Background: The Integra Cadence total ankle replacement (TAR) is a fourth-generation anatomic, fixed-bearing implant requiring minimal tibial and talar resection, which has been in clinical use since June 2016. The primary purpose of this study is to assess its short-term clinical and radiographic outcomes after TAR using this prosthesis. Methods: This is a prospective case series of consecutive patients that underwent TAR using this novel fourth-generation prosthesis between June 2016 and November 2017. The primary outcome of interest was the Ankle Osteoarthritis Scale (AOS). Secondary outcomes included Short Form Health Survey–36 (SF-36) scores, radiographic alignment, complications, reoperations, and revisions. Results: In total, 69 patients were included in our study. Fifty-one patients (73.9%) required a total of 91 ancillary procedures. Postoperatively, AOS pain scores decreased significantly by an average of 17.8±30.1 points from 45.9±18.2 to 28.4±27.3 ( P < .001). AOS disability scores also decreased significantly following surgery by an average of 22.0±30.5 points from 53.9±18.5 to 32.5±27.9 ( P < .001). The SF-36 physical component summary score improved 10.4±9.8 points from 33.1±9.1 to 42.6±9.1 ( P < .001). Radiographic analysis demonstrated significant improvement to neutral coronal plane alignment, which was achieved in 97% of patients ( P < .01) with no cyst formation at 2 years. There was 1 reported complication, 9 reoperations, and no metal or polyethylene component revisions. Overall, the 2-year implant survivorship was 100% in our cohort. Eighteen patients (26.1%) demonstrated fibrous ingrowth of the tibial component. However, outcome scores for these patients did not demonstrate any negative effects. Conclusions: In our hands, this TAR system demonstrated excellent early clinical and radiographic outcomes. Patients reported improved physical health status, pain, and disability in the postoperative period. Total ankle instrumentation allowed for accurate and reproducible implantation with correction of coronal and sagittal plane deformities. Early results for the clinical use of this TAR system are promising, but further long-term prospective outcome studies are necessary. Level of Evidence: Level IV, case series.
Background: Total ankle arthroplasty (TAA) is a surgical procedure commonly reserved for patients suffering from symptomatic end-stage ankle arthritis. As the number of TAAs increases, so does the associated economic burden. Given these economic constraints, there has been interest in the feasibility of outpatient TAA. The purpose of this study is to evaluate the safety, efficacy, and satisfaction of patients undergoing outpatient TAA. Methods: This is a retrospective case series of consecutive patients who underwent outpatient TAA from July 2018 to June 2019. Inclusion criteria included any patient undergoing a primary TAA in the outpatient setting. This was defined as discharge on the same day of surgery or within 12 hours of surgery. All surgeries were completed by a single experienced surgeon through an anterior approach using the Cadence Total Ankle System. Prior to surgery, all patients received a popliteal nerve block. Patients were then discharged home with oral analgesic and a popliteal nerve catheter, which they removed after 48 hours. The primary outcome of interest was postoperative pain control, which was measured using a numeric scale. Secondary outcomes included complication rate, readmission rate, and patient satisfaction. A review of the current literature was then completed to supplement our results. Results: In total, 41 patients were included in our analysis. In terms of the primary outcome, the average numeric scale score was 1.98, indicating excellent pain control. Additionally, nearly all 41 patients stated they were very satisfied with their postoperative pain control regimen. In terms of secondary outcomes, the majority of patients stated they were satisfied with discharge on the same day as surgery. There were no readmissions or major complications in our outpatient TAA cohort. When asked if they would recommend the care they experienced to a friend with the same condition, 95% of patients said that they would recommend this care pathway. Our literature review included 5 original studies, which were all retrospective level IV studies. These studies uniformly demonstrated the safety and efficacy of outpatient TAA. Conclusions: The results of our study demonstrate the outpatient TAA is associated with excellent pain control using a multidisciplinary pain approach. The use of standardized outpatient postoperative pathways was effective in preventing readmissions and complications, while still resulting in high patient satisfaction scores. A review of the literature complemented our results, as there are largely no significant differences between outpatient and inpatient TAA. Level of Evidence: Level IV, case series.
