Aim. Failed consolidation (nonunion) after foot and ankle arthrodesis is a major complication, which can lead to additional revision arthrodesis with increased risk of morbidity. Multiple factors can contribute to developing a nonunion, including a low-grade infection. The aim of this study was to investigate the rate of unsuspected low-grade infection in revision arthrodesis for nonunions after foot and ankle arthrodesis. We also analyzed the outcome of unsuspected low-grade infections. Method. We conducted a retrospective study in The Sint Maartenskliniek, The Netherlands. All patients who underwent revision arthrodesis for assumed aseptic nonunion after foot and ankle arthrodesis between January 2020 and July 2021 were included. Patients were excluded if <5 tissue samples were obtained during revision arthrodesis or if they were treated for infection after the index arthrodesis. For the included patients, at least 5 tissue samples for culture were taken during the revision arthrodesis. The causative microorganisms, antibiotic susceptibility and treatment were assessed. An unsuspected infection was defined as ≥2 positive cultures with phenotypical identical microorganisms. Success was defined as union on imaging during clinical follow-up, without signs of persistent infection after finishing the antibiotic treatment. Results. In total 91 revision arthrodesis due to nonunion were performed. The mean duration between index and revision arthrodesis was 571 days. In 14 patients, an unexpected infection was diagnosed. The most frequent causative bacteria identified were Cutibacterium acnes (n=10) and Staphylococcus spps. (n=5). One infection was caused by a Gram-negative bacilli (Acinetobacter spps.). Two infections were polymicrobial. Of the 14 infections, 12 were treated with antibiotics for 12 weeks, 1 for 6 weeks and 1 was not treated. After one-year follow-up, the success rate was 86% and in one patient re-surgery was performed for a non-infectious reason. Conclusions. In 18% of the revisions for nonunion after foot and ankle arthrodesis, an unexpected low- grade infection was the cause of the nonunion. Nonunion occurring after foot and ankle arthrodesis is a severe complication, leading to additional revision arthrodesis. Low-grade infection should be considered as possible explanation of the nonunion, despite the lack of local inflammatory signs. As 18% of the nonunions were unexpectedly caused by low-grade infection, we strongly recommend obtaining at least 5 tissue samples for culture during revision arthrodesis. The outcome of unexpected infection as cause of nonunion is good, when treated with targeted antibiotics for 12 weeks

Ankle arthrodesis and replacement are the widely accepted options in managing end-stage ankle arthritis. Ankle replacement as an alternate treatment option for ankle arthritis is relatively new and this is in large part to the successes observed with hip and knee arthroplasty for arthritis. Relative benefits of ankle replacement and arthrodesis remains a contentious topic. We conducted a multicenter pilot randomized controlled trial, first of its kind, comparing the clinical outcomes of ankle arthrodesis and ankle replacement in managing ankle arthritis. We hypothesized that clinical outcomes would be similar for both. Patients recruited for this study were part of Canadian Orthopaedic Foot and Ankle Society (COFAS) Database. Canadian orthopaedic surgeons with fellowship training in foot and ankle surgery or extensive experience in the surgical treatment of end stage ankle arthritis determined whether the patient met the criteria for randomization, skeletal maturity, symptomatic ankle arthritis no longer amenable to non-operative management, and ability to give informed consent. Data was collected on patient demographics, follow-up time period, complication rates, and Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) scores. Our analysis of clinical outcomes was divided into two parts: (1) comparison of pre and postoperative data for each cohort separately, and (2) comparison of outcome scores, and revision rates between both cohorts. We employed the Student's t-test and calculated effect sizes in assessing improvements in AOS and SF-36 scores from baseline to latest follow-up within and between the two groups. We also examined postoperative complication and reoperation rates in the study population using the standardized coding system for reoperations following ankle replacement and arthrodesis. Thirty-nine ankles were enrolled in the study with a mean follow-up of 5.1 ± 2.8 years. Ankle osteoarthritis scale scores improved significantly from baseline and last follow-up in both groups. The average baseline AOS total score for ankle replacement improved from 59.4 ±15.9 to 38 ±20 at last follow-up (p-value 19.7 to 31.8 ±16.5 at last follow-up (p-value 25.4 compared to ankle replacement's 20.3 ±23. Two major complications (10.5%) were observed in the ankle replacement cohort while the ankle arthrodesis cohort saw four major complications (20%). Clinical outcomes of ankle replacement and arthrodesis were comparable. The ankle arthrodesis cohort held a slight advantage over ankle replacement in improvement of AOS scores, though not statistically significant. Rates of major complications and reoperations were higher with ankle arthrodesis

