scholarly journals Tibial Torsion May Predict Morphology of the Talus

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0017
Author(s):  
David J. Ciufo ◽  
Erin A. Baker ◽  
Paul T. Fortin
Keyword(s):  
Preoperative Planning ◽  
Total Ankle Arthroplasty ◽  
Patient Specific ◽  
Tibial Rotation ◽  
Foot And Ankle ◽  
Tibial Torsion ◽  
Ankle Arthritis ◽  
Body Angle ◽  
Ankle Arthroplasty ◽  
End Stage

Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: The role of implant positioning in total ankle arthroplasty (TAA) has garnered increasing attention, particularly in defining coronal and sagittal plane alignment. With the ongoing developments in patient specific instrumentation, advanced imaging is becoming a more common tool in preoperative planning. Despite this, there is limited information available on axial rotation of the ankle or variations in anatomy of the talus and foot. We aim to evaluate the rotational profile of the distal tibia and its relationship to morphology of the talus, as well as assess tibiotalar tilt, in a cohort of end-stage arthritic ankles. Methods: Computed tomography (CT) scans and plain radiographs were reviewed in 59 patients with end-stage ankle arthritis. Patients with previous tibial or ankle trauma were excluded. Scans were obtained prior to total ankle arthroplasty surgery as part of standard preoperative planning protocol. Demographic data was recorded. Measurements were obtained at the posterior condyles of the tibial plateau and transmalleolar axis to calculate tibial torsion, as well as along the talar neck and body to evaluate talar angle. Tibiotalar tilt angle was measured on weightbearing mortise view radiographs. Linear regression was performed to evaluate statistical associations between tibial torsion and other measured parameters. Results: The mean tibial torsion was 29.5±9.2 degrees external (range 13.6-50.8 degrees), no internal torsion was found. Mean talar neck-body angle was 38.2±8.8 degrees medial (range 24.1-59.5 degrees). Tibiotalar angle ranged from 26.5 degrees varus to 23.5 degree valgus. There was a statistically significant relationship between increasing tibial torsion and decreasing talar neck-body angle (r=-0.49, p<0.001), demonstrating more angulation of the talar neck corresponding to the least tibial torsion as seen in Figure 1. No relationship was found between tibial rotation and tibiotalar angle when assessing varus/valgus tilt on a spectrum (p=.89) or when evaluating absolute angulation from neutral (p=.43). Our cohort had a mean age of 63.1±8.2 years, and 54% were male. Conclusion: Our cohort displayed wide variation in axial anatomy of the ankle. Our analysis identifies a statistically significant correlation between tibial torsion and morphology of the talus. This is a previously unreported association that could help understand development of foot and ankle deformity and pathology. While there was no clear correlation to degree of tibiotalar angulation, these axial deformities surely play a role in altered foot and ankle mechanics and the development of end-stage ankle arthrosis. In patients undergoing ankle arthroplasty, these are important parameters for the surgeon to consider in conjunction with other aspects of the hindfoot deformity.

scholarly journals Total Ankle Arthroplasty: Is Ankle Plantarflexion Strength Important?

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0002
Author(s):  
Frank E. DiLiberto ◽  
Steven L. Haddad ◽  
Daniel H. Aslan ◽  
Anand M. Vora
Keyword(s):  
Soft Tissue ◽  
Gait Speed ◽  
Total Ankle Arthroplasty ◽  
Joint Torque ◽  
Patient Specific ◽  
Control Group ◽  
Ankle Arthritis ◽  
Ankle Arthroplasty ◽  
Ankle Strength ◽  
End Stage

