Kile, Todd A.

Background: The impact of obesity on outcomes following total ankle arthroplasty (TAA) remains unclear, with existing literature reporting mixed results. Although some studies have identified obesity as a risk factor for perioperative complications and poor clinical outcomes, others have found no significant association. Thus, the purpose of this study was to evaluate the association between obesity, across a range of body mass index (BMI) classifications, and postoperative complications after TAA. Methods: Patients undergoing primary TAA were identified from a large national insurance database. Individuals with a BMI ≥30 were identified and matched 1:1 to nonobese controls using propensity score matching based on demographics and comorbidities. Obese patients were further stratified into BMI categories: 30-34.9, 35-39.9, 40-44.9, and ≥45. Ninety-day complications and 2-, 5-, and 10-year surgery-specific outcomes were assessed. Odds ratios (ORs) with 95% CIs and Kaplan-Meier survival analyses were used to evaluate complication risks. Results: After matching, 3364 patients were included in each cohort. No significant differences in 90-day complication rates were observed for patients with BMI 30-44.9 compared with controls. Patients with BMI ≥45 had increased risk of surgical site infection (OR 2.21, 95% CI 1.29-3.79, P = .003), emergency department visits (OR 1.43, 95% CI 1.04-1.96, P = .025), and readmissions (OR 2.31, 95% CI 1.47-3.63, P < .001). The pooled 90-day complication rate was significantly higher in this group as well (12.9% vs 7.6%, OR 1.77, 95% CI 1.26-2.48, P < .001). At 10-year follow-up, Kaplan-Meier analysis demonstrated that patients with a BMI ≥45 had a higher risk of periprosthetic joint infection (PJI compared with controls (hazard ratio 1.75, 95% CI 1.07-2.85, P = .03). Patients with BMI 30-34.9 had a significantly lower risk of aseptic loosening at both 5 years (OR 0.68, 95% CI 0.49-0.94, P = .019) and 10 years (OR 0.65, 95% CI 0.48-0.88, P = .005). Conclusion: BMI ≥45 was associated with higher all-cause health care utilization, including emergency department visits and hospital readmissions, as well as higher long-term risk of PJI following TAA. Level of Evidence: Level III, retrospective cohort study.

Background: The purpose of this study was to investigate the association between cannabis use and postoperative complications following ankle and hindfoot arthrodesis. Methods: A retrospective cohort study using a large national insurance database from 2010 to 2022 was conducted. All patients who underwent ankle or hindfoot arthrodesis with at least 2 years’ follow-up were included. Patients were divided into 4 groups: cannabis-only users, tobacco-only users, cannabis and tobacco users, and nonuser controls. Groups were matched 1:4 with nonuser controls based on demographic variables and comorbidities. Also, both cannabis and tobacco users were matched 1:4 with tobacco-only users based on demographics and comorbidities. Medical complications within 90 days of surgery and surgery-specific complications within 2 years were compared between groups with multivariable logistic regressions. Results: Compared with nonuser controls, cannabis users only were not at increased risk of 90-day medical complications or 2-year surgical complications. Tobacco use alone was associated with increased risk of postoperative admission (OR 1.32, 95% CI 1.21-1.43) and emergency department (ED) utilization (OR 1.57, 95% CI 1.48-1.66) within 90 days as well as infection (OR 1.24, 95% CI 1.18-1.30), hardware removal (OR 1.12, 95% CI 1.07-1.18), nonunion (OR 1.33, 95% CI 1.27-1.40), and wound dehiscence (OR 1.38, 95% CI 1.27-1.49) within 2 years of surgery compared with nonuser controls. Compared with tobacco-only use, combined cannabis and tobacco use was associated with increased risk of ED visits within 90 days (OR 1.45, 95% CI 1.30-1.62) and nonunion within 2 years of surgery (OR 1.19, 95% CI 1.05-1.35). Conclusion: These findings suggest that although cannabis use alone was not associated with a higher risk of postoperative complications, its concurrent use with tobacco was linked to greater rates of adverse outcomes. Level of Evidence: Level III, retrospective case control study.

