatively. RESULTS The study included 106 consecutive patients who underwent total ankle replacement between March 2006 and December 2009. The posttraumatic osteoarthritis group, which had twenty-eight patients, was significantly younger (mean age, 54.8 yrs; p < 0.05) than the other groups; the rheumatoid arthritis group, which had twenty-two patients, had a significantly lower mean body mass index (24.5 kg/m(2); p < 0.05); and the osteoarthritis group, which had fifty-six patients, had a higher proportion of males (41 males; p < 0.05). The posttraumatic osteoarthritis group reported better scores for two of the eight domains of the SF-36 preoperatively. At one year postoperatively, the posttraumatic osteoarthritis group and the rheumatoid arthritis group had better FAOS results regarding pain than those of the osteoarthritis group, and the posttraumatic osteoarthritis group also reported better scores for the general health domain of the SF-36. At two years, the posttraumatic group continued to show significantly higher scores for the general health domain of the SF-36. There was no significant difference between the groups in terms of the AOFAS scores, other FAOS results, or the patient-satisfaction scores at one and two years postoperatively. CONCLUSIONS Our findings suggest that early outcomes after total ankle replacement for patients with posttraumatic osteoarthritis are comparable with those for patients with osteoarthritis and rheumatoid arthritis.

Postphlebitic syndrome after total knee arthroplasty: 405 patients examined 2-10 years after surgery

We assessed the prevalence and relevance of putative risk factors for significant postphlebitic syndrome (PPS) in a cohort of 405 patients who underwent single limb cemented total knee arthroplasty. All patients were studied by means of a questionnaire and clinical examination to detect the presence of lower limb venous insufficiency. We found 52 (13%) new cases of postphlebitic syndrome. Comparison of those patients with and without PPS revealed no significant differences in the median age, sex ratio, preoperative mass, primary joint pathology or relevance of primary or revision surgery. A confirmed history of pre- or post-operative deep vein thrombosis was associated with the development of disease. Most cases seemed to develop within 5 years of surgery.

Radiographic Severity of Arthritis Affects Functional Outcome in Total Ankle Replacement (TAR)

Background: It has been previously demonstrated that radiographic severity of arthritis predicts outcome following knee replacement. In certain circumstances, patients may undergo arthroplasty without severe radiographic disease. An example may be the patient with significant chondral damage unsuccessfully treated with arthroscopy. This patient may proceed to joint replacement when their radiographs would not normally merit such intervention. We investigated whether these findings were also applicable to total ankle replacements (TARs). Methods: We retrospectively reviewed a single-surgeon, single-implant series of 178 TARs in 170 patients. Of them, 124 patients who took part in the hospital joint registry with a minimum 2-year follow-up were included for this study. The radiographic severity of arthritis was graded using the Kellgren-Lawrence classification. Preoperative weight-bearing radiographs were reviewed for severity of arthritis by 2 blinded observers: the first author and an independent colleague from the radiology department. Patients were grouped into 4 subgroups based on degree of severity of radiographic grading for arthritis—A, B, C, and D (for grades 1, 2, 3, and 4 grades, respectively). Data collected included Foot and Ankle Outcome Score (FAOS; pain, function, and stiffness), MOS 36-item Short-Form Health Survey (SF-36) scores, and patient satisfaction scores collected prospectively and at 1 and 2 years postoperation. Results: Groups were similar in terms of demographic data (P > .1) and preoperative FAOS scores (P > .89) for pain, function and stiffness. Group D had the biggest improvement in all domains of FAOS. This reached significance in each domain when compared to group C. No significant differences were demonstrated in SF-36 scores. Overall, 91.1% of patients in group D were satisfied at 2 years, compared with 50.0% of patients in groups A, B, and C (P < .001). In addition, 93.9% of patients in group D felt that their quality of life had been improved by the surgery, compared to 47% of patients with groups A, B, and C (P < .001). Further, 77.3% of patients from group D said they would have the operation again, vs only 52.2% of patients with grade III or less (P = .014). Patients who were “very satisfied” or “somewhat satisfied” postoperatively had an average Kellgren-Lawrence (KL) grade of 3.9 preoperatively. In contrast the “very dissatisfied” and “somewhat dissatisfied” patients had an average KL grade of 2.9 (P < .05). Conclusion: Although this study does not explain all of the dissatisfaction in TAR, radiologic severity is an important factor that surgeons must consider when planning how best to treat their patients. There may be a different pathophysiology in this patient group that is not well served by arthroplasty. Level of Evidence: Level III, retrospective comparative series.

