Foot & Ankle Orthopaedics最新文献

Background: Total ankle replacement (TAR) is a surgical option for patients with ankle arthritis who have failed conservative measures. Newer implants have markedly improved; however, osteolysis causing aseptic loosening continues to be a main cause of TAR failure. The objective of this study was to review the HINTEGRA TAR experience at a single institution specifically evaluating the presence and outcomes of osteolysis.

Methods: Retrospective study including all HINTEGRA TARs completed by 1 experienced foot and ankle surgeon from 2006 to 2014. Radiographs were reviewed, assessing for implant positioning, presence, location, and progression of cysts as well as relationship between osteolysis with reoperations and revisions.

Results: Fifty-one TARs were identified with radiographic follow-up of 5.8 ± 3.5 years. Eighty-four cysts were detected in 37 patients, with increasing number and size of cysts being correlated to length of time from surgery. The most common location was the posterior tibia. Thirteen patients had enlarging cysts identified over time, with the lateral malleolus being the most common location. Seven patients met criteria for malaligned prosthesis, 12 patients required a reoperation, and 2 patients experienced implant failure.

Conclusion: Osteolysis is a very common finding after TAR using the HINTEGRA prosthesis, specifically on long-term radiographic follow-up. Progressive cysts and prosthesis coronal malalignment appear to be risk factors for developing osteolysis, prosthesis loosening, and reoperation. Most cysts did not result in clinical failure, but progressive lesions identified beyond 1 year warrant closer monitoring. This study also shows excellent and reliable outcomes of the HINTEGRA TAR compared with designer surgeons with acceptable complication and revision rates.

Level of evidence: Level IV, Case series.

Background: Distraction arthroplasty aims to treat ankle osteoarthritis while preserving the native ankle joint, often to prevent or delay ankle arthrodesis or total ankle replacement (TAR). No study to date has explored TAR outcomes in patients who have had prior distraction arthroplasty. Thus, this study described the clinical, radiographic, and patient-reported outcomes for TAR at minimum 2-year follow-up in patients who had undergone prior ankle distraction arthroplasty.

Methods: This retrospective review included 19 ankles in 17 patients who underwent TAR at a single institution subsequent to ipsilateral distraction arthroplasty. The primary aims were to evaluate complication rate and patient satisfaction following TAR. PROMIS scores were obtained preoperatively and at minimum 2 years postoperatively. The proportion of patients who achieved the patient acceptable symptom state (PASS) threshold for each Patient-Reported Outcomes Measurement Information System (PROMIS) domain at final follow-up was used to assess patient satisfaction following TAR.

Results: TAR was performed a mean of 5.3 ± 3.5 years following distraction arthroplasty. At mean 4.4-year follow-up after TAR, 18/19 (94.7%) ankles remained implanted. One ankle was revised because of failure of the talar component, and there were 4 additional reoperations. Radiographic complications were observed in 37% of patients at 2 years postoperatively. Patients experienced significant improvement at 2-year follow-up for PROMIS domains of Physical Function (P = .002), Pain Interference (P = .007), and Pain Intensity (P = .010). At final follow-up, PASS was achieved by 65% and 71% of patients in the Physical Function and Pain Interference domains, respectively, but only 35% in the Pain Intensity domain.

Conclusion: TAR is a viable option to treat ankle osteoarthritis symptoms that persist after distraction arthroplasty. However, many of these patients present with a complex surgical history and, therefore, may be at a greater risk for reoperation. Thus, patients should be counseled appropriately before electing to proceed with distraction arthroplasty before more definitive surgical treatment options.

Level of evidence: Level IV, case series.

Background: Fear of reinjury (FORI) can hinder recovery in several orthopaedic conditions, but its impact after augmented Broström repair is unknown. We sought to determine the prevalence of FORI and its association with functional outcomes in this setting. This study aims to determine whether patients experience FORI following augmented Broström repair and whether FORI impacts functional outcomes.

Methods: 80 patients who underwent Broström repair with InternalBrace augmentation were contacted to complete surveys containing questionnaires with Patient Reported Outcome Measurement Information System (PROMIS) measures of physical function (PF) and pain interference (PI), Cumberland Ankle Instability Tool (CAIT), and whether patients experienced current (at time of survey completion) activity limitations due to FORI.

Results: 64% (51/80) of patients reported postoperative FORI. Average follow-up was 3.9 years. Fear was associated with worse PF (49.9 ± 7.4 vs 54.9 ± 8.4, P = .01) and worse CAIT (19.1 ± 8.0 vs 23.2 ± 8.1, P = .04), and both differences exceeded the minimal clinically important difference (MCID). There was no significant difference in PI (49.8 ± 8.7 vs 46.5 ± 6.9, P = .06). There were no significant differences in the proportion of patients who reported FORI by age, sex, or BMI.

Conclusion: FORI affected nearly two-thirds of patients and was linked to clinically meaningful functional deficits. Although PROMIS scores reached population means overall, addressing psychological barriers may further optimize outcomes after augmented Broström repair.

