Lopez, Ramiro

Background Supination-external rotation (SER) variant ankle fractures can have unstable injury patterns indicating surgical treatment. Medial clear space (MCS) on 2-dimensional radiographs is often variable, and validity of this measurement is argued. Recently, lateral talar subluxation (LTS) has been posed to be a more specific measurement than MCS likely because the pattern of injury is an external rotation pivoting displacement mechanism. However, there have been no studies using computed tomography (CT) scans to investigate the 3-dimensional talar displacement with this novel measurement. This axial rotation measurement of the talus may be a better measure than current standards, as the rotational component of these ankle fractures is underestimated. Methods This study is a retrospective review that initially identified 158 patients with unstable (SER IV) bi- or trimalleolar ankle fracture variants with injury radiographs and CT scans over a consecutive 10-year period from 2013 to 2023. Standardized measurements of radiographic MCS and LTS were acquired as well as CT scan measurements of the axial MCS, axial LTS, and a novel measurement of axial rotation angle, which is the amount of talar rotatory fracture deformity relative to the tibia. Coronal MCS and coronal LTS were also measured (Figure 1). Ultimately, 20 patients fit our inclusion criteria. The primary outcome measure investigated was the degree of external rotation of the talus in SER IV patterns. Secondary outcomes were other measurement surrogates and their correlations. Regression analysis was performed to predict the amount of rotational displacement by MCS or LTS abnormalities. Post hoc power analysis was subsequently performed. Results The mean axial rotation angle was noted to be 6.20 ± 3.79 degrees in external rotation. Axial MCS and axial LTS were 3.64 mm ± 1.10 mm and 2.20 mm ± 1.41 mm, respectively. Coronal MCS and coronal LTS were 3.15 mm ± 1.28 mm and 1.08 mm ± 1.61 mm, respectively. There were significant correlations between both MCS and LTS with respect to talar external rotation on axial CT (r = 0.85 and 0.78, respectively). Regression analysis predicted that for each 1 mm of MCS increase, there are 1.5 degrees of increased talar external rotational displacement. Similarly, for every 1 mm LTS increase, there are 2 degrees of talar external rotational displacement. Conclusion Lateral talar subluxation has previously been described as a useful measurement tool in identifying ankle instability and the potential need for surgical intervention. However, plain radiographs have limitations as the talus undergoes displacement in 3-dimensional positional planes. Using CT imaging, we found that both increased MCS and increased LTS positively correlated with increased talar external rotational as well as other displacement surrogates. There may be unrecognized rotational displacement that persists after SER ankle fracture injury, and careful consideration should be given by the surgeon for this phenomenon. Level of Evidence: Level III, retrospective cohort study

Background: Ankle arthroscopy (AA) is a commonly used operative technique to diagnose and treat a variety of intraarticular pathologies of the ankle joint. In AA, 2 portals are commonly established to achieve visualization of the joint: the anteromedial (AM) and anterolateral (AL) portals. However, the superficial peroneal nerve (SPN) runs near the anterolateral portal site; thus, creation of the AL portal is associated with neuropraxic injuries to the SPN. When AA is combined with additional procedures, such as a Brostrom-Gould ligament repair or open reduction internal fixation (ORIF), the use of a direct lateral incision is required. We present a novel approach to combining AA with lateral adjunct procedures which avoids creation of the AL portal; the AM portal and lateral incision are used for instrumentation instead. The primary objective of this study is to compare complication rates, such as SPN injury, between the lateral incision (LI) approach and conventional arthroscopy plus a lateral incision approach. Methods: Following IRB approval, a retrospective chart review was conducted spanning a time frame from January 2020 to October 2024. Patients were included if they underwent AA plus either a Brostrom-Gould repair or ORIF (AA+) or if they underwent AA plus adjunct procedures using the lateral portal instrumentation method (LI). Ninety-four patients were initially identified; 2 were excluded per criteria. Demographic information, intraoperative details, and any postoperative complications or reoperations were recorded. Descriptive statistics were used to describe demographics and operative data, and 2-tailed Student t tests were used to identify statistical differences between group metrics. Results: Ninety-two patients were included in the study. No statistical differences were observed between cohorts in either of the intraoperative metrics considered (procedural duration and tourniquet duration; P = .44 and .89, respectively). In addition, complication and reoperation rates were not statistically different between the LI and AA+ groups ( P = .94 and .40, respectively). The rate of SPN neuropathy or neurapraxia were also compared between groups, resulting in no statistical differences ( P = .37). Conclusion: In this retrospective cohort study, we observed no differences when only anteromedial and lateral portals are used for an ankle arthroscopy with adjunct procedures compared with the traditional 3-incision approach. We hypothesize that instances of infection or wound dehiscence would decrease given a large enough cohort because of the creation of 1 fewer portal. However, given the small, underpowered sample, we cannot determine whether the lateral approach alters complication risk; larger multicenter studies are needed. Level of Evidence: Level III, retrospective cohort study.