The effect of patient age and diagnosis on the 5-year outcomes of mobile-bearing total ankle replacement

Total Ankle Replacement is an established technique for the management of end-stage ankle arthritis. However, there are few studies focussing on patient-reported outcomes in the medium and long term related to age or arthritis type. We compared demographic data and patient-reported outcomes preoperatively and at five years postoperatively for patients who underwent total ankle replacement with the aim of establishing whether differences exist in outcome depending on patient age or diagnosis. The Foot and Ankle Score (FAOS) and 36-item Short-Form (SF-36) Health Survey were analysed by diagnosis (osteoarthritis, rheumatoid arthritis, post-traumatic arthritis) and age (under or over 60 years). At 5 years, the post-traumatic arthritis group had a significantly higher composite score than the osteoarthritis (p<0.0001) or rheumatoid arthritis groups (p<0.0001). Only the post-traumatic arthritis group experienced a significant increase in composite SF-36 score from baseline (p<0.0001). There was a significant improvement from pre-operatively to 5 years in all three domains of the FAOS and in total scores in both groups (over 60 p<0.0001; 60 and under p=0.0002). There was a significant improvement in composite SF-36 score from pre-operative to 5 years in the patients 60 years or younger at the time of surgery (p=0.0006), but not for the patients over 60. Three patients have been revised (4%), at a mean of 4.8 years following surgery with one patient awaiting revision.

Do Pain, Functional Disability, and Gait in End-stage Ankle Arthritis Worsen with Associated Varus Coronal Plane Deformity?

Category: Ankle Arthritis Introduction/Purpose: There is paucity of literature on quantitative gait changes in patients with increased coronal plane deformity along with end stage ankle arthritis. We aimed to study the difference in spatial temporal parameters of gait and patient reported functional measure in patients with end stage arthritis and no coronal plane deformity vs. varus deformity of >10? Methods: All patients diagnosed with end stage arthritis between April 2016 and December 2017 underwent an objective gait assessment using Tekscan system (BioSense Medicals, UK) as part of routine clinical practice. Of this cohort, patients with bilateral ankle arthritis, previous reconstructive surgery, inflammatory arthritis, hip and knee arthritis, spinal pathology and underlying neurological conditions were excluded. Patients with unilateral ankle arthritis for a diagnosis of osteoarthritis or post traumatic arthritis were included in this study. These patients were grouped into Group A (no coronal plane deformity) vs. Group B (varus deformity of more than 10?). In these patients differences were studied between the groups for temporal spatial parameters of gait and functional disability levels measured by MOX-FQ scores. Statistical tests included normality tests, student t’tests, chi square evaluation and analysis of variance tests with SPSS. Results: Of 33 patients, 22 were in Group A (N=22) and 10 in Group B (N=10). There was no difference in mean age between groups (61.5 vs. 65.07; p=0.335; diagnosis was predominantly OA in both groups MOX-FQ: -  There were similar levels of pain (p=0.570), difficulty with walking / standing (p=0.492) and restriction in social activities (p=0.869) reported Quantitative gait measures: -  For spatial parameters, there was no difference between groups; p>0.05. -  For temporal parameters, there was decreased step time(s) (0.67 vs. 0.61) and mid stance times (0.38 s vs. 0.30 s) in Group B; borderline statistical significance (p=0.052). -  There was increase in stride velocity measured in Group B (79.1 ± 22.7 m/s) compared to Group A (64.0 ± 18.1 m/s), (p=0.05). Conclusion: -  Although there were no differences in functional levels of pain, difficulty with walking / standing and restriction in social activities, measured by MOX-FQ, there were differences observed in objective gait parameters. -  Patients in both groups demonstrated antalgic gait patterns; this was slightly increased in varus group. -  There is a trend for reduction in temporal parameters and stride velocity in patients with end stage ankle arthritis and coronal plane deformity >10?, when compared to patients with end stage arthritis and no coronal plane deformity -  Larger clinical study with increased sample size is required to confirm these findings.

