Mark A. Prissel

Registry Data Trends of Total Ankle Replacement Use

Joint arthroplasty registry data are meaningful when evaluating the outcomes of total joint replacement, because they provide unbiased objective information regarding survivorship and incidence of use. Critical evaluation of the registry data information will benefit the surgeon, patient, and industry. However, the implementation and acceptance of registry data for total ankle replacement has lagged behind that of hip and knee implant arthroplasty. Currently, several countries have national joint arthroplasty registries, with only some procuring information for total ankle replacement. We performed an electronic search to identify publications and worldwide registry databanks with pertinent information specific to total ankle replacement to determine the type of prostheses used and usage trends over time. We identified worldwide registry data from 33 countries, with details pertinent to total ankle replacement identified in only 6 countries. The obtained information was arbitrarily stratified into 3 distinct periods: 2000 to 2006, 2007 to 2010, and 2011. Within these study periods, the data from 13 total ankle replacement systems involving 3,980 ankles were identified. The vast majority (97%) of the reported ankle replacements were 3-component, mobile-bearing, uncemented prostheses. Three usage trends were identified: initial robust embracement followed by abrupt disuse, minimal use, and initial embracement followed by sustained growth in implantation. Before the widespread acceptance of new total ankle replacements, the United States should scrutinize and learn from the international registry data and develop its own national joint registry that would include total ankle replacement. Caution against the adoption of newly released prostheses, especially those without readily available revision components, is recommended.

Incidence of Revision After Primary Implantation of the Scandinavian Total Ankle Replacement System: A Systematic Review

Total ankle replacement was initially popularized in the 1970s as an alternative to ankle arthrodesis for advanced ankle arthritis; however, failures were catastrophic. Current implants show promise, focusing on normal joint anatomy and function with greatly improved materials and more precise surgical technique. Nevertheless, even with advancements in technology and implant engineering, implant failure remains a problem. Debate has existed and published reports vary greatly concerning the incidence of failure and revision of the Scandinavian Total Ankle Replacement system. Thus, a systematic review was performed revealing a 10.7% revision rate at weighted mean follow-up of 64 months.

Management of Extensive Tibial Osteolysis with the Agility™ Total Ankle Replacement Systems Using Geometric Metal-Reinforced Polymethylmethacrylate Cement Augmentation

Although total ankle replacement has endured improvement in implant design since its conception, failure requiring revision remains a known endpoint. We describe a technique for management of extensive tibial osteolysis for failed Agility™ total ankle replacement systems using geometric metal-reinforced polymethylmethacrylate cement augmentation. This technique provides immediate component stability and is a cost-effective alternate to impaction bone grafting. With this technique, the complications we have experienced have been limited to minor delayed incisional healing, and all patients have resumed meaningful weightbearing activities with stable integration of the tibial component.

A Multicenter, Retrospective Study of Early Weightbearing for Modified Lapidus Arthrodesis

The modified Lapidus arthrodesis is a long-established surgical technique for management of hallux valgus that provides reproducible results and quality patient outcomes. The data from 367 consecutive patients undergoing unilateral modified Lapidus arthrodesis from January 1, 2007 to December 31, 2008 at participating centers were retrospectively evaluated. The included patients were categorized into early weightbearing (≤ 21 days) and delayed weightbearing (> 21 days) groups. A total of 24 nonunions (6.5%) were identified, with 13 (7.1%) in the early weightbearing group and 11 (6.0%) in the delayed weightbearing group. To date, the present study is the largest multicenter investigation to evaluate early weightbearing after modified Lapidus arthrodesis and the only large study to directly compare early and delayed weightbearing. The findings of the present study have shown that early weightbearing for modified Lapidus arthrodesis does not increase the risk of nonunion when evaluating various fixation constructs.