Background: Total ankle arthroplasty (TAA) using patient-specific instrumentation (PSI) has increased in popularity with evidence for decreased operative duration, fluoroscopy usage, and increased implant placement accuracy. To date, no comparisons have verified the accuracy of PSI in vivo using preoperative and postoperative weightbearing computed tomography (WBCT). Our study aims to supplement the literature by quantifying the accuracy and precision of PSI-guided implant positioning using WBCT. The primary study outcome is to identify positioning deviations in degrees or millimeters in any plane for talus and tibial PSI-guided resections and subsequent implant placement. Secondary outcomes were correlation and regression analyses performed to identify variables that correlate to resection or implant placement deviation, as well as comparison to existing radiography-based PSI techniques. Methods: This was a single-surgeon, single-implant consecutive patient retrospective study where preoperative and postoperative WBCTs were obtained. TAA was performed by the senior author with the same low-profile implant for all cases. Talus and tibial resection analysis was performed in computer-automated fashion on postoperative segmented WBCTs and is described as 3 possible deviations from plan (cut height in millimeters, sagittal slope, varus/valgus deviation). Overall deformity in this group was not severe. Implant placement factors independent of PSI guides are described as center-of-mass translations (mm) and axial rotation (degrees). Desired accuracy for the PSI system was within ±2 mm or ±2 degrees of the preoperative plan. Statistical analysis of data collected included Student t test and linear regression analyses. Results: Thirty patients were included. Four talus implants were excluded per intraoperative surgeon discretion (deviation from PSI plan, use of conventional instruments). All postoperative tibial measurements were within the desired limits, except for mediolateral center of mass positioning ( P = .003) and slope ( P = .013). Two of six talar parameters also diverged from preoperative measurements: axial rotation ( P = .015) and anteroposterior positioning ( P = .002). In addition, no correlations exceeding r = 0.5 were noted between preoperative deformity measurements and postoperative positioning. Conclusion: For the 26 ankles that did not require an intraoperative deviation from PSI plan and/or use of conventional instruments, total ankle replacement performed with PSI using WBCT results in component placement with relatively little deviation from the preoperative plan. In addition, the lack of correlation between preoperative deformity and implant placement suggests that the magnitude of preoperative deformity in this group was not associated with the accuracy of PSI-guided component positioning. Level of Evidence: Level III, retrospective cohort study.