Level of evidence: Level IV, retrospective case series study.

Background: Assistive devices facilitate daily activities and recovery, and are essential for nonweightbearing ambulation after orthopaedic foot or ankle surgery.This study aimed to compare the usability of forearm crutches (FCs) and hands-free single crutches (HFSCs) during the early postoperative recovery phase in terms of their effects on mobility, speed, safety, range, endurance, personal preference, and quality of life.

Methods: This prospective randomized crossover study included 35 participants. Assessments included the 36-Item Short-Form Survey, Short Musculoskeletal Function Assessment Questionnaire, and European Foot and Ankle Society Score administered preoperatively and at 2 follow-up examinations. Patients were assigned to either device (FC or HFSC) for the first 3 weeks after surgery. The primary outcome was number of stumble events (SEs) during standardized mobility tests. For secondary outcomes (including mobility, speed, and range), patients completed clinical tests such as the 6-minute walk test, stair-climbing test, 10-m walk test, and indoor and outdoor parkour activities. Following the clinical tests, the patients provided qualitative feedback, including personal preference and overall device usage. After switching the devices, the tests were repeated at 6 weeks postoperatively.

Results: Although FCs performed better in most mobility tests, patients favored HFSCs because of enhanced comfort and lower perceived exertion. Despite the physical advantages of FCs, patients tended to prefer HFSCs owing to their ergonomic benefits. The quality of life and physical function scores for both devices declined after surgery, reflecting a typical postoperative recovery phase. Younger and male patients generally performed better with HFSCs, whereas female, older, and overweight patients faced more challenges.

Conclusion: FCs outperform HFSCs with respect to mobility, but patients prefer HFSCs due to comfort and reduced exertion although the clinical significance of these perceived differences remains uncertain. This underscores the need for personalized device recommendations to improve postoperative outcomes. This study highlights the complexity of device selection based on individual patient needs and preferences.

Level of evidence: Level II, prospective, randomized comparative study.

Background: Despite the satisfactory results of hallux valgus surgery in general, the incidence of complications has been considerably high. This study evaluated the incidence and risk factors of short-term reoperations after surgical correction of hallux valgus deformity with first metatarsal osteotomy.

Methods: We conducted a retrospective review of 685 consecutive open first-metatarsal osteotomies performed from 2013 to 2018 in a single university-hospital region. The number, indications, and type of reoperation were collected. The association between reoperation and patient's age, sex, BMI, comorbidities, preoperative hallux valgus angle (HVA), hospital type, osteotomy type, and surgeon's experience was analyzed.

Results: There were 79 reoperations (11.5%) at a median of 14 months (range, 1-83) postoperatively. Fifteen reoperations were merely hardware removals. Most reoperations (46%) were performed because of residual deformity. Preoperative and postoperative HVA, diabetes, and type of osteotomy were statistically significant risk factors for all-cause reoperation both in univariate (P < .0001, P = .0052, and P < .0001, respectively) and multivariate analysis (P < .0001, P = .0059, and P < .0001, respectively). Overall, 4.9% of distal, 18.7% of midshaft, and 29.3% of proximal osteotomies were reoperated.

Conclusion: The incidence of short-term (≤24-month) reoperations was higher than previously reported after open surgical correction of hallux valgus deformity with first metatarsal osteotomy. Larger preoperative and postoperative HVA, diabetes, and type of osteotomy were associated with revision surgery in this retrospective cohort. Proximal osteotomies had the highest risk for reoperation.

Level of evidence: Level IV, case series.

Background: Severe hallux valgus (HV) presents a significant surgical challenge. Traditional methods are being questioned because of their invasiveness, whereas recent minimally invasive techniques raise concerns because of their associated complications. This study evaluates the percutaneous distal metatarsal osteotomy technique, generally found to be effective for mild-to-moderate cases, and tests the hypothesis that it provides effective clinical and radiologic correction for severe deformities.

Methods: This retrospective study analyzed 116 feet that underwent percutaneous distal metatarsal transverse osteotomy with lateral soft tissue release and provisional Kirschner wire fixation, with a mean follow-up of 27.1 months, limited to severe cases (hallux valgus angle [HVA] > 40 degrees). Radiologic assessments included preoperative and postoperative measurements of HVA, intermetatarsal angle (IMA), distal metatarsal articular angle, sesamoid position, first metatarsophalangeal (MTPI) joint congruency, metatarsal length, and sagittal position. Clinical evaluations used the AOFAS scale, documenting the recurrence rate, the nature of complications, reoperations, and the association between them. Patient satisfaction was assessed through self-reported evaluations.

