Outcomes of intra-articular calcaneal fractures: surgical treatment of 114 consecutive cases at a maximum care trauma center

Background The aim of this retrospective monocentric study was to investigate the outcomes of surgically treated intra-articular calcaneus fractures in a maximum care trauma center. Methods One hundred forty patients who had undergone surgery for intra-articular calcaneal fractures between 2002 and 2013 were included. One hundred fourteen cases with 129 fractures were eligible to participate in the study of which 80 were available for a clinical and radiological follow-up. 34 patients were followed up by telephone interview only. Outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, Short Form 36 Health Status Survey (SF-36), complications, and subsequent surgeries. Results Mean follow-up was 91 months (range 12–183). The overall complication rate was 29% (37/129 ft). Disturbed wound healing (11%) and infection (5%) occurred most commonly. Non-union (4%) only occurred in smokers (p = 0.02). A high rate of posttraumatic subtalar arthritis (77%) and need for subsequent subtalar fusion (18%) without independent risk factors for subsequent subtalar fusion was found. The revision rate was high (60%) after primary fusion. Mean AOFAS-hindfoot score was 74 (Sanders I: 99, Sanders II: 74, Sanders III: 77, Sanders IV: 70). The postoperative Boehler angle improved significantly in all subgroups (p < 0.01). Patients with a decreased Boehler angle between postoperative images and the follow-up had significantly lower AOFAS hindfoot scores (p < 0.01). Conclusions Our data can aid decision-making in the treatment of calcaneal fractures. We advocate to use primary subtalar fusion with caution due to the high revision rate. Smoking status should always be considered. Level of evidence: Level III, retrospective cohort study.

Novel Measurement Technique for Talar Height Assessment in Total Ankle Arthroplasty

Category: Ankle Arthritis; Other Introduction/Purpose: Talar and calcaneal height have been identified as important not only to the biomechanics of ankle joint function but of the adjacent joints of the hindfoot as well. Many proposed measurement systems have been introduced to the literature to assess talar height in ankle arthroplasty, but have significant shortcomings. The malleoli frequently develop osteophytes after total ankle arthroplasty. If the subtalar joint is fused or arthritic, methods relying on landmarks such as the angle of Gissane are similarly unreliable. Lastly, subsidence is often asymmetrical. Measuring from the highest point of the talar component may not be reflective of functional talar height. We propose using adjusted talocalcaneal height to assess the functional restoration of talar height. Methods: Pre and post-operative radiographs and weight bearing computed tomography (WBCT) were reviewed for 40 cases of failed total ankle arthroplasty undergoing revision. Bony landmarks were assessed for consistency over a time course of two to four years post operatively. Talocalcaneal height was measured along from the center of the tibial component of ankle arthroplasty on weight bearing lateral radiographs and on sagittal and coronal reconstructions on WBCT (fig 1). Measurements on radiographs and WBCT were compared for agreement. For implants where lateral radiographs could not be used (AgilityTM, Depuy), sagittal and coronal WBCT was used. Results: Average adjusted talocalcaneal height as measured on lateral radiographs, sagittal WBCT, coronal WBCT, and averaged values from sagittal and coronal WBCT was 68mm, 67.4mm, 68.5mm, and 68mm respectively. There was not a significant difference between the lateral radiographs and WBCT measurement methods (p= 0.30, 0.37, 0.46), and correlation was 0.99 for all methods. Measurements did not vary in cases of angular subsidence or subtalar fusion. Conclusion: Adjusted talocalcaneal height is a reproducible and reliable measurement to assess talar height. It accommodates procedures frequently performed in tandem with total ankle arthroplasty such as calcaneal osteotomy and subtalar fusion. It relies on a single, static bony landmark, and remains valid in cases of asymmetric subsidence. Lastly, it incorporates calcaneal height, which affects not only ankle joint mechanics but adjacent joint mechanics as well.

