Foot And Ankle Orthopaedics

Residual supination of the midfoot during reconstruction of the stage II adult-acquired flatfoot deformity (AAFD) is often addressed with a medial cuneiform (Cotton) osteotomy after adequate correction of the hindfoot valgus deformity. The purpose of this study was to determine if there was a correlation between postoperative alignment of the medial cuneiform and patient-reported outcomes. Our study suggests that the surgeon should avoid excessive plantarflexion of the medial cuneiform and use the Cotton osteotomy judiciously as part of a flatfoot reconstruction for stage II AAFD.   To view the article click here.

Rotational ankle fractures can present with an array of possible osseous and ligamentous injury combinations in reliable anatomic locations. What accounts for these different injury patterns and whether specific patient and injury factors underlie the different injury patterns is unclear. The purpose of this study was to determine whether causative factors exist that could account for the various injury patterns seen with rotational ankle fractures. In our cohort of SER IV ankle fractures, regional bone density at the ankle significantly correlated with the presence and number of malleolar fractures compared with ligamentous ruptures. Treating surgeons can use this information to anticipate bone quality during operative fixation based on ankle fracture injury pattern. In addition, the presence of a trimalleolar ankle fracture was a significant indicator of poor bone quality and may represent the first clinical sign of abnormal bone metabolism in many patients.   To view the article click here.

As the popularity of total ankle arthroplasty (TAA) increases and indications expand, surgeons require a better understanding of which patient factors are associated with implant failure. In this study, we aimed to use a large total ankle database to identify independent risk factors for implant failure at mid- to long-term follow-up. This is among the largest studies to analyze the relationship between TAA failure rates and multiple different patient, operative, and radiographic factors. Of note, age, BMI, and amount of deformity were not associated with higher failure rates. Only patients with ipsilateral hindfoot fusion or who received the INBONE I prosthesis were at significantly higher risk of implant failure.   To view the article click here.

Although advances in joint-replacement technology have made total ankle arthroplasty a viable treatment for end-stage arthritis, revision rates for ankle replacements are higher than in hip or knee replacements. The questions asked in this study were what can retrieved ankle devices demonstrate about ankle arthroplasty failures and how can understanding the causes of these failures inform clinical decisions for current and future ankle arthroplasty patients? This study suggests that loosening could be more of a problem in fixed-bearing devices than in mobile bearing devices. Gamma-sterilized polyethylene inserts were found to suffer fatigue damage or fracture in vivo, resulting in the need for revision. Retrieval analysis can provide insight into implant-related reasons for revision, with the goal of understanding the implant-related causes of these failures, informing future ankle design and clinical decisions for current and future ankle arthroplasty patients.   To view the article click here.

The effect of bone mineral density (BMD) on outcomes from total ankle arthroplasty (TAA) has not been studied. BMD can be estimated by measuring Hounsfield units (HU) on standard computed tomography(CT), which is frequently performed prior to TAA. We aimed to identify whether tibial and talar HU measured from preoperative CT scans were associated with periprosthetic fracture or revision risk in patients undergoing TAA In conclusion, lower tibial HU on preoperative CT was strongly associated with periprosthetic fracture risk with TAA. In patients with tibial HU less than 200, surgeons may consider prophylactic internal fixation of the medial malleolus. To view the article click here.

Outcome measures evaluate various aspects of patient health, and when appropriately utilized can provide valuable information in both clinical practice and research settings. The orthopedic community has placed increasing emphasis on patient-reported outcome measures, recognizing their value for understanding patients’ perspectives of treatment outcomes. Patient-reported outcomes are information directly reported by patients regarding their perceptions of health, quality of life, or functional status without interpretation by healthcare providers. The American Orthopaedic Foot & Ankle Society (AOFAS) supports the use of validated patient-reported outcome (PRO) instruments to assess patient general health, functional status, and outcomes of treatment. It is not possible to recommend a single instrument to collect quality orthopedic data as the selection is dependent on the population being examined and the question being asked. We support the use of the PROMIS Physical Function Computerized Adaptive Test (

Overprescription of narcotic pain medication is a major culprit in the present opioid epidemic plaguing the United States. The current literature on lower extremity opioid usage has limitations and would benefit from additional study. The purpose of our study was to prospectively assess opioid consumption patterns following outpatient orthopedic foot and ankle procedures. Our study found that patients who underwent orthopedic foot and ankle procedures were overprescribed narcotic medication by nearly twice the amount that was actually consumed. Although we identified 4 independent factors associated with opioid consumption, the large residual standard error suggests that there remains a substantial degree of unexplained variance of opioid consumption observed in the patient population. Physicians face a challenging task of setting appropriate protocols when balancing pain relief and generalizable guidelines.   To view the article click here.

