Study Finds Good Patient Satisfaction Two Years After TAR Procedure

A recent study in Acta Orthopaedica relates that patients are satisfied with their results after total ankle replacement (TAR).

Study authors examined the results of primary TAR in 241 patients from the Swedish Ankle Registry. Using patient reported outcome measures including Short Form 36, the study notes all absolute scores had improved by two years after ankle replacement. Researchers noted that 71 percent of patients said they were either satisfied or very satisfied with outcomes. The study authors also pointed out that positive outcomes were associated with older age while the prosthetic design had no association with outcomes.

Thomas Roukis, DPM, PhD, FACFAS, notes TAR offers the most improvement for patients when it comes to pain reduction in the ankle joint, improvement in function and improved ankle/hindfoot/midfoot range of motion.

Dr. Roukis says with a TAR, patients with a mobile but arthritic ankle joint and a globally stiff foot will predictably improve or maintain ankle movement, limit stress and associated mechanical pain to their midfoot/hindfoot joints, and have limited need for rocker sole modification in comparison to an ankle fusion. He adds that ankle replacement patients must accept the need for antibiotic prophylaxis, yearly surveillance clinic visits and radiographs for life as well as avoiding steep inclines/declines and uneven ground, and refraining from ballistic activities.

“Ultimately, the ‘best’ prosthesis is the one that allows for the greatest modularity, minimizes soft tissue dissection and bone resection, can be precisely implanted with a minimal learning curve, has been field tested with five- to 10-year outcome data, and has a dedicated revision system,” says Dr. Roukis, a Past President of the American College of Foot and Ankle Surgeons.

Jeffrey McAlister, DPM, notes TAR patients typically do well with pain but adds that this “heavily relies on the preoperative conversation regarding expectations.” He will explain to TAR patients that after a period of non-weightbearing and physical therapy, the range of motion will most likely be slightly improved and the pain relief will be significantly greater.

Historically, Dr. McAlister notes post-traumatic ankle arthritis and rheumatoid arthritis are some of the more common indications for TAR. These patients, who have been living with pain for a long period of time, “typically do very well and are extremely grateful for their replacement,” says Dr. McAlister, who is in private practice at the CORE Institute. He finds that his active retired patients do the best with TAR recovery and have the highest functional outcomes.

Dr. Roukis has not seen an appreciable difference between fixed- or mobile-bearing TARs, or those ankle replacements implanted from an anterior or lateral approach. He emphasizes the importance of the surgeon not extending the TAR indications beyond acceptable standards as well as identifying and managing the complications that are inherent to particular systems. Dr. McAlister has noted increased and more fluid range of motion with a mobile-bearing device but typically sees no differences in postoperative pain per se from a patient perspective.

“The best outcomes are in realistic patients who understand that replacement of the ankle joint does not cure the foot/ankle from all pathology since it does not address the ligaments, tendons and joint capsule that are all damaged with an arthritic ankle regardless of etiology,” emphasizes Dr. Roukis.

Can Topical Prophylaxis Prevent Onychomycosis Recurrence?

By Brian McCurdy, Managing Editor

Topical prophylaxis following antifungal treatment can reduce the recurrence of onychomycosis, according to a recent study in Dermatologic Therapy.

The authors conducted a retrospective chart review of 320 patients receiving either oral terbinafine (Lamisil, Novartis) or itraconazole (Sporanox, Bristol-Myers Squibb) for onychomycosis. After patients achieved complete cure, they used a topical antifungal weekly as prophylaxis. These topical antifungals included amorolfine, bifonazole, ciclopirox olamine or terbinafine spray. The study noted that in comparison to patients not using topical prophylaxis, recurrence was significantly lower in those using topical antifungal prophylaxis following oral terbinafine but was not lower in those using prophylaxis after itraconazole.

Tracey Vlahovic, DPM, finds topical prophylaxis to be key in certain patient populations, noting the longer the patient has had onychomycosis, the more difficult it is to treat. If she can achieve some or total clearing in those patients, she says topical prophylaxis is important whether or not she used oral medication as the initial treatment.

Although Warren Joseph, DPM, FIDSA, has for years advocated having a way to prevent recurrence after oral or even topical therapy, he says this study is the first to apply science to the idea.

Why did the prophylactic agents work better in patients who initially received terbinafine in comparison to itraconazole? Both Drs. Joseph and Vlahovic note terbinafine tends to be a more effective agent. Dr. Joseph adds that terbinafine may have had more of a “reservoir effect,” remaining in the nail unit for a longer period of time than itraconazole and still preventing recurrence.

Dr. Joseph emphasizes that when physicians are concerned about infection, they need to consider the epidemiology of that infection, addressing the host, the pathogen and the environment.

“Any treatment that reduces the organisms in the environment should be useful,” says Dr. Joseph, an infectious diseases attending podiatrist at Roxborough Memorial Hospital in Philadelphia.

To combat onychomycosis recurrence, patients should also consider the environment in the form of socks, shoes and showering, notes Dr. Vlahovic, a Clinical Associate Professor and J. Stanley and Pearl Landau Faculty Fellow at the Temple University School of Podiatric Medicine.

Adducted Forefoot Leads To Elevated Risk Of Jones Fractures

By Brian McCurdy, Managing Editor

An adducted foot posture is a risk factor for Jones fractures, according to a recent study.

The retrospective study, published in the Journal of Foot and Ankle Surgery, focused on 50 patients with acute Jones fractures and 200 control patients. Authors note the risk of Jones fractures is 2.4 times greater with an adducted forefoot posture, particularly the presence of metatarsus adductus, defined as more than 15 degrees of adduction on radiographs. Researchers noted that hindfoot alignment was a less important factor in Jones fractures.

Given that patients cannot avoid a congenital forefoot adduction, William Fishco, DPM, FACFAS, suggests reducing the risk of Jones fractures and/or generalized lateral column pain via sturdy shoe gear and foot orthotics. He notes that orthotics in patients with Jones fractures pronate the foot to offload the lateral column. This typically entails a valgus wedge on the lateral aspect of the orthotic from the heel to the end of the shell at the fifth metatarsal head, according to Dr. Fishco, a faculty member of the Podiatry Institute, who is in private practice in Phoenix.

Dr. Fishco emphasizes that the Jones fracture is a stress fracture caused by repetitive overloading of the fifth metatarsal, noting the injury may occur after a simple misstep. He says some patients with a Jones fracture have had stress on the lateral column for years “and the bone just gave way with a little twist.” Dr. Fishco says there is a high risk of Jones fractures in athletes, such as gymnasts or dancers, who experience repetitive loading of the foot. Athletes who perform repetitive cutting in cleats in sports such as football, soccer and baseball are at risk, and Dr. Fishco says basketball players are also at risk for Jones fractures due to play on a court surface.  

Dr. Fishco does not recommend a walking boot for Jones fractures. He notes that Jones fractures are hard to heal due to the tenuous blood supply to the bone and because most patients who have Jones fractures have lateral column overload, which will keep stressing the fracture site. He says non-surgical treatment consists of non-weightbearing for six weeks followed by a period of protected weightbearing in a fracture boot for four weeks. Dr. Fishco may order a bone growth stimulator for patients with Jones fractures, especially if there are risk factors for non-union such as smoking, diabetes, vitamin D deficiency and/or osteoporosis. In cases of delayed union or in the athlete patient population, he will consider surgery, including internal or external fixation techniques.