Autologous bone has been the gold standard for grafting material in foot and ankle arthrodesis. While autograft use has been effective, the harvest procedure does present risks to the patient including readmission, infection, and persistent graft harvest site pain. Previous studies have examined graft harvest site pain, but most have focused on the iliac crest and none have long term follow-up. The purpose of this study was to examine long-term (7–10 year) harvest site pain in subjects undergoing autograft harvest from multiple sites for hindfoot and/or ankle arthrodesis. Sixty (60) subjects underwent hindfoot or ankle arthrodesis supplemented with autograft as part of the control arm of a prospective, randomized trial. The mean subject age was 59.4 years (range, 24.7–76.8) and mean body mass index was 30.6 kg/m2 (range, 22.0–44.0). There were 29 males and 31 female subjects. Subjects had the tibiotalar (37.9%), subtalar (24.1%), talonavicular (10.3%), subtalar/talonavicular (5.1%), or subtalar/calcaneocuboid/talonavicular (22.4%) joints arthrodesed. Autograft was harvested from either the proximal tibia (51.7%), iliac crest (17.2%), calcaneous (15.5%), distal tibia (6.8%), or other location (8.6%). Graft harvest site pain was evaluated using a 100-point visual analog score (VAS), with clinically significant pain being any score greater than 20. Subjects were followed a mean of 9.0 years (range, 7.8–10.5). The percentage of subjects who reported clinically significant pain was 35.7%, 21.4%, 18.2%, 10.5%, 8.9%, and 5.2% at 2, 6, 12, 24, 52 weeks, and final follow-up (7.8–10.5 years), respectively. The mean VAS autograft harvest site pain at final follow-up was 4.4 (range, 0.0–97.0), with 37.9% of subjects reporting at least some pain. For three subjects (5%) with clinically significant pain (VAS >20) at final follow-up, two had proximal tibial harvest sites and one had an iliac crest harvest site. There was no correlation between graft volume and harvest site pain. This study is the first to examine long-term pain following autologous bone graft harvest for hindfoot and/or ankle arthrodesis. Over a third of patients reported having some pain at an average follow-up of nine years, with 5% experiencing clinically significant pain. The results of this study suggest that harvesting autograft bone carries a risk of persistent, long-term pain regardless of the volume of graft that is harvested. This potential for persistent pain should be considered when informing patients of procedure risks and when deciding to use autograft or a bone graft substitute material

A significant portion of ankle arthroplasty and ankle arthrodesis procedures performed in British Columbia are funded by the public medical services plan (MSP). However, some patients are treated privately through self-pay or by the workers compensation board (WCB), with the latter two groups being more likely to receive treatment sooner. The potential effect of payer on patient-reported outcomes and reoperation rates has not been previously explored. A retrospective chart review was performed using data from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database. N=443 patients (393 MSP, 26 self-pay, 24 WCB), treated with total ankle replacement or ankle arthrodesis by three subspecialty-trained surgeons in Vancouver from 1999–2003, were analyzed. Outcomes were compared, by payer, preoperatively and at long-term follow-up (6.3 years, range 2–14 years). Function was assessed using the Ankle Osteoarthritis Scale (AOS) Total score (primary outcome) and the AOS Pain and Difficulty subscores. Expectation and satisfaction with symptoms was assessed using the Musculoskeletal Outcomes Data Evaluation and Management Scale, and physical and emotional quality of life was assessed using the Short Form-36 (SF-36) Health Survey in terms of the mental component summary (MCS) and physical component summary (PCS). Swelling and reoperation rates were also compared. AOS Total score was not significantly different between payers. WCB patients had significantly worse preoperative AOS Difficulty scores (73, 95%CI 65–80) compared to MSP (65, CI 63–67) and self-pay patients (56, CI 49–63)(p < 0 .008). Their SF-36 MCS scores were also significantly worse pre- and postoperatively (WCB: 43, CI 38–49, 45, CI 40–50, MSP: 51, CI 50–52, 51, CI 50–52, self-pay: 51, CI 46–56, 54, CI 49–58)(p < 0 .03). AOS Pain scores and SF-36 PCS scores were not different. Pre- and postoperatively, MSP patients reported more satisfaction with symptoms (1.31, CI 1.24–1.38, 3.21, CI 3.07–3.35), compared to WCB (1.13, CI 0.84–1.41, 2.83, CI 2.26–3.41) and self-pay patients (1.19, CI 0.91–1.47, 2.88, CI 2.33–3.44). Preoperatively, WCB patients had the lowest expectations (76, CI 69–84), the worst AOS Total (64, CI 57–71) and SF-36 scores (MCS 43, CI 38–49, PCS 28, CI, 25–32), and the most swelling (3.5, CI 3.1–4). Conversely, self-pay patients had the highest preoperative expectations (88, CI 81–95), the best AOS Total (53, CI 46–60) and SF-36 scores (MCS 51, CI 46–56, PCS: 34, CI 30–37) and the least swelling (3, CI 2.6–3.4). Postoperatively, WCB and self-pay patients had lower expectations met (35, CI 23–47 and 40, CI 28–51) and worse AOS Total scores (36, CI 27–45 and 35, 26–43), compared to MSP patients (Expectations: 29, CI 26–32, AOS Total: 31, CI 29–33). Reoperation rates were similar among groups. WCB patients had significantly more difficulty with symptoms prior to surgery and worse SF-36 MCS scores pre- and postoperatively. The preoperative expectations of WCB patients were lowest, while those of self-pay patients were highest. Both groups had lower expectations met postoperatively