Category: Ankle Arthritis Introduction/Purpose: Ankle push off power, which requires gastroc-soleus muscle strength, is a critical aspect of healthy gait and increases as gait speed increases. It is therefore surprising that one-to-two-year outcomes following total ankle arthroplasty (TAA) include improved gait speed but deficient ankle power. One possible explanation for low ankle power following TAA is ankle plantarflexion weakness. Information on plantarflexion strength is extremely limited in people before or after TAA. Evaluating plantarflexion strength may inform postoperative expectations and guide rehabilitation programs. The purpose of this study was to evaluate the change in ankle plantarflexion strength, ankle power during gait, and gait speed before and after TAA in people with end-stage ankle arthritis, and in comparison to a healthy matched control group. Methods: Twenty-five participants were included in this prospective case-control study. TAA group participants (n = 13) [mean (SD): Age 60.9 (15.3) years; BMI 30.53 (5.5) Kg/m2; 85% male] with end-stage ankle arthritis who received a TAA were evaluated preoperatively and six months postoperatively. Performance of adjunct soft tissue procedures were patient specific (5/13 participants received tendo-achilles lengthening). All patients received formal physical therapy. Healthy control participants (n=12) were matched to the TAA group on age, gender and BMI. Ankle peak isokinetic plantarflexion strength (torque at 60 and 120 degrees/second; Nm/kg) was measured with an instrumented dynamometer. Peak ankle power (joint torque x segmental velocity; W/kg) was calculated via three-dimensional multi-segment foot motion analysis while participants walked barefoot over a force plate at controlled speeds. Gait speed (m/s) was measured with the Six-Minute Walk Test. Appropriate nonparametric comparisons were made to evaluate differences across time, between limbs, and between groups. Results: Compared to preoperative values, involved limb ankle strength was preserved at 60 and 120 degrees/second following TAA (both p > 0.59). Postoperative involved limb ankle strength at both speeds were 37-56% lower than the non-involved limb and control group (all p < 0.05) (Figure 1). Similarly, involved limb ankle power was preserved following TAA (p = 0.43), but remained at least 38% lower than the non-involved limb or control group (both p < .01). A subset analysis revealed that TAA participants with tendo-achilles lengthening had 25-33% less involved limb postoperative ankle power and strength than TAA participants without tendo-achilles lengthening. Interestingly, gait speed increased following TAA (p = 0.01) and was similar to control group speeds [TAA 1.5 vs. Control 1.6 m/s; p = 0.59]. Conclusion: Robust improvements in gait speed were observed following TAA. These values approached normative gait speed in spite of diminished ankle strength and power. Ankle plantarflexion weakness reduces the capacity to generate ankle power during gait, regardless of possible contributing factors (i.e. preexisting atrophy/weakness, tendo-achilles lengthening). Accordingly, improvements in gait speed were likely linked to proximal joint compensations (i.e. hip, knee). The long term consequences of plantarflexion weakness may negatively affect implant loading. Study findings provide new information and point to the importance of targeting strength during postoperative TAA rehabilitation, potentially adjusting strategies for patients receiving soft tissue lengthening procedures.

scholarly journals Total Ankle Arthroplasty Results Using Fixed Bearing CT-Guided Implants in Post-Traumatic Versus Non-Traumatic Arthritis

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0009
Author(s):  
Assaf Albagli ◽  
Susan M. Ge ◽  
Patrick Park ◽  
Dan Cohen ◽  
E. Ruth Chaytor ◽  
...  
Keyword(s):  
Total Ankle Arthroplasty ◽  
Patient Specific ◽  
Foot And Ankle ◽  
Fixed Bearing ◽  
Ankle Arthritis ◽  
Ankle Osteoarthritis ◽  
Ankle Arthroplasty ◽  
Traumatic Group ◽  
Post Traumatic