In an effort to minimize narcotic analgesia and its potential side effects, anti-inflammatory agents offer great potential provided they do not interfere with bone healing. The safety of ketorolac administration after foot and ankle surgery has not been well defined in the current literature. The purpose of this study was to report clinical healing and radiographic outcomes for patients treated with a perioperative ketorolac regimen after open reduction and internal fixation (ORIF) of ankle fractures. Our study found perioperative ketorolac use was associated with a high rate of fracture union by 12 weeks. This is the first study to examine the effect of ketorolac on radiographic time to union of ankle fractures. Additional studies are necessary to determine whether ketorolac helps reduce opioid consumption and improve pain following ORIF of ankle fractures.   To view the article click here.

Reconstruction of the stage II adult-acquired flatfoot deformity (AAFD) often requires the use of multiple osteotomies and soft tissue procedures that may not heal well in older patients. The purpose of our study was to determine whether patients older than 65 years with stage II AAFD had inferior clinical outcomes or an increased number of subsequent surgical procedures after flatfoot reconstruction when compared with younger patients. Our study found that patients older than 65 years with stage II AAFD have improvements in patient-reported outcomes and rates of revision surgery after surgical reconstruction that were not significantly different than those of younger patients.   To view the article, click here.

Residual forefoot supination after correcting the hindfoot in stage IIb adult-acquired flatfoot deformity can be addressed with a dorsal opening wedge medial cuneiform (Cotton) osteotomy. The amount of correction is generally judged clinically, and there currently are no preoperative guides that can predict the size of graft needed. The aim of this study was to evaluate the correlation between patient and operative factors and the correction achieved with the Cotton osteotomy. Correction of longitudinal arch collapse, as measured by the CAA, was primarily influenced by the size of the graft used for the Cotton osteotomy in a linear fashion. The preoperative CAA may help surgeons titrate the proper amount of graft placed intraoperatively.   To view the article, click here.

A recent publication reported preoperative Patient-Reported Outcomes Measurement Instrumentation System (PROMIS) scores to be highly predictive in identifying patients who would and would not benefit from foot and ankle surgery. Their applicability to other patient populations is unknown. The aim of this study was to assess the validation and generalizability of previously published preoperative PROMIS physical function (PF) and pain interference (PI) threshold t scores as predictors of postoperative clinically meaningful improvement in foot and ankle patients from a geographically unique patient population.    PROMIS PF threshold scores from published data were successful in classifying patients from a different patient and geographic population who would improve with surgery. If functional improvement is the goal, these thresholds could be used to help identify patients who will benefit from surgery and, most important, those who will not, adding value to foot and ankle health care.    To view the article,

Many patient factors have been associated with higher or lower expectations of orthopaedic surgery. In foot and ankle surgery, the diverse diagnoses seen may also influence expectations. The aim of this study was to investigate the relationship between diagnosis and patients’ preoperative expectations of elective foot and ankle surgery.   Diagnosis of ankle instability or osteochondral lesion, female sex, non-Caucasian race, and lower Foot & Ankle Outcome Score daily activities subscale score were all associated with higher expectations. These findings may help inform and guide surgeons as they counsel patients preoperatively.   To view the article, click here.

The authors describe a method of collecting patient-reported outcomes (PROs) using computerized adaptive tests (CATs) in a high-volume orthopedic surgery practice with limited resources and no research coordinator. Using tablets to administer CATs and entering the data in the electronic medical record for later retrieval was an effective technique to collect PROs. An adequate number of tablets are needed for acceptable completion rates. Modest sample size requirements for comparative studies highlight the potential of these tools and techniques.   To view the article, click here.