Results: Significant improvements were noted for HVA (median correction from 43.1 to 14.6 degrees) and IMA (median correction from 17.2 to 8.5 degrees). The metatarsal was shortened by 5.4 mm. There was a notable reduction in the degree of sesamoid displacement and MTPI congruency. Sagittal position remained unchanged in 85.3%. The median AOFAS score improved from 44.0 to 90.5, well above the clinically significant improvement threshold, and 87.9% of patients were satisfied or very satisfied. We recorded no major complications and minor complications at a rate of 35.3%. Reoperation rate was 14.7%, primarily due to exostoses. Significant associations were found between postoperative sesamoid position and clinical outcome, and between reoperation rate, exostosis, and MTPI congruency, emphasizing the importance of correcting these parameters. Recurrence rate was 6%. Patient satisfaction was associated with reoperation and complications, but not with radiologic parameters.

Conclusion: Percutaneous distal metatarsal osteotomy achieved substantial correction of severe hallux valgus with significant improvements in angular measurements, high patient satisfaction (87.9%), and no major complications. Although the technique shows promise as a less invasive alternative with comparable radiographic outcomes, the 14.7% reoperation rate (primarily for exostoses) and 6% recurrence rate must be considered. Prospective comparative studies are needed to establish its role relative to other surgical approaches for severe deformities.Level of Evidence: Level IV, retrospective case series.

Background: Subtle Lisfranc injuries, defined by 2-5 mm of first webspace diastasis, pose unique treatment challenges distinct from more severe injuries. This study aimed to evaluate whether a primary open reduction internal fixation (ORIF) or a primary arthrodesis (PA) optimizes clinical outcomes and minimizes complications in treating subtle Lisfranc injuries.

Methods: This study included patients who had a nondislocation Lisfranc injury with a proximal first webspace (between the medial cuneiform and second metatarsal base) diastasis of 2-5 mm, and underwent either a primary ORIF or primary arthrodesis. Preoperative weightbearing radiographs were reviewed to confirm subtle Lisfranc injuries. Of the 73 patients who met the inclusion criteria, 41 received a PA and 32 received an ORIF. Treatment selection was based on surgeon preference. Patient-reported outcomes via PROMIS scores were collected preoperatively and at least 2 years postoperatively. Subsequent procedures were also recorded.

Results: We received PROMIS surveys from 57 patients (78%). The average preoperative diastasis of the ORIF group significantly differed from that of the PA group (P < .05). Both ORIF and PA cohorts demonstrated significant improvement in all physical PROMIS criteria on minimum 2-year follow-up (P < .05). Our results did not demonstrate a significant difference in patient-reported outcomes between the ORIF and PA groups. There was no significant difference in the incidence of complications between groups, but the ORIF group underwent significantly more hardware removal procedures than the PA group (P < .01).

Conclusion: This study compared outcomes of subtle Lisfranc injuries treated with ORIF and PA. Our results demonstrated no significant differences between ORIF and PA outcomes. This study suggests that both ORIF and PA may be viable options for subtle Lisfranc injuries; however, further research is needed to determine which may be optimal for different patient populations.

Level of evidence: Level III, retrospective comparative study.

Background: The role of venous thromboembolism (VTE) chemoprophylaxis following ankle fracture surgery remains controversial. Although pharmacologic prophylaxis is standard in major orthopaedic procedures, its utility in foot and ankle trauma surgery is unclear because of low reported VTE rates and potential bleeding risks. Furthermore, no consensus exists on the cost-effectiveness of prophylactic agents in this population.

Methods: A literature review and the TriNetX Research Network were used to identify postoperative symptomatic VTE rates following ankle open reduction internal fixation (ORIF). The cost of treating a symptomatic VTE was estimated from existing literature and adjusted to 2025 US dollars. Drug pricing data were obtained from an online pharmacy database. A break-even analysis was conducted to calculate the absolute risk reduction (ARR) and number needed to treat (NNT) for each agent to be cost-effective. A subanalysis compared 30-day bleeding and transfusion rates between patients who received prophylaxis and those who did not.

Results: The low and high literature-based VTE rates were 0.33% and 1.2%, whereas the TriNetX-derived VTE rate was 0.56%. Among 64 184 patients undergoing ankle ORIF without prophylaxis, 384 developed a symptomatic VTE. Aspirin (81 mg and 325 mg) and warfarin (5 mg) were cost-effective at all 3 VTE rates, with NNTs ranging from 9217 to 10 547. Enoxaparin (40 mg) was only cost-effective at the highest VTE rate (NNT = 131), whereas rivaroxaban (20 mg) was not cost-effective at any rate. Enoxaparin and rivaroxaban became cost-effective only when VTE treatment costs exceeded $50 000 and $1 500 000, respectively. Patients receiving prophylaxis had higher bleeding (0.56% vs 0.26%) and transfusion (0.82% vs 0.25%) rates (P < .001).

Conclusion: In summary, this study found that aspirin 81 mg, aspirin 325 mg, and warfarin are cost-effective for VTE chemoprophylaxis following ankle fracture fixation. Enoxaparin and rivaroxaban are generally not cost-effective, and their use may be appropriate only in high-risk patients.

Level of evidence: Level IV, economic analysis.