All-Inside, Anatomical Lateral Ankle Stabilization for Revision and Complex Primary Lateral Ankle Stabilization A Technique Guide

Lateral ankle instability is a common mechanical problem that often requires surgical management when conservative efforts fail. Historically, myriad open surgical approaches have been proposed. Recently, consideration for arthroscopic management of lateral ankle instability has become popular, with promising results. Unfortunately, recurrent inversion ankle injury following lateral ankle stabilization can occur and require revision surgery. To date, arthroscopic management for revision lateral ankle stabilization has not been described. We present a novel arthroscopic technique combining an arthroscopic lateral ankle stabilization kit with a suture anchor ligament augmentation system for revision as well as complex primary lateral ankle stabilization.

Incidence of Nonunion of First Metatarsal-Phalangeal Joint Arthrodesis with Autogenous Iliac Crest Bone Graft after Failed Keller-Brandes Arthroplasty: A Systematic Review

The Keller-Brandes arthroplasty has well-documented outcomes, including many complications that culminate in arthrodesis of the first metatarsal-phalangeal joint. In the setting of a large osseous defect, the autogenous iliac crest is the most commonly referenced source for the autogenous bone graft. We undertook a systematic review of electronic databases and other relevant sources regarding the incidence of nonunion after arthrodesis of the first metatarsal-phalangeal joint using autogenous iliac crest bone graft for failed Keller-Brandes arthroplasty. Six studies involving 42 arthrodeses met our inclusion criteria. The incidence of nonunion was 4.8% (2 of 42). It has been inherently accepted that revisional surgery can increase the incidence of nonunion. Our systematic review of the available data revealed that the use of an autogenous iliac crest bone graft results in a high incidence of primary union (95.2%) for salvage arthrodesis. However, additional appropriately weighted prospective studies and comparative analyses are needed regarding this topic.

Incidence of Nonunion of the Unfixated, Isolated Evans Calcaneal Osteotomy: A Systematic Review

The Evans calcaneal osteotomy is frequently implemented in flatfoot reconstructive surgery for correction of planar deformity. Rigid fixation across an osteotomy is a documented, accepted technique to gain stability. However, since the original description of this osteotomy, which involved no internal fixation, debate has existed regarding the necessity of fixation. Conventional wisdom suggests that the nonunion rate would increase with an unfixated osteotomy. Thus, in an effort to determine the incidence of nonunion of the unfixated, isolated Evans calcaneal osteotomy, we conducted a systematic review. Studies were eligible for inclusion only if they included the following: the nonunion rate for unfixated, isolated Evans calcaneal osteotomy, follow-up of at least 1 year and a sample size of at least 5 feet. After considering all potentially eligible studies, 2 evidence-based medicine level 2 and 3 evidence-based medicine level 3 studies met our inclusion criteria. A total of 73 feet, with a weighted mean age of 22.6 years, were included. The weighted mean follow-up of the included studies was 3.6 years. A total of 1 nonunion (1.4%) was reported. The results of our systematic review revealed an acceptably low rate of nonunion for the unfixated, isolated Evans calcaneal osteotomy. However, considering the limited data available, additional prospective investigations are warranted to further validate the nonunion rate with this technique.

Plantar Plate Repair Using a Direct Plantar Approach: An Outcomes Analysis

ABSTRACT Direct plantar plate repair using a plantar approach has been described previously, but with few reports of the outcomes or clinical results. The purpose of the present study was to determine the outcomes of this technique. We performed a retrospective analysis of patients who had undergone direct plantar plate repair with or without concomitant Weil osteotomy and a prospective patient‐reported subjective outcomes analysis. Ultimately, 131 patients (144 toes) were included, and the response rate for the mailed surveys was 53.5% (77 of 144 toes). The clinical outcomes reported a well‐aligned toe in 87.1% of cases, with a recurrence rate of 7.6% (11 of 144) and a revision rate of 2.8% (4 of 144). Statistically significant improvement in the overall modified Foot Function Index (p < .001) and subscale scores for pain (p < .001), disability (p < .001), and activity limitation (p = .001) were noted postoperatively compared with the preoperative data. The median postoperative visual analog pain scale level reported at survey completion was 2.0 (range 0.0 to 10.0; mean ± standard deviation 2.3 ± 2.6). Despite the modified Foot Function Index scores, the patient satisfaction questionnaire data reported mixed results. Our modified Foot Function Index results demonstrated that this approach provides excellent postoperative pain relief, improvement of associated disability, and improvement in activity limitations. The importance of managing patient expectations is acknowledged secondary to the discrepancy with the patient satisfaction data and the modified Foot Function Index results. Further prospective study is warranted to compare this technique with alternate dorsal approaches for plantar plate repair with and without associated commercially available suture passing systems.

