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

Preoperative talar valgus deformity increases the technical difficulty of total ankle replacement (TAR) and is associated with an increased failure rate. Deformity of ≥15° has been reported to be a contraindication to arthroplasty. The goal of the present study was to determine whether the operative procedures and clinical outcomes of TAR for treatment of end-stage ankle arthritis were comparable for patients with preoperative talar valgus deformity of ≥15° as compared to those with <15°. We will describe the evolving surgical technique being utilized to tackle these challenging cases. Fifty ankles with preoperative coronal-plane tibiotalar valgus deformity of ≥15° “valgus” group) and 50 ankles with valgus deformity of <15° (“control” group) underwent TAR. The cohorts were similar with respect to demographics and components used. All TARs were performed by a single surgeon. The mean duration of clinical follow-up was 5.5 years (minimum two years). Preoperative and postoperative radiographic measurements of coronal-plane deformity, Ankle Osteoarthritis Scale (AOS) scores and Short Form (SF)-36 scores were prospectively recorded. All ancillary (intraoperative) and secondary procedures, complications and measurements were collected. The AOS pain and disability subscale scores decreased significantly in both groups. The improvement in AOS and SF-36 scores did not differ significantly between the groups at the time of the final follow-up. The valgus group underwent more ancillary procedures during the index surgery (80% vs 26%). Tibio-talar deformity improved significantly toward a normal weight-bearing axis in the valgus group. Secondary postoperative procedures were more common in the valgus group (36%) than the controls (20%). Overall, re-operation was not associated with poorer patient outcome scores. Metal component revision surgery occurred in seven patients (three valgus and four controls). These revisions included two deep infections (2%), one in each group, which were converted to hindfoot fusions. Therefore, 94% of the valgus group retained their original components at final follow-up. Thus far, this is the largest reported study that specifically evaluates TAR with significant preoperative valgus alignment, in addition to having the longest follow-up. Satisfactory midterm results were achieved in patients with valgus mal-alignment of ≥15°. The valgus cohort required more procedures during and after their TAR, as well as receiving more novel techniques to balance their TAR. Whilst longer term studies are needed, valgus coronal-plane alignment of ≥15° should not be considered an absolute contraindication to TAR if the associated deformities are addressed

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

Researchers and clinicians measuring outcomes following total ankle replacement (TAR) are challenged by the wide range of outcome measures used in the literature without consensus as to which are valid, reliable, and responsive in this population. This review identifies region- or joint-specific outcome measures used for evaluating TAR outcomes and synthesises evidence for their measurement properties. A standard search strategy was conducted of electronic databases MEDLINE, EMBASE and CINAHL (to June 2015) to identify foot/ankle measures in use. A best evidence synthesis approach was taken to critically appraise measurement properties [COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)] of identified measures. The review was restricted to English publications and excluded cross-cultural adaptations. Measurement properties collected from each article were coded for validity, reliability, responsiveness, or interpretability. Clinimetric evidence exists for identified measures tested in non-TAR populations, but were not the focus of this review. The search identified 14 studies to include in the best evidence synthesis with 32 articles providing clinimetric evidence for eight of the measures (one CBO, seven PRO), however only five measures were tested in a TAR population (Foot Function Index, Ankle Osteoarthritis Scale, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale [AOFAS], Foot and Ankle Outcome Score, Self-Reported Foot and Ankle Score). Five studies provided clinimetric evidence in a TAR population and their methodological quality was assessed: (1) Validity—two good quality studies examining different measures provide moderate evidence supporting construct validity (FFI, AOS, AOFAS self-reported items; SEFAS); (2) Reliability—two good quality studies examining different measures provide moderate evidence supporting internal consistency and test-retest reliability (FFI, AOS, AOFAS self-reported items; FAOS, SEFAS); (3) Responsiveness—three poor quality studies, thus unknown evidence for responsiveness; (4) Interpretability—two studies provide interpretability values (AOS, FFI, AOFAS self-reported items; AOS). This review offers a basis for choosing the most appropriate instrument for evaluating TAR outcomes. Numerous outcome measures were identified with evidence supporting their use in populations with various foot/ankle conditions, but none have strong evidence supporting use in a TAR population. Measures must have adequate clinimetric properties in all patient groups in which they are applied. Evidence supporting or critiquing an instrument should not be based on studies with poor quality methodology, as identified by this review. Further testing in a TAR population would benefit identified measures with emphasis on adequate sample sizes, testing a priori hypotheses, and evaluating their content validity for a TAR population

