Faculty Bibliography

BACKGROUND:Total ankle arthroplasty (TAA) provides pain relief and motion preservation for end-stage ankle arthritis, yet outcomes and utilization vary widely. Social determinants of health (SDOHs) such as socioeconomic, demographic, and behavioral factors may contribute to these disparities, but their influence on TAA has not been systematically evaluated. METHODS:A systematic review was registered on PROSPERO (CRD420251156933) and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PROGRESS-Plus framework to identify studies examining the impact of SDOH on TAA utilization and outcomes. PubMed, Embase, and Scopus were searched through 2025. Study quality was assessed with the Risk Of Bias In Nonrandomized Studies of Interventions tool, and certainty of evidence for each domain was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation framework. Data were synthesized narratively with random-effects meta-analysis where feasible. RESULTS:Forty-four studies including more than 200,000 patients were analyzed. Social determinants were found to influence both access to TAA and postoperative outcomes. Men demonstrated slightly better postoperative function, whereas women reported more pain and higher rates of nonhome discharge. Older patients experienced more perioperative complications but achieved similar long-term implant survival compared with younger cohorts. Patients from minority racial and ethnic groups had higher complication rates and were less likely to receive TAA compared with arthrodesis. Lower income, public insurance, and treatment in rural or lower-volume hospitals were consistently linked with reduced access to TAA, longer hospital stays, and greater healthcare costs. Behavioral factors such as smoking and preoperative opioid use were strongly associated with wound complications, prolonged hospitalization, and poorer recovery. CONCLUSION/CONCLUSIONS:SDOH significantly shape access to surgery, complication risk, and recovery after TAA. Recognition of these influences and targeted strategies such as preoperative optimization, equitable referral pathways, and improved access to rehabilitation may help reduce disparities and improve outcomes in ankle arthroplasty. LEVEL OF EVIDENCE/METHODS:Level III, systematic review of predominantly Level III studies.

BACKGROUND:Patient-specific instrumentation (PSI) has been proposed to improve accuracy and efficiency in total ankle arthroplasty (TAA). Although cadaveric studies suggest improved precision, the clinical value of PSI over standard instrumentation (SI) remains uncertain. METHODS:A systematic review and meta-analysis following PRISMA guidelines was performed using PubMed, Embase, and Cochrane databases through July 2025. Comparative studies evaluating PSI vs SI in TAA were included. Outcomes analyzed included patient-reported outcome measures (PROMs), radiologic alignment, intraoperative efficiency, complication and revision rates, and cost. Random effects models were used to pool standardized or mean differences (MDs) or risk ratios with 95% CIs. RESULTS: < .001). No statistically significant differences were detected in complication and revision rates. Cost analysis produced conflicting results, with one study suggesting potential savings and another finding PSI more expensive after accounting for preoperative imaging. CONCLUSION/CONCLUSIONS:PSI in TAA reduces fluoroscopy time but does not appear to enhance functional outcomes, complication rates, or revision risk compared with SI in the short term. PSI may result in greater deviation from sagittal alignment, and its cost-effectiveness remains uncertain. High-quality prospective studies with long-term follow-up are needed to clarify its role in routine and complex cases.

Graphical Abstract.

Stenosing tenosynovitis/tendinitis of the flexor hallucis longus (FHL) tendon is a relatively common occurrence in dancers. When nonoperative management fails, surgical tenolysis/tenosynovectomy has been shown to successfully reduce pain and restore function. In this study, we present the case of a professional contemporary dancer with FHL stenosing tenosynovitis/tendinitis who underwent a z-lengthening of the FHL proximal to the intact tendon sheath which resulted in a rupture of the FHL upon return to dance. He subsequently underwent a FHL reconstruction with tendon allograft. He returned to unrestricted professional dance at 11 months postoperative, which has been maintained at 4-year clinical and MRI follow-up.Level of evidence: V.

BACKGROUND/UNASSIGNED:The Trabecular Metal Total Ankle Implant differs from other newer-generation implants in the transfibular approach, multiplanar external frame for alignment, tantalum trabecular metal interfaces, curved geometry, and shallow resection depths. The primary aim of this study was to report midterm clinical and radiographic results, as well as survivorship and adverse events at a minimum of 5-year follow-up. METHODS/UNASSIGNED:A total of 83 ankles (81 patients, average age 60.6 years old, 50.6% females) with average 6.3 years' (range, 5.0-10.1) follow-up were included. Postoperative patient-reported outcome measures (PROMs) included SF-12 physical (PCS) and mental component summary (MCS) scores, Ankle Osteoarthritis Scale (AOS), pain visual analog scale (VAS). Radiographic outcomes included postoperative range of motion (ROM) and coronal/sagittal alignment. Adverse events were reported using the Canadian Orthopaedic Foot and Ankle Society Reoperation Coding System (CROCS). RESULTS/UNASSIGNED:Preoperative tibiotalar coronal deformity included 27 valgus (10 degrees, range 2-20 degrees) and 25 varus ankles (-9 degrees, range -2 to -25 degrees), corrected to neutral postoperatively. Postoperative tibiopedal ROM was 17.8 degrees dorsiflexion and 21.8 degrees plantarflexion. Adverse events occurred at average 28.7 months, most commonly gutter debridement (n = 17, 16.7%) and subsequent operative treatment unrelated to metal components (n = 10, 12.0%). There were 2 cases (2.4%) of acute deep infection treated with irrigation and debridement, polyethylene exchange, and retention of metal components without recurrence of infection. There were no cases of fibular nonunion, septic or aseptic loosening, or implant subsidence. Postoperative PROMS included SF-12 PCS: 40.4; SF-12 MCS: 56.0; VAS: 2.3; AOS Pain: 17.0; and AOS Disability: 24.9. Overall implant survival, defined by retention of the metal components, was 100% at final follow-up. CONCLUSION/UNASSIGNED:At a minimum of 5 years, patients who underwent TM TAA reported minimal ankle pain and regained neutral ankle alignment and mobility, without septic or aseptic implant loosening. Although having certain limitations, this study suggests that TM TAA is a viable option for the treatment of end-stage ankle arthritis.