Introduction. Review of the literature indicates variable results for ankle arthrodesis with many complications. With improved prothesis and technique for total ankle arthroplasty and an increase in severe ankle deformities such as Charcot's joint and the neuropathic diabetic foot we are faced with the need to decrease the variables in ankle arthrodesis in primary and salvage arthrodesis. We will review current methods for ankle arthrodesis and critic how they deal with primary and revision ankle arthrodesis surgery. Materials and methods. A customised plate or modified synthes proximal tibial plate and technique for salvage of complex pathology utilising a anterior approach and application of a contoured ustomised plate with co-axial screw fixation. Anterior incision was performed with removal of the lateral malleolus, for bone grafting in revision cases only. Thirteen arthrodeses were performed; four of these were pan-talar. All patients underwent objective and subjective assessments including overall patient satisfaction. The American Orthopaedic Foot and Ankle Society ankle/hind foot scoring system was used. The aim of this study is to identify the time taken to achieve radiologic arthrodesis, complications encountered, the required post-operative recovery for arthrodesis to be achieved and the overall patient satisfaction of results in the early to midterm post-operative period have been followed up for three years. Conclusion. The technique offers considerable flexibility allowing the calcaneus to be incorporated in the proposed arthrodesis where necessary. With multiple points for fixation and coaxial screw entry points the contoured customised plate provides a rigid fixation for arthrodesis stabilisation with added compression being the major advantage of this technique

We aim to assess the outcome of ankle arthrodesis performed for painful osteoarthritis in the presence of a coronal plane deformity of 20 degrees or more. To our knowledge this is the first reported series of such a cohort of patients. We have a consecutive and complete series of 24 patients with 26 ankle arthrodeses which were all performed for painful osteoarthritis in the presence of large coronal plane deformity. These patients have a minimum of twelve months clinical follow-up. The results showed a low non-union rate of 8% (2 ankles). These have subsequently been re-fused satisfactorily, and are excluded from further analysis. The results of the remaining 24 ankles, which united primarily, show that patients were very pleased with the outcome of their surgery. AOFAS scores were used to measure pain and function, both pre-operatively and post-operatively. These scores showed large improvements for both pain and function, and had a high statistical significance (p<0.0001). All patients improved in their walking distance and many patients reduced their need for walking aids. Stair climbing ability was also improved in some patients. It is recognised that an ankle arthrodesis usually relieves pain but does not result in a normal gait and full function. We feel that the high level of patient satisfaction in this series was due to the combination of deformity correction, restoring a functional foot position, and achieving a painless ankle. Arthroplasty of the ankle is a good procedure for relief of pain and restoration of function. However, in the presence of a large coronal plane deformity, ankle arthroplasty is known to fare badly with early failure. Therefore for patients with painful osteoarthritis and a coronal plane deformity of 20 degrees or more, we recommend ankle arthrodesis as the procedure of choice

Spezializing in subfields of Orthopaedics is common in anglo-american countries for more than 20 years. IThe aim of this paper is to demonstrate the necessity of fellowship programms in extremity orientated subfileds of orthopaedics. Analyzing the results of ankle arthrodesis performed by general orthopaedic surgeons campared to ankle arthrodesis performed by spezialized foot and ankle surgeons the difference in results will be demonstrated. Patients and methods. In 40 patients an ankle arthrodesis was performed between 1998 and 2012. Group A was formed by 20 consecutive patients treated by spezial trained Foot and Ankle surgeons and group B was formed by 20 patients treted by general orthopaedic surgeons. The average age in group A at the time of surgery was 59,9y (34 to79y) compared to 63,4y (41 to 80y) in group B. The average follow up was 34 months respectively 32 months after surgery. The study included a spezial questionnaire with the AOFAS score and rating of patients dissatisfaction. The successful healing of the arthrodesis was determied by using standardized radiographs, Furthermore a pedobarography, and a videoanalyzis of the walking was incuded. Results. All procedures in group A were performed using an anterior approach. Neither pseudarthroses, equinus or other malositions were detected in this group. In group B wurdenin 16 patients an anterior and in 4 patients a lateral approach was used. Complications included 3 pseudarthroses, 4 equinus malpositions, 4 varus malpositions, 4 valgus malpositions and 8 penetrations of the subtalar joint. The AOFAS score on average was 78 (46–92) points in group A and 75 (34 – 94) in group B. Conclusion. The analyzis of the data revealed that the results in Group A were comparable to the results published in the literature. Results in group B were inferior to those in group A and to the results published in the literature of Foot and Ankle surgery. Foot and Ankle surgery became more demanding over the last decades. As already shown in anglo-american countries spezializing in certain fields of orthopaedics is a necessity. More complex hindfoot surgery should be performed in special centers with an adequate case load