Background: Ankle injuries are more common in the National Basketball Association (NBA) compared with other professional sports. Purpose/Hypothesis: The purpose of this study was to report the incidence and associated risk factors of ankle injuries in NBA athletes. It was hypothesized that factors associated with an increased physiologic burden, such as minutes per game (MPG), usage rate, and associated lower extremity injury, would be associated with increased ankle injury risk and time loss. Study Design: Descriptive epidemiology study. Methods: Ankle injury data from the 2015-2016 through 2020-2021 NBA seasons were evaluated. The truncated 2019-2020 season due to the COVID-19 pandemic was omitted. The primary outcome was the incidence of ankle injuries, reported per 1000 game-exposures (GEs). Secondary analysis was performed to identify risk factors for ankle injuries through bivariate analysis and multivariable logistic regression of player demographic characteristics, performance statistics, injury characteristics, and previous lower extremity injuries. Factors influencing the time loss after injury were assessed via a negative binomial regression analysis. Results: A total of 554 ankle injuries (4.06 injuries per 1000 GEs) were sustained by NBA players over 5 NBA seasons, with sprain/strain the most common injury type (3.71 injuries per 1000 GEs). The majority of ankle injury events (55%) resulted in 2 to 10 game absences. The likelihood of sustaining an ankle injury was significantly associated with a greater number of games played ( P = .029) and previous injury to the hip, hamstring, or quadriceps ( P = .004). Increased length of absence due to ankle injury was associated with greater height ( P = .019), MPG ( P < .001), usage rate ( P = .025), points per game ( P = .011), and a prior history of foot ( P = .003), ankle ( P < .001), and knee injuries ( P < .001). Conclusion: The incidence of ankle injuries was 4.06 per 1000 GEs in professional basketball players. Games played and prior history of hip, hamstring, or quadriceps injuries were found to be risk factors for ankle injuries. Factors associated with physiologic burden such as MPG and usage rate were associated with an increased time loss after injury.

AbstractOsteochondral lesions (OCLs) in the ankle are more common than OCLs of the foot, but both share a similar imaging appearance. Knowledge of the various imaging modalities, as well as available surgical techniques, is important for radiologists. We discuss radiographs, ultrasonography, computed tomography, single-photon emission computed tomography/computed tomography, and magnetic resonance imaging to evaluate OCLs. In addition, various surgical techniques used to treat OCLs—debridement, retrograde drilling, microfracture, micronized cartilage-augmented microfracture, autografts, and allografts—are described with an emphasis on postoperative appearance following these techniques.

Abstract Postoperative ankle imaging requires knowledge of the underlying surgical techniques, the usefulness of various imaging modalities, as well as an appreciation for the desired clinical outcomes. Surgical procedures discussed in this article are tibiotalar fracture fixation, tibiotalar, subtalar, and tibiotalocalcaneal arthrodesis, total ankle arthroplasty, talar osteochondral lesion repair and grafting, lateral ligamentous repair and reconstruction, and peroneal and Achilles tendon repair and reconstruction. Imaging can play a vital role in determining if the expected outcome has been achieved and identifying complications, with particular emphasis placed on the use of radiographs, computed tomography (including weight-bearing), magnetic resonance imaging, and ultrasonography.

In the setting of below-knee amputation, compartment syndrome is a rare complication. Early clinical symptoms of an acute compartment syndrome following below-knee amputation can mimic or be masked by postoperative pain management. We present the case of a 38-year-old male with a significant past medical history of Proteus syndrome who underwent an elective transtibial below-knee amputation. Following surgery, the patient had extensive postoperative pain and high pain medication requirements and returned to the operating room for irrigation and debridement due to suspicion of an infection. Upon return to the operating room to manage the infection, the necrotic tissue was discovered and removed which had developed due to a suspected missed acute compartment syndrome. The necrotic tissue secondary to the compartment syndrome subsequently resulted in infection. Multiple irrigation and debridement procedures were performed to further manage the infection, and ultimately, the patient was deemed stable for discharge. Acute compartment syndrome (ACS) following below-knee amputation (BKA) is a rarely documented but critical complication. This case describes the unique setting in which a compartment syndrome can be masked due to postoperative pain management and infection. Orthopedic surgeons should be aware of the varying risk factors and presentations of an acute compartment syndrome (ACS) as it can occur and is a devastating complication.