Category: Midfoot/Forefoot Introduction/Purpose: 'MoAkin' biplanar proximal phalanx closing wedge osteotomy with dorsal cheilectomy has been described as an effective procedure for treatment of hallux rigidus with hallux valgus interphalangeus (HVI). Its role as an adjunct procedure to first metatarsophalangeal joint hemiarthroplasty using a synthetic cartilage implant has not been well described. The purpose of this radiographic analysis was to examine radiographic changes associated with the MoAkin osteotomy performed in patients who underwent first MTPJ hemiarthroplasty using the Cartiva implant. Methods: A retrospective study of all patients with hallux rigidus and HVI treated with a synthetic cartilage implant and MoAkin osteotomy between 2009 and 2020 was conducted. Radiographs were performed preoperatively and at six- and/or twelve-month postoperatively, and evaluated using standardized measurement techniques. Hallux valgus angle (HVA), interphalangeal angle (IPA), and intermetatarsal angle (IMA) were measured. Results: Fifty-four patients were included in the study (37 male; 17 female). Mean preoperative HVA, IPA, and IMA were 11.7+- 4.2 degrees, 15.8+-4.6 degrees, and 8.2+-2.4 degrees, respectively. Mean six-month postoperative HVA, IMA, IPA were 7.7+-4.2 degrees, 15.7+-5.7 degrees, and 8.2 +- 3.0 degrees. Mean twelve-month postoperative HVA, IMA, IPA were 8.0+-4.5 degrees, 15.2+-6.1 degrees, and 8.1+-2.9 degrees. No statistical differences were found between the six-month and twelve-month radiographic analysis (p>=0.59). There was a statistically significant reduction in the hallux valgus angle at six and twelve-month follow up compared to the preoperative angles (p<0.001, d=0.73-1.16). No statistically significant differences were noted in terms of IPA and IMA (p>=0.31). Conclusion: MoAkin osteotomy improves the hallux valgus angle in patients with hallux rigidus and HVI undergoing first MTPJ hemiarthroplasty with the Cartiva implant. Further studies are warranted to evaluate the impact of these radiographic findings on patient-reported outcomes and other clinical outcomes.
Category: Ankle, Ankle Arthritis Introduction/Purpose: Over the last few decades, total ankle replacement (TAR) emerged as a reliable treatment option in end-stage ankle osteoarthritis (OA) while preserving motion and physiological load. The Cadence™ prosthesis, manufactured by Integra LifeSciences, is a two-component, fixed-bearing implant with minimal tibial and talar resection and has been in clinical use since June 2016. The purpose of this study is to assess the two-year validated clinical outcome scores and radiological parameters of the Cadence™ prosthesis at our hospital. Methods: Thirty-one consecutive patients who received the Cadence™ prosthesis between June 2016 and December 31st, 2016 were enrolled. All patients who underwent a primary TAR with the Cadence™ prosthesis and who had at least two years follow- up were included. All surgeries were performed by a single surgeon with experience in total ankle arthroplasty. At the yearly clinical evaluation, patients were administered the Ankle Osteoarthritis Scale (AOS) and the Short Form Health Survey (SF-36), and their radiological outcomes pre and post-surgery were assessed. Results: Thirty-one patients fulfilled the inclusion criteria. Forty ancillary procedures were performed on twenty-four TAR’s. Radiological analyses showed preoperative talar sagittal translation with 25 anterior, 2 posterior, and 4 neutral. Sagittal translation decreased from an average 3.11 mm to 1.0 mm. Eleven ankles had a perioperative talar Varus and Valgus deformity that was corrected, with neutral alignment in all. At the two-year clinic visit, x-rays showed no lucencies or stress fractures and none of the ankles required revision of metal components. The pre and post-operative pain and disability scores displayed major improvement wherein AOS pain scores decreased -20.28 ± 14.34 points from an average of 47.86 points while AOS disability scores decreased -32.11 ± 22.70 from an average of 57.15 points. Conclusion: The overall outcome of the total ankle arthroplasty with the Cadence™ prosthesis showed excellent clinical and radiological outcomes. Compelling clinical evidence shows that the quality of life, functional measures, and pain in patients suffering from end-stage arthritis significantly improved following surgery with the Cadence™ total ankle replacement system. The semi- constrained design of this two-component implant and utilization of biased polyethylene inserts allowed for correction of the talus in both the sagittal (talar anterior / posterior translation) and coronal planes (talar varus / valgus).