As an alternative to ankle replacement, ankle arthrodesis remains a mainstay in the treatment of end-stage arthritis. Arthroscopic techniques for ankle arthrodesis have more recently been developed, although there has been limited research exploring the cost of arthroscopic (AAA) versus open ankle arthrodesis (OAA), and comparing ankle fusions to replacement (TAA). We hypothesise that resource use after AAA will be lower than that after OAA, and both will be lower than TAA. We performed a retrospective review of a prospectively collected database. The COFAS database was used to identify patients with >2 years of follow up who have undergone AAA, OAA or Hintegra TAA at St Paul's Hospital between 2003–2010. Ninety patients with TAA, 52 with AAA and 56 with OAA met our inclusion criteria. The following data were documented: patient demographics (age, gender, presence of diabetes, inflammatory arthritis or any smoking history), factors related to the index surgery (type of surgery, OR time, length of stay) and factors relating to the post-operative course (number of post-operative clinic visits, OR time for re-operations, length of stay for additional hospital admissions). In terms of the index surgery, AAA required less initial OR time compared to either OAA or TAA. Initial length of hospital stay was significantly longer for both TAA and OAA, compared to AAA. Patients attended more follow-up visits after TAA or OAA compared to after AAA. In terms of additional OR time required, no significant differences were found among the groups. The most common reason for re-operation was infection or wound breakdown (38% of re-operations), followed by removal of hardware (15%). TAA also required significantly more additional days in hospital compared to either OAA or AAA. For all significant comparisons, p < 0.05. For each primary TAA, on average an additional one hour of surgery, three days in hospital and seven clinic visits were required on top of the cost factored for the primary arthroplasty. For each primary AAA, an additional four clinic visits, 23 minutes of revision surgery and one day in hospital were required. For each primary OAA, an average additional five clinic visits, three minutes of OR time, and 0.2 days of additional hospital stay occurred during follow up. Using several measures of resource use, we find that arthroscopic ankle fusions compare favourably to both ankle replacements and open ankle fusions. We also show that resource utilisation measurements can be a useful surrogate for complications, and that resource utilisation can demonstrate the practical implications of complications for patients, surgeons and health care resources

Introduction. Ankle arthrodesis is a common treatment for destroyed ankle arthrosis with sacrificing the range of motion. On the other hand, total ankle arthroplasty (TAA) is an operation that should develop as a method keeping or improving range of motion (ROM); however, loosening and sinking of the implant have been reported in especially constrained designs of the implant. The concept of FINE TAA is the mobile bearing system (Nakashima Medical Co., Ltd, Okayama Japan) that can reduce stress concentration to implants. The purpose of this study is to evaluate the short-term results of FINE TAA. Objectives and Methods. We performed FINE TAA for osteoarthritis (OA) (2 ankles of 2 patients) and rheumatoid arthritis (RA) (4 ankles of 3 patients). All patients were female. The mean age of the patients was 71.4 years old at the operation. The mean follow-up period was 32.6 (range, 18–55) months. All patients were assessed for Japan Orthopedic Association (JOA) score and ROM in plantar flexion and dorsiflexion at the point of pre-operation and final follow-up. We evaluated radiolucent line, subsidence, and alignment of implants at the latest follow-up. Results. JOA score improved from 34.8 to 72.2 on average. ROM improved from 4.0 ± 5.5 º to 7.0 ± 4.5 º on average in plantar flexion and from 21.0 ± 17.0 º to 31.0 ± 16.0 º in dorsiflexion. One case underwent an ankle arthrodesis because of the implant loosening. This failed case was very obese (70 kg of body weight, 31.0 of Body Mass Index) and her activity was relatively high. One ankle showed radiolucent line around the components with no symptoms. The alignment of implants was slightly varus and anteversion (the mean values of alpha angle was 88.0 ± 1.2º, beta angle was 84.0 ± 9.2º, and gamma angle was 2.1 ± 0.2º). Discussion. The ankle joint is highly loaded up to five times body weight on small surface of contact area during walking. Therefore, the poor results have been published after TAA with using fixed-bearing 2-component prostheses compared to ankle arthrodesis. On the other hand, FINE TAA was designed as 3-component mobile bearing system that can reduce stress concentration compared to conventional TAA. We experienced implant failure in one obese case but short-term results of other cases were acceptable. Good clinical results can be expected with FINE TAA except for the obese case. We should pay careful attention to the surgical indication. Conclusion. Our short term results of FINE TAA were acceptable except for one obese case. We should evaluate further mid- and long- clinical results