Purpose. Weight loss is often advised to our patients and considered to make a substantial difference in most musculoskeletal symptoms. Patients with end stage ankle arthrosis have severe pain, diminished health related quality of life, and limited physical function. They frequently refer to increased weight as a simple indicator of decline in their quality loose weight. Patients assume that weight loss will follow after surgery secondary to increased activity with reduced pain and disability. Method. Changes in the body mass index, mental and physical component of SF36 and Ankle Scale Osteoarthritis of 145 overweight and obese patients after ankle surgery were assessed up to five year after surgery with a mean of 37.1 month follow up from 2002 to 2009. Results. The Ankle Osteoarthritis Scale and Physical component of SF36 significantly improved, by a mean of 34.8, 9.8, respectively after ankle surgery but there was not significant change in Body mass index. Conclusion. Pain and disability of end stage ankle arthritis usually resolve gradually within one and two year after surgery but body mass index changes was insignificant in five year period. In fact following successful ankle fusion or replacement, 1/3 of our patients gained 1 unit BMI or more, 1/3 lost one unit BMI or more and 1/3 remained within one unit of their pre op BMI. This suggests that obesity is a multifactorial and an independent disease

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

Aim. The purpose of this clinical series is to prospectively review the mid-term clinical and radiographic outcomes of the Scandinavian Total Ankle Replacement (STAR) performed at two academic Canadian University centres. Methods. Between 1998 and 2005, 111 STAR were implanted into 98 patients at two Canadian centres. Prospective clinical and radiographic follow-up was performed. Validated and non-validated outcome questionnaires consisting of the AAOS foot and ankle questionnaire, AOFAS Hindfoot score, Foot Function Index (FFI), Ankle Osteoarthritis Scale (AOS) were completed. Sixty four patients were followed with these scores prospectively and 50 retrospectively. Both groups had prospective radiographic follow-up using measures described by Hintermann et al, and Wood et al. Results. The average follow-up for both groups was 6.3 years (4.6-8.5 years). Of the 111 implanted STARs, 12 (11%) STARs had a metal component revision performed giving an overall survival of 89% (99) of the originally implanted metal components at the conclusion of the study. Thirty five patients (32%) had a re-operation performed during the follow-up period, 15 procedures (14%) were for replacement of fractured polyethylene liners. The sustained benefit across questionnaires from the STAR persisted to final follow up. Some evidence of osteolysis was present in 110/111 (99%) ankles at the final follow-up, more commonly around the talar component. No significant differences between the two centres in pre-operative or intra-operative data were identified. Conclusion. The STAR, in the mid-term, shows acceptable survival and revision rates. There are, however, some concerning findings on radiographic follow-up. Further investigation and longer follow-up is required to substantiate these concerns

Objectives. A defect following resection of Giant Cell Tumour of the distal radius (GCT-DR) is reconstructed by either vascularised free fibular transfer (VFF) or non-vascularised structural iliac crest transfer (NIC). The purpose of this study was to compare these procedures. Methods. Twenty-seven patients at two centres were identified, 14 underwent VFF and 13 NIC. The two groups were comparable for age, sex, and tumour grade. Functional outcomes were assessed with TESS, MSTS, and DASH. In the VFF group, ankle joint morbidity was assessed with the Ankle Osteoarthritis Scale. In the NIC group, iliac crest morbidity was assessed with a short questionnaire. Results. Two local recurrences occurred in the VFF group and one in the NIC group. Following the index surgery, three patients in the VFF group underwent surgery for cosmesis, hardware removal or tendon release, and one is scheduled for tendon release. In the NIC group two infections required debridement, one of which went on to free fibular transfer, but there were no re-operations for union or donor site morbidity. The surgical time was significantly shorter for NIC. Functional scores showed no differences between the groups on any of the parameters studied for the upper limb (Mann-Whitney test). The Anke OA scale and the iliac crest morbidity questionnaire revealed only a few mild problems with donor site morbidity in either group. Conclusion. Both VFF and NIC are effective surgical techniques that result in a well-functioning wrist arthrodesis. VFF should be considered when there is a significant skin defect, as it allows the inclusion of a vascularised skin paddle, or when the osseous defect is too long for NIC. We were unable to demonstrate any difference in functional scores between VFF and NIC. As the re-operation rate is less for NIC and surgical time is shorter, we recommend NIC whenever possible