Category: Ankle; Ankle Arthritis; Trauma Introduction/Purpose: The majority of ankle osteoarthritis are post-traumatic in etiology. Previous studies have shown that patients with post-traumatic ankle osteoarthritis are less satisfied, experience significantly more pain during normal activities and have higher revision rates. However, these studies were performed with older generation implants. The objective of this study was to compare patients hat had undergone total ankle arthroplasty secondary to either post-traumatic or non-traumatic etiologies using patient specific, third generation fixed bearing implants and compare clinical as well as radiographic outcomes. Methods: A retrospective chart review was conducted on 41 patients who had undergone total ankle arthroplasty using a third- generation fixed bearing implant with CT-based patient specific cutting guides from July 21, 2015 to December 13, 2017 performed by 2 foot and ankle surgeons. Demographic and operative data was collected. Etiology was determined based on clinical notes, operative notes, and x-rays. Clinical outcomes were obtained using the Foot and Ankle Ability Measure questionnaire. Radiographic assessment of the coronal and sagittal alignments were carried out to assess implant migration or loosening. Results: We had 26 patients in the post-traumatic group and 15 in the non-traumatic group with a mean follow-up of 32.5 months and 30.4 months respectively. There was no significant difference between both groups in terms of FAAM ADL subscore with the post-traumatic group did slightly better with 7 patients scoring ‘nearly normal’ (26.9%) and 18 patients scoring ‘normal’ (69.2%). Whereas in the non-traumatic group 5 patients score ‘nearly normal’ (33.3%) and 9 patients score ‘normal’ (60%). In terms of the self-rated subjective functioning score, mean score of 79.2% and 73.4% respectively. On radiographs, there was no subsidence or significant implant movement for both groups at mean follow-up of 28.3 months for the post-traumatic group and 26.3 months for the non-traumatic group. Conclusion: Unlike in previous studies in older implants where clinical outcomes were worse in post-traumatic ankle arthritis, our study showed that those receiving total ankle arthroplasty due to post traumatic osteoarthritis do slightly better than those with non-traumatic osteoarthritis, with more patients reporting normal levels of activity. These results may help quantify improvements in newer generation patient specific implants as well as to gain insight into how different implant designs affect post- operative outcomes based on etiology of ankle osteoarthritis.

scholarly journals Accuracy and Reproducibility of a Patient-Specific Instrumentation in Total Ankle Arthroplasty

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0010
Author(s):  
Pierre-Marc April ◽  
Philippe Hugo Champagne ◽  
Magalie Angers ◽  
Karl-Andre R. Lalonde ◽  
Brad Meulenkamp ◽  
...  
Keyword(s):  
Tibial Component ◽  
Total Ankle Arthroplasty ◽  
Patient Specific ◽  
Foot And Ankle ◽  
Ankle Arthritis ◽  
Ankle Arthroplasty ◽  
Component Size ◽  
Patient Specific Instrumentation ◽  
Operation Rate ◽  
Accuracy Of Prediction

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis (OA) is a frequent and debilitating disease with the two primary surgical options being ankle arthrodesis or total ankle arthroplasty (TAA). TAA has the advantages maintenance of range of motion (ROM), a more normalized gait and potentially improved functional outcome over arthrodesis. Malaligned protheses have been demonstrated to have increased peak component pressures, potentially leading to component loosening, failure and overall worse outcomes. One TAA system uses pre-op CT to build patient-specific surgical instrumentation, with purported benefit of more reliable and accurate component positioning. The goal of this study is to evaluate reproducibility and accuracy of this system by surgeons without affiliation with the prosthesis design team. Methods: A retrospective radiological study was performed including two centers with four fellowship-trained foot and ankle surgeons using the patient-specific TAA system. All patients operated on between 2015-2018 were included. The primary outcome was alignment of the tibial implant in coronal and sagittal orientation relative to the tibia anatomic axis. All measurements were performed in duplicate an orthopaedic foot and ankle fellow and a musculoskeletal fellowship-trained radiologist. Secondary outcomes included accuracy of prediction of tibial and talar component size implanted compared to the engineered pre-operative plan, rate of prosthesis revision (at least one component) and overall re-operation rate. Results: 79 patients were included in the final review. The mean absolute deviation of the tibial component from tibial anatomical axis was 1.31° +/- 1.14in the coronal plane and 2.68°+/- 1.74 in sagittal alignment. 94.7 % of the implants were implanted within 3°of varus or valgus and 73.7% within 3°of dorsiflexion or plantiflexion. 86 % of the implanted tibial component were of the size predicted by the pre-op plan whereas it was found to be the case in 63 % of the talar component.At a mean follow-up of 22 months(3-52), two TAA (2.5%) have been revised due to aseptic tibial implant loosening. Conclusion: The patient-specific guide has been found to be a reliable system for coronal tibial implant alignment but less in the sagittal plane in the hand of surgeons not involved in the design of any TAA system. Accuracy of prediction of the tibial component size is high, moderate on the talar side. In this series there was a low rate of early component revision (2.5 %).