Hind and mid foot arthritis is often noted in patients who have previously had an ankle arthrodesis. It has been suggested that this arthritis may be precipitated or exacerbated as a direct result of the ankle fusion. The aim of this study was to investigate the degree and pattern of pre-existing ipsilateral foot arthritis in patients who have subsequently undergone ankle arthrodesis. A retrospective review of the most recent pre-operative radiographs of 70 patients who underwent 71 arthrodeses between 1993-2003 was performed. Patients with rheumatoid disease were excluded. The immediate pre-operative AP and lateral ankle radiographs were assessed and the presence and severity of osteoarthritis for the sub-talar, talo-navicular, naviculo-cuneiform and calcaneo-cuboid joints was recorded using the Kellgren and Lawrence grading score. This was performed simultaneously by two reviewers and a consensus obtained. A total score out of 16 was given for each radiograph. 68 (96%) of the radiographs reviewed showed evidence of pre-existing hind or mid foot arthritis prior to ankle fusion. The sub-talar joint was the most commonly and severely affected. The median total arthritis score for each radiograph was 5. There was no association between age or causative pathology and the degree of arthritis. This study has demonstrated that hind and mid foot arthritis is very common in patients with co-existent ankle arthritis prior to ankle fusion. This has previously been assumed to have developed as a result of the surgery but is, in fact, present at the time of the operation and this needs to be taken into consideration when evaluating the results of ankle arthrodesis

Numerous studies have demonstrated that concomitant lower back pain (LBP) results in worse functional outcomes in patients undergoing surgical treatment for the management of end stage hip and knee arthritis. However, no equivalent studies have analysed the impact of back pain on the outcomes of patients with end stage ankle arthritis. Furthermore, given that two widely accepted surgical options exist in the treatment of ankle arthritis, namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA), it is possible that one surgical technique may be superior in patients with LBP. The aim of this study was to determine the incidence of LBP in people with ankle arthritis, analyse its effect on functional outcomes, and explore whether there was a treatment advantage from either TAA or AA. Prospectively collected data from the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was analysed in this study. All patients with ankle arthritis who underwent surgery performed by three fellowship-trained foot and ankle surgeons at a single institution between January 2003 and July 2012 were studied. Patient demographics were collected pre-operatively, including the absence or presence of back pain, and post-operative follow up was performed at 2 and 5 years, evaluating patient-reported functional outcome measures including the Ankle Arthritis Score (AAS) and the 36-item short form survey (SF-36). Using a linear regression model, a multivariate analysis was performed to examine the relationship between back pain, TAAs and AAs. In total, 451 patients were studied. 164 patients (36.4%) presented with concomitant LBP. At presentation, the LBP group had worse AAS scores (54.8 vs 57.8 p. At 2 years postoperatively, the AAS score was the same in both groups (28.9 vs 26.8 p = 0.3), but patients with LBP had worse SF-36 PCS (42.1 vs 36.6 p 0.05) in any of the functional outcome scores at 2 or 5 years post-operatively. The results of this study suggest there is no advantage of TAA over AA in the treatment of ankle arthritis in patients with concomitant lower back pain. Although pre-operative back pain resulted in worse SF-36 outcomes at 2 and 5 years post- operatively, this was not the case for AAS scores

Patients often comment on swelling after foot and ankle surgery. However the relationship between swelling and outcome (pain and function) has not previously been outlined. A recent study by Pinsker and Daniels demonstrated that while swelling was rated as important by patients it was rarely included in outcome scores. The purpose of this paper was to determine the relationship between swelling and outcome after ankle fusion or replacement. A secondary purpose was to determine how this relationship changed in time, how swelling score changed before and after surgery, and determine differences in swelling score between total ankle replacement (TAR), open ankle arthrodesis (OAA) and arthroscopic ankle arthrodesis (AAA). The COFAS prospective ankle arthritis database enrolls patients in 4 centers undergoing surgery by one of 6 surgeons since 2002. The MODEMS outcomes package from AAOS was used, with the validated ankle osteoarthritis score (AOS) score being used to assess outcomes in the pain and disability domains. The swelling score was indexed from 1 to 5, 1 being no swelling and 5 being severe swelling. Outcomes were recorded preoperatively and annually up to 2010. Statistical analysis was performed using 95% confidence intervals and correlations being determined using Pearson's correlation and r2 values. The swelling score was correlated with AOS score with an r2 of 0.13 for postoperative patients. With the swelling score analysed categorically the difference of outcome was significant with a mean AOS score of 15.1 (CI 13.3 to 16.9) for a swelling score of 1, 23 (CI 21.7 to 24.9) for a swelling score of 2, 31 (CI 29.6 to 33.1) for 33.6 (CI 34.9 to 38.8) for 4, and 39 (CI 35.3 to 43.0) for 5. Swelling scores fell outside the 95% confidence intervals for all groups indicating that the AOS outcome of swelling score 5 patients was worse than the 4 group, 4 worse than 3, 3 worse than 2, and 2 worse than 1. Patients with swelling scores of 1 scored 24 points better than those with a swelling score of 5. Swelling scores were the same preoperatively for total ankle arthroplasty, Arthroscopic and open fusions. However swelling scores were lower for arthroscopic fusions after surgery for all time periods at an average of 2.1 (CI 1.9 to 2.2), compared to total ankle arthroplasty (2.5, CI 2.4 to 2.6) and open ankle fusion (2.5, CI 2.4 to 2.6). Swelling has a major relationship with outcome. Swelling may be the cause of poorer outcomes for open ankle fusion compared to arthroscopic. Swelling is an independent factor as swelling scores for TAA were higher compared to AAA despite similar outcomes. Arthroscopic surgery reduces the postoperative swelling. Methods to reduce swelling such as compression stockings, elevation, controlling bleeding may result in better outcomes. Minimising the invasiveness of surgery achieves this goal. Patient education about swelling, elevation and compression stockings would assist in these goals