Background: Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time. Purpose: To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus. Study Design: Descriptive laboratory study. Methods: Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated. Results: Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm 2 (95% CI, 13.3-14.7 cm 2 ), while the mean area visible via an open approach was 2.1 cm 2 (95% CI, 0.5-3.6 cm 2 ). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%). Conclusion: These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate. Clinical Relevance: Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

Background: While anemia has been associated with poor surgical outcomes in total knee arthroplasty and total hip arthroplasty, the effects of anemia on total ankle arthroplasty remain unknown. This study examines how preoperative anemia affects postoperative outcomes in total ankle arthroplasty. Methods: A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from 2011 to 2018 for total ankle arthroplasty procedures. Hematocrit (HCT) levels were used to determine preoperative anemia. Results: Of the 1028 patients included in this study, 114 patients were found to be anemic. Univariate analysis demonstrated anemia was significantly associated with an increased average hospital length of stay (2.2 vs 1.8 days, P < .008), increased rate of 30-day readmission (3.5% vs 1.1%, P = .036), increased 30-day reoperation (2.6% vs 0.4%, P = .007), extended length of stay (64% vs 49.9%, P = .004), wound complication (1.75% vs 0.11%, P = .002), and surgical site infection (2.6% vs 0.6%, P = .017). Multivariate logistic regression analysis found anemia to be significantly associated with extended hospital length of stay (odds ratio [OR], 1.62; 95% CI, 1.07-2.45; P = .023) and increased reoperation rates (OR, 5.47; 95% CI, 1.15-26.00; P = .033). Anemia was not found to be a predictor of increased readmission rates (OR, 3.13; 95% CI, 0.93-10.56; P = .066) or postoperative complications (OR, 1.27; 95% CI, 0.35-4.56; P = .71). Conclusion: This study found increasing severity of anemia to be associated with extended hospital length of stay and increased reoperation rates. Providers and patients should be aware of the increased risks of total ankle arthroplasty with preoperative anemia. Level of Evidence: Level III, retrospective comparative study.

Background: Patients diagnosed with melanoma of the foot have been reported to have a poor prognosis. We reviewed our experience at a tertiary-care medical clinic to determine the disease course in patients diagnosed with melanoma of the foot. Methods: A retrospective review was performed of 38 patients with a diagnosis of primary or locally recurrent melanoma of the foot treated between January, 1988, and July, 2004. The main outcome measures included methods of diagnosis, clinical and histopathologic features, and patterns of recurrence. Results: The mean age at diagnosis was 61 years; most were women (58%) and Caucasian (95%). The average time to diagnosis was 17 months. Initial clinical diagnosis had been considered benign in 12 (32%). The median Breslow thickness was 1.75 mm, T1 lesions were the most common, and acral lentiginous melanoma accounted for 42%. Thirteen patients (34%) had ulcerated lesions. Sentinel lymph node biopsy specimens of 25 patients identified four (16%) with metastatic disease. Surgical complications occurred in 12 patients, usually after skin graft or soft-tissue flap reconstruction. Systemic recurrence developed in six patients, four of whom also had regional recurrence. Conclusions: Most patients were elderly Caucasian women and most presented with early-stage disease, but diagnosis can be difficult and a subgroup presented with thick melanomas. Reconstructive surgical procedures had a high rate of complications; however, overall functional outcomes were good. Stage of cancer at diagnosis was associated with systemic metastases.

Background: The purpose of this study was to determine safety and efficacy of lateral transtendinous popliteal blocks performed after induction of general anesthesia for intraoperative and postoperative pain control in elective foot and ankle surgery. Methods: The charts of 475 consecutive patients were retrospectively reviewed. The technique was a lateral transtendinous popliteal block under nerve stimulator direction (described in the text). Patient records were retrospectively evaluated from the postanesthesia care unit, as well as at followup on postoperative day 1 and weeks 2, 6, and 12. Results: The block was complete in 398 patients (83.7%). An incomplete block was found in 77 patients (16.2%). In the incomplete category, 21 patients (4.4%) had no pain but some motor function, 32 patients (6.5%) reported mild to moderate pain, and 24 patients (5.3%) had severe pain. The average block duration was 16.5 hours. There were no adverse effects documented in any patient at followup. Conclusions: Lateral popliteal nerve block after induction of general anesthesia appears to be safe and effective for intraoperative and postoperative pain control in elective foot and ankle surgery.