The Impact of Concomitant Ipsilateral Knee Pain on Functional Outcomes in Total Ankle Arthroplasty

2020 ◽  
pp. 193864002095089
Author(s):  
Michael J. Symes ◽  
Alastair Younger ◽  
Mario Escudero ◽  
Murray J. Penner ◽  
Kevin Wing ◽  
...  
Keyword(s):  
Outcome Measures ◽  
Knee Pain ◽  
Functional Outcomes ◽  
Total Ankle Arthroplasty ◽  
Ankle Arthritis ◽  
Pain Group ◽  
Ankle Arthroplasty ◽  
End Stage ◽  
The Impact ◽  
Disease Specific

In end-stage ankle arthritis, little is known about the impact of concomitant knee pathology, including the impact of ipsilateral knee pain on total ankle arthroplasty (TAA) outcomes. The aim of this study was to determine the prevalence of ipsilateral preoperative knee pain in patients undergoing TAA and analyze its impact on patient-reported functional outcome measures (PROMs). A retrospective review was performed on the Vancouver End Stage Ankle Arthritis Database at a single institution. In total, 114 patients were studied, with patient demographics collected preoperatively, including the presence or absence of knee pain. Postoperative follow-up was performed at 5 years, primarily analyzing disease-specific PROMs, including the Ankle Osteoarthritis Score (AOS) and Ankle Arthritis Score (AAS). Multivariate mixed-effects linear regression models compared the scores between the groups. In total, 31 patients (27.2%) presented with concomitant ipsilateral knee pain. Despite more females in the knee pain group (64.5% vs 36.1%) there were no other significant differences at baseline between the knee pain and no knee pain groups in terms of demographics or baseline primary disease specific PROMs. At 5 years, the patients with knee pain had significantly worse AAS (37.9 ± 23.8 vs 21.2 ± 16.3, P = .004) and AOS total scores (38.1 ± 24.1 vs 21.9 ± 15.5, P = .005) compared with the no-knee pain group. Both groups improved significantly from baseline across all outcome measures; however, the magnitude of improvement was less in the knee pain group. Our study demonstrated that over one-quarter of patients with end-stage ankle arthritis undergoing TAA present with ipsilateral concomitant knee pain. If present, it is associated with worse functional outcomes at the 5-year mark. Further studies are needed to evaluate if knee pain influences complications, implant failure rates, and survival. Levels of Evidence: Level III

scholarly journals Quality of Modern Total Ankle Arthroplasty Research

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0016
Author(s):  
Daniel Bohl ◽  
Emily Vafek ◽  
Simon Lee ◽  
Johnny Lin ◽  
George Holmes ◽  
...  
Keyword(s):  
Cohort Studies ◽  
Case Reports ◽  
Case Series ◽  
The United States ◽  
Total Ankle Arthroplasty ◽  
Ankle Arthritis ◽  
Level Of Evidence ◽  
Ankle Arthroplasty ◽  
End Stage

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is gaining popularity as an alternative to ankle arthrodesis in the setting of end-stage ankle arthritis. However, compared to hip and knee arthroplasty, there is a relative dearth of evidence to support its use. This study assesses the quality of literature surrounding modern TAA designs. Methods: A search of all peer-reviewed, English-language journals was conducted to identify publications involving TAA. The initial search identified 444 articles published during 2006-2016. Of these, 182 were excluded because they were not clinical outcomes studies, 46 because the TAA implant was no longer available, and 15 because the primary outcome of the study was not related to TAA, leaving 201 articles for analysis. Results: No Level I studies were identified. Seventeen (8%) studies were Level II, 48 (24%) Level III, 128 (64%) Level IV, and 8 (4%) Level V. One hundred forty-three studies (71%) were retrospective in nature. Stratification by study design revealed 128 (64%) case series, 33 (16%) experimental cohort studies, 19 (10%) case-control studies, 13 (6%) observational cohort studies, and 8 (4%) case reports. The number of studies published each year steadily increased from 2006 to 2016. A total of 51% of TAA research was published in only two journals: Foot and Ankle International and the Journal of Bone and Joint Surgery. Publications from the United States accounted for 36% of total publications. The most published implant was the Scandinavian Total Ankle Replacement (Figure 1). Conclusion: While the number of TAA studies published each year has steadily increased since 2006, the quality of this research as measured by level of evidence remains suboptimal. This analysis highlights the need for continued improvement in methodology and development of robust prospective registries to advance our knowledge of TAA as a treatment for end-stage ankle arthritis.