Background. Total ankle arthroplasty (TAA) is an alternative to ankle arthrodesis, replacing the degenerated joint with a mechanical motion-preserving alternative. Implant loosening remains a primary cause of TAA revision, and has been associated with wear-mediated osteolysis. Differing implant designs have a major influence on the wear performance of joint replacements. Providing a range of implant sizes allows surgeons a greater intra-operative choice for varying patient anatomy and potential to minimise wear. Minimal pre-clinical testing exists in the literature that investigates the effect of implant size on the wear behaviour. The aim of this study therefore was to investigate the effect of two different implant sizes on the wear performance of a TAA. Materials & Methods. Six ‘medium’ and six ‘extra small’ BOX® (MatOrtho Ltd, UK) TAA implants, of the same conceptual design and polyethylene insert thickness, were tested in a modified 6 station pneumatic knee simulator. 5 million cycles (Mc) of wear simulation were completed for each implant size, under kinematics aiming to replicate an ankle gait cycle (Figure 1) [1]. The simulator used had six degrees of freedom, of which four were controlled. The maximum axial load was 3150N, equivalent to 4.5 times body weight of a 70kg individual. The flexion profile ranged from −15° plantarflexion to 15° dorsiflexion. Rotation about the tibial component ranged from −2.3° of internal rotation to 8° external rotation, and anterior/posterior (AP) displacement ranged from 3.1 mm anterior to −0.9 mm posterior displacement. The lubricant used was 25% bovine serum supplemented with 0.04% sodium azide to prevent bacterial degradation. The wear of the TAA polyethylene inserts were determined gravimetrically after each Mc, with unloaded soak controls used to compensate for the uptake of moisture by the polyethylene. Results. There were no significant differences (P = 0.872) in the mean wear rates (± 95% confidence limits) between the medium (11.00 ± 3.06 mm3/Mc) and extra small (10.64 ± 4.61 mm3/Mc) implant sizes (Figure 2). An observation of insert surfaces showed clear signs of abrasive wear and burnishing (Figure 3). There was evidence of polyethylene transfer and scratching on the tibial components, while talar components displayed fine linear scratching in similar directions for both implant sizes. Conclusions. The wear rates of both implant sizes are comparable to the wear rate (13.30 ± 2.50 mm3/Mc) of a previous wear study, which was conducted on ‘medium-sized’ Corin Zenith TAAs, under the same simulator conditions for 2 Mc [1]. The wear rates for both implant sizes are substantially lower than the wear of four ‘small-sized’ BOX® ankles (18.60 ± 12.80 mm3/Mc) for 2Mc [2]. The considerable difference in wear rates may be due to the lower forces, higher AP and deionised water as the test lubricant [2], which does not replicate the features of the natural synovial fluid and produce tribological artefact. The results from this study suggest that under the same kinematic and kinetic conditions, the wear rates are unaffected by a change in TAA implant size

Ankle arthrodesis is the gold standard for treatment of end stage ankle arthritis. We analysed the data of 124 Ankle Arthrodesis (Open Ankle Arthrodesis (OAA) −27; Arthroscopic Ankle Arthrodesis (AAA)- 97) performed between January 2005 and December 2015 by fellowship trained foot and ankle surgeons in a single institution. Based on preoperative deformity (AAA- 28 degree valgus to 26 degrees varus; OAA- 41 degree valgus to 28 degree varus), they were subdivided into 2 groups based upon deformity more than 15 degrees. Union rates, time to union, length of hospital stay and patient related factors like smoking, alcoholism, diabetes, BMI were assessed. Mean age of patients was 60 years (Range 20 to 82 years)(Male:Female-87:32). Overall fusion rate was 93% in AAA and 89% in OAA (p=0.4). On sub group analysis of influence of preoperative deformity, there was no difference in union rates of AAA versus OAA. 7 patients in AAA and 3 in OAA required further procedures. Average time to union was 13.7 in AAA and 12.5 weeks in OAA (p=0.3). Average hospital stay was 2.6 days in AAA and 3.8 days in OAA (p=0.003). Smoking, alcoholism, Diabetes, BMI did not have any correlation with union rates. Although both AAA and OAA showed good union rates, hospital stay was significantly shorter in AAA. A larger deformity did not adversely affect union rates in AAA. Time to union was higher in AAA though it was statistically insignificant. Lifestyle risk factors did not have cumulative effect on union. We conclude that AAA is a reproducible method of treating end stage tibiotalar arthritis irrespective of preoperative deformity and patient related factors