Purpose. Coronal plane malalignment at the level of the tibiotalar joint is not uncommon in advanced ankle joint arthritis. It has been stated that preoperative varus or valgus deformity beyond 15 degrees is a relative contraindication and deformity beyond 20 degrees is an absolute contraindication to ankle joint replacement. There is limited evidence in the current literature to support these figures. The current study is a prospective clinical and radiographic comparative study between patients who underwent total ankle arthroplasty with coronal plane varus tibiotalar deformities greater than 10 degrees and patients with neutral alignment, less than 10 degrees of deformity. Method. Thirty-six ankles with greater than 10 degrees of varus alignment were compared to thirty-six ankles which were matched for implant type, age, gender, and year of surgery. Patients completed preoperative and yearly postoperative functional outcome scores including the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores, the Ankle Osteoarthritis Scale (AOS) and the Short Form-36 Standard Version 2.0 Health Survey. Weightbearing preoperative and postoperative radiographs were obtained and reviewed by four examiners (AC, AQ, TD, TT) and measurements were taken of the degree of coronal plane deformity. Results. After a mean follow-up of 27 months (9–54), the varus ankles improved significantly on the AOFAS (P<0.0001), AOS-Pain Score (P<0.0001), AOS-Disability Score (P<0.0001), and SF-36 Physical Component Score (P<0.0001). There was no improvement in SF-36-Mental Component Score. (P=0.722). There was no statistically significant differences between the two groups when comparing AOFAS (P=0.155), AOS-Pain Score (P=0.854), AOSDisability Score (P=0.593), SF-36-Physical Component Score (P=0.433), SF-36 Mental Component Score (P=0.633). Sixteen of Thirty-Six ankles in the varus group needed a secondary procedure (implant failure, infection, malalignment) which was approaching significance in comparison to eight ankles in the neutral group. (P = 0.079). Secondary procedures in the varus group included: tendon transfers, calcaneal / metatarsal / malleolar ostoetomies and ligament reconstructions. Radiographically, the pre-operative coronal plane varus tibiotalar deformity averaged 19.4 6.4 and postoperatively 1.44 2.6 (P< 0.0001). There was no statistical difference in post operative tibiotalar alignment between the varus and neutral groups (P<0.05). Conclusion. The clinical outcome of TAR performed in ankles with pre-operative varus alignment >10 degrees is comparable with that of neutrally aligned ankles. The increased number of secondary procedures in the varus group was attributed to the complexity of the deformity and the steep learning curve. Outcomes as measured radiographically and through validate scores were similar to patients without deformity suggesting that varus coronal plane deformity of the talus is not a contraindication to total ankle replacement

Purpose. To investigate the effect of obesity on functional outcome following total ankle arthroplasty. Method. We identified 43 obese patients (46 ankles) (BMI > 30kg/m2), using a prospectively collected database of total ankle arthroplasties. Inclusion criteria included: (a) Post-traumatic or inflammatory arthritis; (b) Minimum two-year follow-up, (c) Coronal plane deformity less than 10 degrees. Exclusion criteria: (a) Co-morbidity affecting physical function; (b) Recent total joint arthroplasty. American Orthopaedic Foot and Ankle Society (AOFAS), Ankle Osteoarthritis Scale (AOS) and SF-36 questionnaires were used preoperatively and at latest follow-up. Revision was defined as any intervention requiring replacement of part or whole of the prosthesis. A control group of non-obese individuals (BMI 18.5–29.9kg/m2) was devised matching for age within 10 years, gender, diagnosis, implant and length of follow-up (within 1 year). From the original group of 46 ankles, we matched 28 ankles, thereby constructing two groups for comparison (matched obesity and control). Results. From the original obesity group (n=46, mean BMI 34.7, age 65.1 years and follow-up 3.5 years), four patients were lost to follow-up. There were 10 revisions (21.7%) including five for liner exchange, four full component and one revision to fusion. Statistically significant (p<0.001) improvements were detected with all outcome measures (AOFAS, AOS and SF-36). In the matched obesity and control groups we used 11 STAR, 11 Mobility and six Hintegra implants. Delayed wound healing affected one patient in each group. In the matched obesity group (mean BMI 35), there were six revisions (three liner exchange, three full component) (21.4%), at a mean of 3.2 years. One patient was lost to follow-up (known to be revised). Statistically significant improvements were noted with all outcome measures. In the control group (mean BMI 26.1), there were three revisions (two liner exchange and one full component) (10.7%), at a mean of 2.3 years. All patients were followed-up. Statistically significant improvements were associated with all outcome measures except the mental component summary of the SF-36 (52.2 to 54, p=0.37). The same score pre-operatively was lower in the matched obesity group (45 vs. 52.2, p=0.193). Overall, no difference was found in mean outcome score improvement between groups. In the matched obesity group, the mean pre-operative AOS pain score was higher (58.8 vs. 46.5) (p=0.016), as was the preoperative AOS disability score (68.4 vs. 58.5) (p=0.082). The mean post-operative AOS pain and disability scores were also higher, although not reaching significance (p=0.096 and p=0.241 respectively). Conclusion. Obesity is associated with greater functional and psychological preoperative burden, although the overall improvement in functional outcome is comparable to non-obese matched controls. Obese patients can expect a significantly higher revision rate (21.4% vs 10.7%) within five years of surgery