BACKGROUND:In the past decade, the transfibular approach to Total Ankle Replacement (TAR) has emerged as an alternative to anterior approach with reduced bone resection. The purpose of this systematic review is to report survival, complications, and reoperation rates of transfibular TAR. METHODS:We conducted a systematic search of studies that evaluated complications, reoperations, and survival of transfibular TAR following PRISMA guidelines across PubMed, Scopus and Web of Science. RESULTS:Our review included data from 12 cohorts, comprising 919 patients across 7 countries, with an average age of 62 years (59% posttraumatic). Over an average follow-up period of 3 years, adverse events occurred in 23% of cases, with 18% requiring surgical reintervention, mostly due to hardware removal. The survival rate of the transfibular TAR metal components was 97% at the final follow-up. CONCLUSION/CONCLUSIONS:Transfibular TAR demonstrates a 97% survival rate at a 3-year follow-up. LEVEL OF EVIDENCE/METHODS:Level II.

This study was designed to investigate the accumulation of advanced glycation end-products (AGEs) and the expression of the receptor of AGEs (RAGE) in tendinopathic tissues. In this study, tendinopathic posterior tibial tendons (PTT) were collected from patients (n=6). Redundant autografts of flexor digitorum longus tendon (FDL; n=3) were used for controls. The control and tendinopathic tendon tissues were used for extraction of proteins for western blot and sectioned for histology and immunohistochemistry. Tendinopathy of the PTT was confirmed histologically by the presentation of disorderly organized collagen fibers, high cellularity and increased vascularity. By immunohistochemistry, heterogeneous accumulation of AGEs was detected on the PTT sections and concentrated in areas, where collagen fibers were disorderly and tangled. In the PTT, roundish tenocytes were also AGEs-positive. In contrast, AGEs were diffuse, lightly stained in the FDL. A greater number of tenocytes within the tendinopathic lesions in the PTT were RAGE positive, compared to the tenocytes in the FDL. Western blot confirmed the expression of AGEs and RAGE in both tendinopathic PTT and control FDL but their band densities were not significantly different. The spatial relation of the accumulated AGEs and RAGE- positive tenocytes within the tendinopathic lesions indicates their involvement in the molecular pathology of tendinopathy.

BACKGROUND/UNASSIGNED:fragments and then immediately reimplanted back into the chondral defect and sealed with fibrin glue during a single-stage surgery. The purpose of this study was to characterize the suitability of these minced cartilage fragments as immediate autograft for the treatment of OLTs. METHODS/UNASSIGNED:fragments and cell count, cell density, and cell viability were determined. In addition, physical characteristics of the OLT lesion were recorded intraoperatively and analyzed including size, location, Outerbridge chondromalacia grade of the surrounding cartilage, density of underlying bone, and whether the surgeon thought the OLT was primarily hyaline or fibrocartilage. RESULTS/UNASSIGNED:An average of 419 000 cells was able to be obtained from the harvested OLT fragments. The cells were 71.2% viable after mincing. Specimens from younger patients and from lesions with worse chondromalacia adjacent to the OLT had significantly higher cell numbers. Those from lateral lesions and with worse neighboring chondromalacia had a significantly higher cell density. None of the remaining physical OLT characteristics studied seemed to significantly affect cell number or viability. CONCLUSION/UNASSIGNED:fragments. These can be reimplanted into the chondral defect in a single-stage surgery. Future clinical studies are needed to determine if the addition of these live autologous cells either alone or in conjunction with other techniques significantly improves the quality of the repair tissue and clinical outcomes. LEVEL OF EVIDENCE/UNASSIGNED:Level IV, case series.

BACKGROUND:Assessing patient's risk of infection is fundamental for prevention of periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA). The Mayo Prosthetic Joint Infection Risk Score (Mayo Score) is based on data from total hip and knee arthroplasty and has not been validated for application for TAA. METHODS:A total of 405 consecutive TAA cases were followed for 6 months for PJI. Individual patients' Mayo Scores were calculated and analyzed with logistic regression and receiver operating characteristic (ROC) for predictability for PJI. A critical cut-off Mayo Score for patients at high risk of PJI was determined by best Youden index. Among the Mayo Score-defined high-risk patients, the contribution of different risk factors were compared between the PJI and non-PJI patients. RESULTS: < .001). Logistic regression showed that the probability of PJI increased with higher Mayo Scores (odds ratio 1.48, 95% CI 1.23-1.78). All but 1 PJI patients had a Mayo Score >5. The sensitivity and specificity were 90.0% and 84.3%, respectively, when a Mayo Score >5 was used as a criterion for high risk of PJI. CONCLUSION:This study demonstrated that the Mayo Score could similarly predict PJI risk after TAA as in total hip and knee arthroplasty. Data analysis suggests that a Mayo Score >5 could be a criterion for identifying high-risk patients for PJI, although further validation with a large number of PJI cases is necessary. LEVEL OF EVIDENCE:Level II, developing diagnositic criteria with consecutive cases.