Total Ankle Arthroplasty (TAR) vs. Ankle Arthrodesis (AA) for Primary Ankle Osteoarthritis: A Nationwide Analysis

Category: Ankle Arthritis; Ankle Introduction/Purpose: Ankle arthrodesis (AA) has historically been the gold standard for operative management of end-stage ankle osteoarthritis (OA). Recent increases in utilization of total ankle arthroplasty (TAR) have been observed secondary to new implant designs, improved surgical technique, and favorable functional outcomes. However, there is minimal data comparing clinical complications between the two procedures. The purpose of this study was to compare incidences of postoperative joint and systemic complications for patients that received primary AA vs. TAR for primary ankle osteoarthritis between 2007-2017 using a comprehensive Medicare database. Methods: A retrospective review of patients that received primary AA or TAR was performed using the PearlDiver database (Fort Wayne, IN). All patients and associated complications were identified using ICD-9/ICD-10 and CPT codes. Patients with a history of ankle fracture, prior AA/TAR, or active ankle infection during the index procedure were excluded. Demographic data and overall joint complication rates were compared at 90-days, 1-year, and 2-years postoperatively using a Chi-Square test. Postoperative rates of subtalar fusion, prosthetic joint infection, hardware removal, periprosthetic fracture, and systemic complications were compared using logistic regression. Statistical significance was set at p < 0.05. Results: A total of 1,580 patients received operative management of primary ankle OA: 1,100 (70%) patients received AA and 480 (30%) patients received TAR. The overall joint complication rate was higher in the AA group at 90-days (30% vs. 17%, p < 0.001), 1-year (36% vs. 21%, p < 0.001), and 2-years (38% vs. 22%, p < 0.001) post-discharge. AA patients were more likely to have a subsequent subtalar fusion at 90-days (OR 4.49), 1-year (OR 5.10), and 2-years (OR 5.36) post-discharge, as well as periprosthetic fracture at 1-year (OR 1.69) and 2-years (OR 1.77). Hardware removal was less likely for AA patients at 90-days (OR 0.43), 1-year (OR 0.41), and 2-years (OR 0.43). Neither group was more likely to develop systemic complications postoperatively. Conclusion: The present study found that AA patients have higher incidences of major joint complications in both the short- term and mid-term. Patients that received AA were more likely to have a subsequent subtalar fusion and sustain a periprosthetic fracture. Relative to TAR patients, a greater proportion of these patients were under the age of 65, obese, had diabetes, and used tobacco. TAR patients were more likely to have hardware removal post-discharge. Further study is warranted to better quantify patient selection for AA vs. TAR and trend the long-term complications of these procedures.

Subtalar Fusion for Correction of Forefoot Abduction in Stage II Adult-Acquired Flatfoot Deformity

Background Correction of talonavicular uncoverage (TNU) in adult-acquired flatfoot deformities (AAFD) can be a challenge. Lateral column lengthening (LCL) traditionally is utilized to address this. The primary study objective is examining stage II AAFD patients and determining if correction can be achieved with subtalar fusion (STF) comparable to LCL. Methods Following institutional review board approval, retrospective chart review performed identifying patients meeting criteria for stage IIB AAFD who underwent either STF with concomitant flatfoot procedures (but not LCL) to correct TNU, or who underwent LCL as part of their flatfoot reconstruction. Patients indicated for STF had one or more of the following: higher body mass index (BMI), were older, had greater deformity, lateral impingement pain, intraoperative spring ligament hyperlaxity. Patients without 1-year follow-up or compete records were excluded. All other patients were included. A total of 27 isolated STFs identified, along with 143 who underwent LCL. Pre-/postoperative radiographic parameters obtained as well as PROMIS (Patient-Reported Outcomes Measurement Information System) and FAOS (Foot and Ankle Outcome Score) scores. Radiographic and patient reported outcomes both preoperatively and at 1-year follow-up evaluated for both groups. Results STF patients were older ( P < .05), with higher BMIs ( P < .004). STF had significantly worse TNU ( P < .001) than LCL patients, and average change in STF TNU was larger than LCL change postoperatively ( P = .006), after adjusting for age, BMI, gender. PROMIS STF improvement reached statistical significance in Physical Function (P 0.011), for FAOS Pain (P 0.025) and Function ( P = 0.04). Conclusions STF can be used in appropriately indicated patients to correct flatfoot deformity without compromising radiographic or clinical, correcting not only hindfoot valgus, but also talonavicular uncoverage (TNU) and corresponding medial arch collapse. Levels of Evidence: Level III: Retrospective chart review comparison study (case control)