PROMS and Radiological Outcomes in Mobile Bearing Total Ankle Arthroplasty for Patients with Varus or Valgus Deformity

Category: Ankle Arthritis Introduction/Purpose: There is increasing evidence that outcomes for total ankle arthroplasty (TAA) are not adversely affected by pre-operative varus deformity. There is a sparsity of evidence relating to outcomes in valgus ankle arthritis. We present our outcomes using a mobile bearing prosthesis (Mobility TAA system, DePuy, Raynham, Massachusetts, USA) with a comparison of neutral, varus and valgus ankles. Methods: This is a single surgeon, retrospective cohort study of consecutive cases. Cases were identified from a locally held joint registry which routinely records PROMS data pre-operatively and at annual intervals. Patients undergoing primary TAA between March 2006 and June 2014 were included. Rrevision procedures along with those with inadequate radiographic images for deformity analysis were excluded. Patients with inadequate PROMS data were included in the radiological analysis but not the PROMS analysis. Data collected included FAOS (Womac Pain, Function and Stiffness), SF-36 scores and patient satisfaction. Radiological data was gathered from routinely taken AP weight bearing radiographs pre-operatively, immediately post-operatively and at final follow up. Pre-operative deformity was measured between the tibial anatomical axis and a line perpendicular to the talus. Patients were classified as neutral, varus (≥10 degrees varus) or valgus (≥10 degrees valgus). Results: 230 cases (see image) underwent radiological classification (152 neutral, 60 varus, 18 valgus) and were included in the radiological analysis (mean follow-up 55.9 months). 164 cases were included in the PROMS analysis (mean follow-up 61.6 months). The groups were similar with regards to BMI and length of follow-up but neutral ankles were younger (P<0.001). Baseline scores were equal except physical health with valgus ankles scoring lowest (P=0.045). Valgus ankles had statistically better post-operative pain (P=0.0247) and function (P=0.012) than neutral ankles. Pre to post-operative change did not reach statistical significance except physical health where valgus outperformed neutral and varus (p=0.039). Mean post-operative angle was 3.1 and final angle 3.7 with no significant differences. There was no significant differences in revision rates. Conclusion: Our study confirms previous evidence that varus deformity does not affect outcome in TAA. Contrary to this, valgus ankles in our cohort performed better post-operatively than neutral ankles. Post-operative coronal radiological alignment was not affected by pre-operative deformity and was maintained over a number of years. Coronal plane deformity does not negatively impact either radiological or clinical outcomes in TAA should not be considered an absolute contra-indication.

Topographic Pain Mapping versus Radiological Inter-observer Variation in Ankle Arthritis

