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.

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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.

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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 (PF CAT) or Lower Extremity Computerized Adaptive Test (LE CAT), which can be assessed with other domains such as Pain Interference. In addition, a disease-specific measure can be used when available.

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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.

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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.

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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.

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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.

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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.
  

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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.
 

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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.

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