The purpose of this study was to compare the functional and radiographic outcomes of patients who received juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate (JACI-BMAC) for treatment of talar osteochondral lesions with those of patients who underwent microfracture (MF). JACI-BMAC and MF resulted in improved functional outcomes. However, while the majority of patients improved, functional outcomes and quality of repair tissue were still not normal. Based on our results, lesions repaired with DeNovo NT allograft still appeared fibrocartilaginous on MRI and did not result in significant functional gains as compared to MF.   To view the article, click here.

The historic treatment of Charcot foot arthropathy has been immobilization during the active phase of the disease process, followed by accommodative bracing of the acquired deformity. Evidence derived from modern patient-reported outcomes investigations has convinced many surgeons to attempt operative correction of the acquired deformity with a goal of improving quality of life. Operative correction of the acquired deformity of Charcot foot arthropathy was performed with a goal of improving quality of life. Stratification of patients by deformity pattern allowed alterations of the basic surgery to afford improved outcomes. In addition to achieving historic goals of resolution of infection and limb salvage, almost 80% of the patients were able to achieve the functional goal of independent ambulation with commercially available therapeutic footwear. The clinical outcomes achieved in this retrospective case series appear to support the modern paradigm of operative correction of deformity in this complex patient

Over the past decade, total ankle arthroplasty (TAA) has become a mainstay in the treatment of end-stage ankle arthritis. Currently in its fourth generation, the Scandinavian Total Ankle Replacement (STAR) is the only 3-piece mobile bearing ankle prosthesis available in the United States. Our current study reports implant survivorship at 15 years and patient outcomes for a subset of these survivors available for study. Our small cohort demonstrated STAR ankles with retention at 9 years were highly likely to survive to 15 years,and patients continued to have significant improvement in pain relief and minimal decrease in function. At 15 years from TAA, metal survivorship was 73%. As with all ankle replacements, supplementary procedures were common.   To view the article, click here.

Capsular interposition arthroplasty is a joint- and motion-sparing procedure that has been shown as an effective alternative to fusion. This study aimed to evaluate patient function and satisfaction after long-term follow-up. The mean VAS for pain was 7.9 preoperatively and 1.8 postoperatively (P = .003). The mean preoperative SF-12 physical score was 42.0 vs 64.2 postoperatively (P = .02). The mean preoperative SF-12 mental score was 50.7, while the postoperative SF-12 mental score was 54.6 (P = .01). The total FFI score also significantly improved, with a preoperative value of 98.3 and a postoperative mean score of 49.6 (P = .001). The mean patient satisfaction score was 7.4 of 10. Overall, 39 of 42 patients (92.9%) stated they would have the surgery again. Four of the 42 patients (9.5%) required conversion to hallux metatarsophalangeal fusion at a mean of 6.1 years after the index procedure secondary to pain, but no other complications were reported.   To view the article, click here.

We present our results with an INBONE I (Wright Medical, Memphis, TN) prosthesis that have a minimum of 4 to 10 years of follow-up and include a preoperative deformity analysis on outcomes. Patients who underwent INBONE I fixed-bearing total ankle arthroplasty demonstrated significant improvement in outcomes at a mean of 5.9 years. Catastrophic talar component collapse did occur (2.7% of cases), but relatively rarely. The patients with preoperative coronal plane tibiotalar deformity had similar pain relief, function, and need for revision of implant components. Despite the presumed shortcomings of the INBONE I’s design, this implant showed promising results, with or without deformity, at midterm follow-up with survivorship of 90.6%.   To view the article, click here.

Grading systems are used to assess severity of any condition and as an aid in guiding treatment. This study examined the relationship of baseline motion, pain, and observed intraoperative cartilage loss with hallux rigidus grade. Irrespective of the grade, positive outcomes were demonstrated for both fusion and synthetic cartilage implant. Clinical symptoms and signs should be used to guide treatment, rather than a grade consisting of radiographic, symptoms, and range of motion factors.   To view the article, click here.

Foot and ankle surgeons are increasingly relying on patient-reported outcome measures (PROMs) such as the Ankle Osteoarthritis Scale (AOS) to evaluate treatment options. The objectives of this retrospective cohort study were 2-fold: (1) to examine the AOS instrument using psychometric analysis and (2) to revise the questions on the AOS to improve the effect of questions on the score and remove redundancies. The AAS is shorter and has improved psychometric properties as compared to the AOS. Further investigation is required to better characterize the clinical utility of this proposed new patient-reported outcome score.   To view the article, click here.