A Review of 399 Total Ankle Replacements: Analysis of Ipsilateral Subtalar Joint Arthrodesis and Associated Talar Component Subsidence

Abstract Total ankle replacement (TAR) is an accepted treatment for end‐stage ankle arthritis. When concurrent subtalar joint pathologic features exist, ipsilateral subtalar joint arthrodesis (STJA) can be performed either simultaneous with TAR or as a staged procedure. Limited data exist on the effect of talar component subsidence and prosthesis survivorship. The present study purpose was to evaluate the effect of STJA on talar component subsidence after primary TAR and its effect on TAR survivorship. All patients, a minimum of 18 years old, from a single institution with modern‐generation TAR and 1‐year minimum follow‐up data available were evaluated. The study group included patients who had also undergone STJA, and the control group (no STJA) was matched 1:1 by age, gender, and prosthesis. The initial postoperative weightbearing and most recent weightbearing radiographs were compared for talar component subsidence. We reviewed 399 primary TARs from 2004 to 2012. A total of 33 patients with ipsilateral STJA met the inclusion criteria and had an appropriate control group match. In the study group, 8 patients required a return to the operating room for 4 revisions and 4 reoperations at a median follow‐up point of 24.3 months. Of the controls, 9 patients required a return to the operating room, with 4 revisions and 5 reoperations at a median follow‐up point of 38.4 months. No statistically significant radiographic differences were found between the 2 groups. Primary TAR and ipsilateral STJA were infrequently required (41 of 399; 10.3%). TAR did not result in decreased survivorship when performed with ipsilateral STJA at an early follow‐up point. Further study is warranted to determine any differences among previous, simultaneous, and subsequent STJA with ipsilateral TAR, and a matched longitudinal analysis is needed to determine longer term survivorship. &NA; Level of Clinical Evidence: 3

Ankle Arthrodesis: A Retrospective Analysis Comparing Single Column, Locked Anterior Plating to Crossed Lag Screw Technique

ABSTRACT Ankle arthrodesis is performed to eliminate pain due to end‐stage osteoarthritis, regardless of etiology. This procedure remains the reference standard treatment for end‐stage ankle arthritis, despite recent advancements in total ankle replacement. The objective of the present study was to retrospectively evaluate the radiographic and clinical fusion rates and time to bony fusion for patients who underwent ankle arthrodesis using an anterior approach with a single column locked plate construct versus crossed lag screws. We identified 358 patients who had undergone ankle arthrodesis from January 2003 to June 2013. Of the 358 patients, 83 (23.2%) met the inclusion criteria for the present study. Of the 83 included patients, 47 received locked anterior (or anterolateral) plate fixation, and 36 received crossed lag screw constructs. The overall nonunion rate was 6.0% (n = 5), with 1 nonunion in the anterior plate group (2.1%) and 4 nonunions in the crossed lag screw group (11.1%; p = .217). No differences were identified between the 2 groups for normal talocrural angle [χ2 (1) = 0.527; p = .468], normal tibial axis/talar ratio [χ2 (1) = 0.004; p = .952], and lateral dorsiflexion angle (p = .565). Based on our findings in similar demographic groups, ankle arthrodesis using locked anterior plate fixation is a safe technique with similar complication rates and radiographic outcomes to those of crossed lag screws.