Category: Ankle, Ankle Arthritis Introduction/Purpose: Topographic pain mapping has gained popularity during 20th century, providing opportunities for patients to demonstrate spatial distribution of pain. Despite this, evidence of clinical application in orthopaedics remains largely limited to spinal pathologies. We investigate how clinician interpretation of routine radiological studies compares to patient pain mapping in ankle arthritis. Methods: Between 2014 and 2016 we identified 21 patients ultimately diagnosed with ankle arthritis, who underwent comprehensive gait analysis (including topographic pain mapping) on referral to our institution. Patients were requested to map up to three pain areas, assigning a visual analogue score (VAS) of 0-10, to signify severity of pain in each area. A consultant orthopaedic foot and ankle surgeon, and orthopaedic trainees undertook blinded evaluation of relevant radiological studies, estimating patients’ mapping and VAS scores on the basis of radiological pathology. For the purpose of analysis findings were applied to five distinct regions around the ankle: three anterior (antero-medial; central; and antero-lateral), lateral and medial. Results were correlated between the different assessors, as well as to the patients’ pain mapping, using Spearman’s Rho & Kendall Tau correlation statistics, significance taken as p=<0.05. Results: There is a strong radiological inter-observer correlation for anterior ankle pain in ankle arthritis [Antero-lateral 0.751(p=0.012); Central 0.912(p=<0.001)]. These findings also correlate well with patient pain mapping [Central consultant-patient 0.920(p=<0.001); trainee-patient 0.982(p=<0.001)]. Assessment of medial (tibialis posterior) and lateral (subtalar/peroneal) pathology demonstrates poorer inter-observer correlations (p>0.05). Correlation to patient pain mapping was even poorer, with radiological assessment consistently over- estimating symptom severity (p=>0.05). Conclusion: There is a statistically strong correlation between topographic pain mapping and radiological evaluation of ankle arthritis. We strongly recommend that additional pathology around the ankle is excluded by use of pre-operative MRI imaging prior to surgery for ankle arthritis. Pain from ankle arthritis appears to mask additional soft tissue pathology surrounding the ankle noted on MRI scan.

Is Ankle Arthritis More Disabling than Midfoot Arthritis and 1st MTPJ Arthritis

Category: Ankle Arthritis, Midfoot/Forefoot Introduction/Purpose: There is wide array of outcome tools available for assessment of level of pain and symptoms in osteoarthritis, there are less disease and region specific outcome measures to evaluate the level of disability caused by arthritis in ankle, mid foot arthritis (including Talo-navicular joint, Calcaneo-cuboid joint and tarso metatarsal joints) and 1st Metatarso phalangeal joints. We aimed to measure the level of disability incorporating elements of physical, mental and social well-being using patient reported outcome measures as recommended by the International classification of Functioning, disability and health (ICF) Methods: This is a prospective data series, patients with arthritis of ankle, mid foot or 1st MTPJ who were diagnosed in new patient clinic were asked to take part in this survey. They completed a questionnaire consisting of MOX-FQ (Manchester Oxford Foot Questionnaire), EQ-5D (General Health Status) and FAOS (Foot and Ankle Outcome Scores). Patients were grouped in to 3 groups (Group A - ankle arthritis. Group B - midfoot arthritis (either Talo navicular, Calcaneo-cuboid or TMT joint); Group C - arthritis of 1st Metatarso-phalangeal joint of the foot). The results of summary scores were calculated for responses to individual questions and compared between the groups. Demographic factors were included in the statistical analysis carried out using SPSS Version 22, Illinois. Results are reported as follows Results: There were 26 patients in (Group A); 12 patients in (Group B) and 19 patients in (Group C). There was no difference in mean age of patients between groups (p>0.05) For components in MOX-FQ, there was no difference in pain scores (p=0.353) between the groups. For difficulty with walking/standing, Group A patients reported significantly worse scores (77 ± 19.4) when compared to Group C (53.7 ± 35.5). There was no difference in scores between groups for social function component of MOX- FQ (p=0.487). For EQ-5D, although Group C patients reported higher scores they failed to achieve statistical significance (p>0.05). For FAOS, Group A patients reported significantly lower scores for pain and symptoms, ADL, ability to take part in Sports/Recreation (p=0.008) and Quality of Life (p=0.003). Conclusion: In conclusion, although patients with ankle arthritis, mid foot arthritis and 1st MTP joint arthritis report similar level of disability in terms of general health and social function, patients with ankle arthritis reported higher level of disability in terms of pain, difficulty with standing/ Walking, ability to do Activities of Daily living, ability to take part in recreational activities and overall Quality of Life.