Aims. Smoking is associated with post-operative complications but smokers often under-report the amount they smoke. Our objective was to determine whether a urine dipstick test could be used as a substitute for quantitative cotinine assays to determine smoking status in patients. Patients and Methods. Between September 2013 and July 2014 we conducted a prospective cohort study in which 127 consecutive patients undergoing a planned foot and ankle arthrodesis or osteotomy were included. Patients self-reported their smoking status and were classified as: ‘never smoked’ (61 patients), ‘ex-smoker’ (46 patients), or ‘current smoker’ (20 patients). Urine samples were analysed with cotinine assays and cotinine dipstick tests. Results. There was a high degree of concordance between dipstick and assay results (Kappa coefficient = 0.842, p < 0.001). Compared with the quantitative assay, the dipstick had a sensitivity of 88.9% and a specificity of 97.3%. Patients claiming to have stopped smoking just before surgery had the highest rate of disagreement between reported smoking status and urine testing. Conclusion. Urine cotinine dipstick testing is cheap, fast, reliable, and easy to use. It may be used in place of a quantitative assay as a screening tool for detecting patients who may be smoking. A positive test may be used as a trigger for further assessment and counselling. Cite this article: Bone Joint J 2016;98-B:1418–24

Background. Total ankle arthroplasty is an accepted alternative to arthrodesis of the ankle. However, complication and failure rates remain high compared to knee and hip arthroplasty. Long-term results of the Scandinavian Total Ankle Replacement (STAR) are limited, with variable complication and failure rates observed. This prospective study presents the long-term survivorship and the postoperative complications of the STAR prosthesis. Additionally, clinical outcomes and radiographic appearance were evaluated. Methods. Between May 1999 and June 2008, 134 primary total ankle arthroplasties were performed using the STAR prosthesis in 124 patients. The survivorship, postoperative complications and reoperations were recorded, with a minimum follow-up period of 7.5 years. Clinical results were assessed using the Foot Function Index (FFI) and the Kofoed score. The presence of component migration, cysts and radiolucency surrounding the prosthesis components, heterotopic ossifications and progression of osteoarthritis in adjacent joints were determined. Results. The cumulative survival was 78% after a 10-year follow-up period (Figure 1). An ankle arthrodesis was performed in the 20 ankles that failed. Fourteen polyethylene insert fractures occurred. Other complications occurred in 29 ankles, requiring secondary procedures in 21 ankles. Nevertheless, the postoperative clinical results improved significantly. Osteolytic cysts were observed in 59 ankles and the surface area of these cysts increased during follow-up, without any association with the prosthesis alignment or clinical outcome. Heterotopic ossifications at the medial malleolus were present in 58 cases and at the posterior tibia in 73 cases, with no effect on clinical outcome. Osteoarthritis of the subtalar joint and talonavicular joint developed in 9 and 11 cases, respectively. Conclusion. The long-term clinical outcomes for the STAR were found to be satisfactory. These results are consistent with previous studies; however, the survival and complication rates are still disappointing compared to the results obtained in knee and hip arthroplasty. Higher rates of successful outcomes following ankle arthroplasty are required, and these results highlight the need for further research to clarify the origin and significance of the reported complications. Figure 1. Kaplan-Meier survivorship analysis with revision or removal of the tibia and/or the talus component for any reason as the endpoint, showing 78% (95% confidence interval 0.63–0.88) survival at 10.28 years follow-up. For figure, please contact authors directly

Arthroscopic ankle arthrodesis is an alternative to more traditional open techniques. Potential advantages include more rapid time to union, decreased complication rate, shorter hospital stay and more rapid rehabilitation. Advances in instrumentation and techniques have made the procedure more reproducible and easier to perform. The literature on the subject is reviewed including the indications and contraindications. The surgical technique is also presented along with the potential surgical pitfalls

End-stage ankle arthritis (ESAA) is a debilitating disease that does not affect all individuals equally. Gender differences have been identified in patients with end-stage hip and knee arthritis and have stimulated research to explain these findings. The present study was undertaken to examine if gender has a significant effect on pre-operative disability and post-operative outcomes in patients with ESAA. Patients undergoing ankle arthrodesis (AA) or total ankle replacement (TAR) with minimum 2-year follow-up were identified in the Canadian Orthopaedic Foot and Ankle Society prospective ankle reconstruction database. Demographic data, revision data, patient satisfaction questionnaires, and outcome data using the Ankle Osteoarthritis Scale (AOS) and Short-form 36 (SF-36) health survey were collected. TAR: 384 patients were included, with 198 females and 186 males. Patient BMI, comorbidities, and duration of follow-up were similar between groups. Males were slightly older at the time of surgery (65.1 vs 62.4 years, p=0.01)). The most common etiology was post-traumatic arthritis for both genders, however females had a higher rate of rheumatoid arthritis (17% vs 5%, p=0.001). Implant types included STAR, Hintegra, and Mobility, and were similar between groups. Preoperatively females had higher rates of pain and disability, demonstrated by lower SF-36 physical component scores (PCS) (31.0 vs 34.5, p<0.001), and higher AOS pain (54.7 vs 51.1, p=0.05) and AOS disability scores (66.5 vs 59.6, p<0.001). Postoperatively, both groups had significant improvement in PCS, AOS pain, and AOS disability scores. Females, however, continued to demonstrate lower PCS scores (38.3 vs 41.9, p<0.001) and higher AOS disability (31.0 vs 25.8, p=0.02) than males. Regression analysis found that preoperative PCS, gender, age, and arthritis etiology all had a significant impact on postoperative PCS scores, with preoperative PCS scores having the largest impact. Preoperative AOS pain and disability scores had the largest impact on postoperative AOS pain and disability scores, respectively. Gender had no significant impact on AOS pain and disability scores postoperatively. Patient satisfaction was similar between males and females postoperatively. Secondary surgery was performed in 13.6% of females and 16.1% of males. Five males and five females underwent revision to arthrodesis. In patients with ESAA, females tend to have higher pre-operative levels of pain and disability compared to males, which persists post-operatively. This is consistent with the hip and knee arthroplasty literature. This finding may be due to females undergoing surgery at more advanced disease states, arthritis etiology, referral bias, or treatment bias. Both males and females have significant and similar degrees of improvement in pain and disability scores after TAR, and reoperation rates and patient satisfaction rates are similar despite the apparent disparity in outcomes