Short- to Midterm Follow-up of Cemented Total Ankle Replacement Using the INBONE II: A Retrospective Chart Review

2020 ◽  
pp. 193864002091312
Author(s):  
Gregory C. Berlet ◽  
Roberto A. Brandão ◽  
Devon Consul ◽  
Pierce Ebaugh ◽  
Christopher F. Hyer
Keyword(s):  
Case Series ◽  
Retrospective Chart Review ◽  
Total Ankle Arthroplasty ◽  
Ankle Arthritis ◽  
Retrospective Case ◽  
Ankle Arthroplasty ◽  
Major Complications ◽  
End Stage ◽  
Complications Rate

Background: Total ankle arthroplasty is a viable option for the treatment of end stage ankle arthritis. The purpose of this study is to report on the mid-term results with a cemented total ankle prosthesis, the Inbone™ II implant over a 5 year period. Methods: A retrospective, single-center chart and radiographic review of all patients with end stage ankle arthritis treated with Inbone™ II TAR) as the primary index procedure from 12/1/2012 to 3/1/2017. Clinical data were evaluated at 3 month, 6 month, 1 year and subsequent intervals for the study period. Preoperative diagnosis, pertinent patient demographics adjunctive procedures, implant associated complications, subsequent surgeries, and revisions were recorded. Results: 121 total ankles met our inclusion criteria. Patients had an INBONE™ II TAR implant placed with bone cement with a minimum of a 12 months follow up. Average age was 62.88 (range, 32-87) years, average body mass index was 32.74 (range, 21.8-56.04) kg/m2 and average follow up was 28.51(range, 12-69) months. Using the COFAS complication classification there were 14 minor, 11 moderate, and 5 major complications. 6/121 (5.0%) revisions which included: polyethylene exchange, device explant/fusion, and antibiotic spacer in situ. No complications over the course of this study ended in amputation. Conclusion: Total Ankle Arthroplasty utilizing the cemented INBONE™ II yielded good midterm results with regards to minor, moderate, and major complications. Rate of revision 6/121 (5.0%) was within the reported range with only 5 patients converted to fusion during the study period resulting in a 95% survivability at mid-term follow up. Levels of Evidence: Level IV: Retrospective case series

scholarly journals Total Ankle Arthroplasty with Simultaneous Versus Secondary Hindfoot Arthrodesis

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0047
Author(s):  
Michel Taylor ◽  
Elizabeth Cody ◽  
Mark Easley ◽  
Selene Parekh ◽  
James Nunley ◽  
...  
Keyword(s):  
Short Form ◽  
Total Ankle Arthroplasty ◽  
Functional Improvement ◽  
Foot And Ankle ◽  
Ankle Arthritis ◽  
Extensive Experience ◽  
Ankle Arthroplasty ◽  
Sf 36 ◽  
Outcome Scores ◽  
Hindfoot Arthrodesis