Category: Ankle Arthritis Introduction/Purpose: Outpatient total joint arthroplasty (OTJA) allows for a safe, cost effective pathway for appropriately selected patients. Total ankle arthroplasty (TAA) is a surgical procedure commonly used for patients with painful arthritis. As the number of TAA procedures increase, so does the associated economic burden. The purpose of this study was to evaluate patients undergoing total ankle arthroplasty, who were discharged on the same day as undergoing surgery. These patients have stayed in the hospital for <12 hours, and are referred to as ‘‘outpatients.’’ Outpatients were evaluated with regard to the following outcomes: (1) postoperative pain; (2) perioperative complications and healthcare provider visits (readmission). We also assessed patients’ satisfaction regarding discharge on the same day as surgery. Methods: The medical records of 46 consecutive TAA outpatients from July 2018 to June 2019 with a minimum 1 month post- operative follow-up, were reviewed. All patients received an Integra Cadence TAA. Prior to surgery, all patients received popliteal blocks. Patients were discharged home with a popliteal catheter, which they were to remove themselves after 48 hours. After removal of the catheter, patients were prescribed oral pain medication to help with any pain or discomfort. The following data was collected: demographics, comorbidities, (ASA) class, and perioperative complications, including wound breakdown, infection, revision and non-revision surgeries. At their 1-month post-operative visit, patients completed a questionnaire regarding their satisfaction post-surgery, which consisted of six questions. Results: There were no readmissions for pain control, no signs of wound infection among the 46 outpatients. All patients were ‘very satisfied’ with the surgical procedure and with recommend methods of pain control. The majority of patients were also very satisfied with discharge on the same day as surgery with the exception of patients who would have liked to stay overnight. When asked if they would recommend the care they experienced to a friend with the same condition, 46 patients said that they would definitely recommend this process to a friend. In terms of rating their pain on a scale of 0-10 (0 being no pain, 10 being worst pain imaginable), the average score for the 46 patients was 2.03. Conclusion: Our study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory outpatient experience and no readmissions for pain control.
Category: Ankle; Ankle Arthritis Introduction/Purpose: The success of total ankle arthroplasty (TAA) depends on many factors, including patient selection, prosthetic design, soft tissue balancing, severity of joint deformity, and component position. Malposition of the components increases contact pressures and diminishes prosthesis survival / patient outcomes; therefore, anatomic alignment of the prosthesis is desirable. Sagittal malalignment of the talar component is common and has been associated with lower outcome scores. Cadance Total ankle system is unique in that it has modular polyethene components with both an anterior and posterior biased option that may help improve reduction of the talus in the sagittal plane. The purpose of this study is to evaluate the effectiveness of anterior and posterior biased polyethylethene liners in improving sagittal component alignment in patients with preoperative sagittal translational deformities Methods: This is a prospective radiographic and clinical study of patients that underwent TAA with the CadenceTM system using biased polyethylene liners with at least 12-months follow-up. All surgeries were performed by a single surgeon with extensive experience in TAA between July 2016 and December 2018. Patients underwent TAA in a standard fashion using an anterior approach, and then underwent clinical evaluation at standardized time points with administration of the Ankle Osteoarthritis Scale (AOS) and the Short Form Health Survey (SF-26). Radiographic outcomes included assessment of sagittal plane component alignment using the tibiotalar (TT) ratio and tibial-axis-to-lateral-process distance at preoperative and at postoperative visits. Results: The cohort included a total of 7O TAA which demonstrated pre-operative sagittal talar malalignment and/or intra- operative sagittal instability where a biased polyethylene liner was inserted. Preoperative talar sagittal translation was 54 anterior, 6 posterior and 10 were neutral. 30 anterior biased polyethylene and 40 posterior biased polyethylene were used. Sagittal translation decreased from an average 4.2 mm to 0.8 mm. The T-T ratio averaged 40.8 +- 10.8 % on preoperative x-ray and 38.1 +- 3.6 % on postoperative. The pre and post-operative pain and disability scores displayed statistically significant improvements wherein AOS pain scores decreased 25.28 +- 14.34 points from an average of 45.86 points while AOS disability scores decreased -30.11 +- 22.70 from an average of 56.15 points. Conclusion: Sagittal translational deformities associated with end-stage ankle arthritis are common and should be corrected during TAA to improve loading kinematics and implant longevity. The Cadence TAA has anterior and posterior biased polyethylene liners that help to correct sagittal talar translational deformities. This study demonstrates that biased liners are effective in improved postoperative clinical outcomes with significant correction of pathological sagittal translation to near anatomic alignment.