Introduction. Total Ankle replacement designs continue to evolve, and provide an alternative to ankle arthrodesis for patients with ankle arthritis. It has been our practice to offer total ankle replacement to selected patients with ankle arthritis. The purpose of this study was to analyse the short term results of our patients with the Mobility R Total Ankle Replacement (TAR) system. Methods. All patients who received TAR in our practice from 2004 to 2011 were reviewed. American Orthopaedic Foot and Ankle Scores AOFAS were assessed and compared both preoperatively and at time of follow-up. All complications both intra-operative and post-operatively were noted. Weight bearing X-rays were taken at follow-up, and implant alignment and the presence of lucencies were noted. Results. 21 patients were evaluated. All showed an improvement in AOFAS scores; however the improvement showed a wide variation. All patients showed an improvement in pain scores. Post-operative ankle stiffness, specifically dorsi-flexion, was problematic in several patients. Marked prolonged swelling was problematic for many patients. Conclusions. Total ankle replacement provides a good option for patients with ankle arthritis. Swelling and post-operative stiffness continue to be a problem, and should be explained to patients. MULTIPLE DISCLOSURES

Background. Ankle arthroplasty is increasingly used to reduce pain and improve or maintain joint mobility in end-stage ankle arthritis. Both treatments show similar results with regard to functional outcome scores and sport related activities. However, the rates of complications and reoperations were higher after ankle replacement. Particularly for the first implant designs, with more promising results for newer designs. One of these newer designs is the Mobility Total Ankle System. Short term results in recent literature describe an improvement of functional outcomes; however complication rates vary widely, ranging from 9 to 37% and the 4-year survival rates ranging between 84 and 98 percent. Therefore, the aim of this study was to assess the clinical and radiographic short term results of the Mobility prosthesis. Methods. Between March 2008 and September 2013, 67 primary total ankle arthroplasties with the Mobility prosthesis were performed, in 64 patients, by one experienced foot and ankle surgeon. Complications, reoperations, failures and the survival rate were retrospectively examined. Patient reported outcomes were assessed with the use of the FFI score and visual analogue scale (VAS) for pain. Prosthesis alignment was measured on the first weightbearing radiographs of the ankle according to the procedure described by Rippstein et al.1 (Fig. 1). Results. The mean follow-up period was 40 months (range 12–78 months). There were two intraoperative and 13 postoperative complications, requiring seven reoperations. The reason for reoperation was painful impingement of the medial and/or lateral gutter (n=4), a deep infection (n=1), subsidence of the talus component (n=1) and a cyst located in the tibiofibular joint (n=1). Failure occurred in three of the 67 cases, with one early deep infection with a loose tibia component, one case of aseptic loosening and one case of chronic ankle pain without an assignable cause. A two-stage revision, ankle arthrodesis and amputation of the lower leg was performed, respectively. The mean cumulative survival after 61.4 months was 95% (CI 84–98) (Fig. 2). There was a significant decrease in the median FFI pain and disability score. The pain subscore decreased from 56.4 to 22.2 points and the disability score from 61.1 to 33.3 points. The mean VAS pain was 26.5 for the ankle region. The tibial components were placed in a mean of 1.5° varus relative to the mechanical axis of the tibia in the frontal plane. Malalignment (>5°) was observed in four cases with a mean of 6.0° varus. In the sagittal plane, a mean posterior slope of 1.6° relative to the mechanical axis of the tibia was measured, with one case of 7.5° of anterior slope. The talar component was centred too far posteriorly in five cases, which was considered as malalignment. Conclusion. Despite few intraoperative complications and satisfactory clinical and radiological outcome, the incidence of postoperative complications, reoperations and failure indicate the importance of further development and research in the field of ankle arthroplasty. To view tables/figures, please contact authors directly