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) for ankle arthritis leads to a more normal gait pattern compared to ankle arthrodesis, prompting many to hypothesize that TAA slows development of adjacent joint arthrosis. However, following TAA, patients may also develop hindfoot pain, deformity and dysfunction, ultimately requiring arthrodesis procedures. Many patients with AA also have subtalar and/or talonavicular arthrosis. In these cases, simultaneous TAA and hindfoot arthrodesis may be performed. Previous studies have found that TAA in conjunction with hindfoot arthrodesis procedures led to inferior outcomes compared to isolated TAA. The purpose of this analysis was to compare the functional outcomes of simultaneous vs. subsequent hindfoot arthrodesis procedures and to describe the change, if any, in outcome scores following a subsequent hindfoot arthrodesis procedure. Methods: After receiving Institutional Review Board approval, the TAA database at our institution was reviewed for all TAA performed between 1998 and 2015. All patients who received a TAA and either a simultaneous or subsequent hindfoot arthrodesis with at least two years of clinical follow up were included in the analysis. All surgeries were performed by one of three fellowship-trained orthopaedic foot and ankle surgeons with extensive experience in TAA and associated hindfoot arthrodesis procedures. Outcome measures included preoperative and 2-year postoperative visual analog scale (VAS) scores, Short Musculoskeletal Function Assessment (SMFA), Short Form (SF)-36 and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores. Results: 64 patients met the inclusion criteria. 39 patients underwent TAA with simultaneous hindfoot arthrodesis (Sim) and 25 underwent a subsequent arthrodesis procedure (Sub) an average 22.2 months following TAA. 20 patients underwent double arthrodesis (11 Sub) and 44 patients underwent subtalar fusion (14 Sub). There were no differences in preoperative questionnaire scores between the two groups. Both the Sim and Sub groups experienced significant improvement in their postoperative VAS, SMFA, SF-36 and AOFAS scores. Postoperative VAS and SMFA bother scores were significantly lower for the Sim group (p<0.05). In the Sub group, there was no difference in outcome scores before and after the fusion procedure. Demographics and questionnaire scores are shown in the Table. Conclusion: These results support previous findings demonstrating significant functional improvement and decrease in pain scores following TAA and associated fusion procedures. However, these results also suggest that simultaneous fusion procedures may provide better reduction in pain when compared to sequential procedures. In addition, for patients who underwent subsequent fusion, the improvement experienced in terms of pain and function tends to be maintained postoperatively.

scholarly journals Tibial Torsion and Ankle Arthritis: Is External Tibial Rotation Associated with Varus Deformity in Patients with Ankle Arthritis?

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0002
Author(s):  
Collin C. Barber ◽  
Teresa Hall ◽  
Tyler Madden ◽  
Parin D. Kothari ◽  
Monica LaPointe ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Standard Deviation ◽  
Lower Extremity ◽  
External Rotation ◽  
Varus Deformity ◽  
Tibial Rotation ◽  
Tibial Torsion ◽  
Ankle Arthritis ◽  
Ankle Arthroplasty ◽  
The Mean

Category: Ankle; Ankle Arthritis; Hindfoot Introduction/Purpose: The effect of tibial torsion on lower extremity mechanical alignment has been well studied in the literature, including its effect on lower extremity osteoarthritis. It has been suggested that external tibial torsion is associated with cavus hindfoot deformity and may lead to varus osteoarthritis of the ankle. To our knowledge, there are no studies investigating this relationship. The purpose of this study is to characterize the relationship of tibial torsion with ankle coronal plane deformity in patients with ankle arthritis. Methods: The study is a retrospective, cohort of 223 patients who have undergone total ankle arthroplasty at a single institution. Preoperative computerized tomography was used to measure tibial torsion and coronal deformity. Descriptive statistics and regression analysis were used to analyze the data. Results: Descriptive analysis of all 223 patients demonstrated a maximum of 23.9 degrees varus and 20.5 degrees valgus among all patients. The mean for varus deformity was 6.86 degrees with a standard deviation of +- 6.39. Tibial rotation was calculated at an average of 20.8 degrees external rotation, with a maximum of 15.2 degrees internal rotation and 59.5 degrees external rotation in all patients. Plotting overall coronal ankle tilt versus tibial torsion revealed overall varus deformity with R2 of 0.016. Regression analysis of all varus deformities against external tibial torsion revealed a R2 of 0.02. Varus deformity 1 standard deviation above the mean against external tibial torsion demonstrated a R2 of 0.072. Valgus deformity against external tibial torsion revealed a R2 of 6.75 x10-5. Conclusion: An association between external tibial torsion and varus ankle arthritis has been proposed in the literature. The results of our study did not show an association between tibial torsion and coronal deformity in ankle arthritis in all patients undergoing total ankle arthroplasty at our institution. A difference may exist in certain subgroups, such as patients with neuromuscular disorders, but further investigation will be necessary to determine this relationship.

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