Introduction: Calcaneus is one of the most commonly fractured tarsal bones. The use of computed tomography (CT) has enabled more accurate fracture configuration and classification of fractures. The outcomes of operative versus nonoperative treatment of these fractures have been extensively debated with variable results. Significant complications following intra-articular fractures have been reported in the literature despite management by experienced surgeons. This article will discuss the treatment of calcaneus fractures by open reduction and internal fixation in a prone position with a calcaneal traction pin, and assess the outcomes following this novel technique. Methods: Fifty-three patients with 58 acute displaced intra-articular calcaneal closed fractures (Sanders type II and III), presented to one tertiary center, were treated by open reduction and internal fixation in a distracted prone position through an extensile lateral approach by a single surgeon and assessed for postoperative wound and soft tissue complications. The primary outcome measure was postoperative wound complications. Secondary outcome measures were postoperative ankle and subtalar range of motion and return to work. Radiological assessment of anatomical reduction by measuring preoperative and postoperative Bohler’s angle, Gissane angle, and posterior facet joint depression was conducted. A comparison was made with paired sample t-test with a confidence interval of 95%. Results: Fifty-three patients with 58 calcaneus fractures were treated surgically. Three cases (5.6%) developed postoperative wound infection, of which only one needed surgical intervention. The reoperation rate was 5.6% in our study. Half of the patients (50%) were able to be followed up long-term, and the radiographs showed significant restoration of Bohler’s angle and posterior facet joint depression in 24 patients. Return to full duties was achieved in an average of 5.6 months for 16 of 22 patients, who were available for follow-up questions with regard to return-to-work status. Conclusion: Operative treatment of calcaneus fracture by open reduction and internal fixation in the novel distracted prone position technique has shown a low rate of the wound and soft tissue complications and can be considered as an alternative approach in treating these fractures.
Category: Ankle Introduction/Purpose: Wound complications can lead to devastating outcomes in major ankle procedures such as total ankle arthroplasty. Up to 28% wound healing complications have been reported with anterior approach to the ankle. Anteromedial approach is an angiosome based approach for ideal wound healing especially in those with high risk factors. Methods: The procedure includes the following steps: 1. Make the Incision along the medial border of the anterior angiosome fed by anterior tibial artery and dorsalis pedis 2. Create full thickness lateral flap by dissecting through the extensor retinaculum, along the course of the tibialis anterior tendon 3. Stay sutures are placed full thickness through the retinaculum and EHL, the full thickness flap is then retracted laterally with the anterior neurovascular bundle 4. The interval between the tibialis anterior tendon and lateral flap is used to perform the total ankle replacement 5. Adequate and full exposure of the distal tibia and ankle joint is achieved. Retrospective chart review of patients who underwent anteromedial approach for elective ankle procedures from Jan 2012 to 2018 was performed. Patient demographics (age, BMI), medical comorbidities, smoking status, pertinent trauma history, follow up duration, and wound complications were collected. Results: Total 73 patients underwent extensile anteromedial approach. Mean age was 48, mean follow up was 24 (range 12 to 73) months. There were no instances of skin flap necrosis. One patient with chronic venous insufficiency developed a small superficial wound infection that healed with dressing changes alone. Conclusion: Anteromedial approach to ankle is a reasonable alternative to standard anterior approach to achieve optimal wound healing in ankle procedures in a high-risk patient for wound healing. The approach allows complete access to the ankle joint keeping the angiosomes intact which helps in excellent wound healing. [Figure: see text]
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