Background: End-stage ankle arthritis is successfully treated with surgery with either ankle arthrodesis (AA) or total ankle arthroplasty (TAA). Much is described comparing the 2 treatments in tightly selected patient groups. Limited evidence attempts to examine specific elements of technical complexity that increase perioperative risk for the surgical treatment of ankle arthritis. There is suspicion that AA may be preferable in the setting of elevated patient complexity, or that procedures may require staging to diminish complication risk when there is also foot deformity present. The aim of this study is to evaluate the effect of adjunctive procedures on overall postoperative complication (POC) risk, for both TAA and AA. Primary outcome measures were to compare overall complication and reoperation risk for TAA and AA. Secondary outcome measures were to identify patient factors, intraoperative factors, and factors of procedural complexity via number of associated surgeries and the incidence of complications and reoperation. Methods: A retrospective chart review of AAs and TAAs performed at a single academic institution from the years 2008-2024 was performed using Current Procedural Terminology ( CPT ) codes identifying AA and TAA. Patient demographics, operative details, and postoperative data were abstracted to collect relevant information. Statistical analyses, including odds ratios and analysis of variance, were then performed to reveal specific risk factors and correlations. Results: Four hundred ninety-one patients were identified in the initial database query. After exclusions, 246 remained, of which 110 underwent AA and 136 underwent TAA. The mean length of follow-up was 36.4 months for TAA patients and 46.1 months for AA patients in this study. Overall, patients who underwent TAA were older and had an increased number of preoperative comorbidities (5.74 ± 3.07) compared to AA (4.74 ± 2.76) ( P = .008). Additionally, TAA patients experienced a lower overall rate of POCs (20/136, 14.71%) and reoperation (14/136, 10.29%) compared with patients who underwent AA (21/110, 19.09%; 21/110, 19.09%) ( P = .36 and P = .05, respectively). As the number of adjunctive procedures increased, so did the rate of POCs, but not reoperation, in patients who underwent TAA. The number of adjunctive procedures was not significantly associated with complication or reoperation risk in AA patients. There were no specific adjunctive procedures that demonstrated a significant correlation with increased risk of complications or reoperation in both groups. Osteoporosis and coagulopathies were identified as predisposing TAA patients to postoperative complications. Conclusion: In our retrospective cohort study with relatively low statistical power, we found that patients who undergo TAA or AA plus adjunctive procedures did not experience an increased risk of major complications or reoperation compared to patients who did not undergo adjunctive procedures. Several preexisting comorbidities in TAA patients were associated with higher rates of POCs or reoperation, including osteoporosis and coagulopathies; no comorbidities were linked to increased reoperation or POC risk in the AA group. These findings suggest a need to evaluate comorbidities, and lifestyle factors when recommending an ankle reconstruction procedure to minimize the odds of postoperative complications and improve likelihood of patient satisfaction. Level of Evidence: Level III, retrospective cohort study.

Background: Total knee arthroplasty (TKA) and hindfoot reconstruction (HFR) are often used to treat osteoarthritis and deformities of the knee and hindfoot. Despite the proven clinical effectiveness of these treatments, postoperative patient dissatisfaction is high. The knee and ankle are adjacent joints in the lower extremity, and angular deformity of either joint is known to affect positioning of the anatomical and mechanical axes of the entire limb. Although it is understood this relationship exists, there are limited studies evaluating outcomes of ipsilateral procedures on patients with pathologies of both knee and hindfoot. This article aims to evaluate whether TKA or TAA/HFR sequencing influences postoperative outcome. The study hypothesis is that TKA prior to TAA/HFR results in lower reoperation. Methods: A retrospective chart review using Current Procedural Terminology ( CPT ) codes was performed encompassing all patients who underwent TKA in conjunction with a variety of hindfoot procedures. All procedures were performed at a single academic medical site between 2000 and 2022. Exclusion criteria included those patients not having both ipsilateral TKA and hindfoot procedures or those lacking conclusive postoperative data. The primary outcome of this study was to identify significant reoperations such as adjacent joint arthrodeses, hardware removal, or unrelated ipsilateral limb surgery. Secondary outcomes included identification of revision procedures including revision TKA or revision HFR and other postoperative complication data. Results: This study included 158 patients, with 79 patients in each group. In the TKA-first group, the mean follow-up time was 10.24 years (range, 1.10-22.42 years) and the mean time to HFR was 5.94 years. In the HFR-first group, the mean follow-up time was 9.01 years (range, 1.01-23.55 years) and the mean time to TKA was 5.51 years. In patients who underwent TKA first, the mean reoperation rate was not significantly different from those who underwent HFR/TAA first, 30.4% vs 19.0% ( P = .12). In patients who underwent TKA first, the rate of HFR reoperations (22.78%) was greater than TKA reoperations (7.59%) ( P < .01). The revision rate was higher in the TKA-first group (17.7%) when compared to the HFR-first group (6.3%) ( P = .03). Additionally, there were more revision HFR procedures in the TKA-first group (9/79) compared with the HFR-first group (1/79) ( P = .009). Conclusion: In contrast to the study hypothesis that TKA first would result in less reoperation, our study found that TAA or HFR performed before TKA had an overall lower complication rate. However, these findings should be interpreted cautiously as the sample size was limited. Level of Evidence: Level III, retrospective cohort study.