BackgroundThe surgical treatment of end-stage tibiotalar arthritis continues to be a controversial topic. Advances in surgical technique and implant design have lead to improved outcomes after both ankle arthrodesis (AA) and total ankle arthroplasty (TAA), yet a clear consensus regarding the most ideal form of treatment is lacking. In this study, the outcomes and complications following AA and TAA are compared in order to improve our understanding and decision-making for care and treatment of symptomatic tibiotalar arthritis.MethodsStudies reporting on outcomes and complications following TAA or AA were obtained for review from the PubMed database between January 2006 and July 2016. Results from studies reporting on a minimum of 200 total ankle arthroplasties or a minimum of 80 ankle arthrodesis procedures were reviewed and pooled for analysis. All studies directly comparing outcomes and complications between TAA and AA were also included for review. Only studies including modern third-generation TAA implants approved for use in the USA (HINTEGRA, STAR, Salto, INBONE) were included.ResultsA total of six studies reporting on outcomes following TAA and five reporting on outcomes following AA met inclusion criteria and were included for pooled data analysis. The adjusted overall complication rate was higher for AA (26.9%) compared to TAA (19.7%), with similar findings in the non-revision reoperation rate (12.9% for AA compared to 9.5% for TAA). The adjusted revision reoperation rate for TAA (7.9%) was higher than AA (5.4%). Analysis of results from ten studies directly comparing TAA to AA suggests a more symmetric gait and less impairment on uneven surfaces after TAA.ConclusionsPooled data analysis demonstrated a higher overall complication rate after AA, but a higher reoperation rate for revision after TAA. Based on the existing literature, the decision to proceed with TAA or AA for end-stage ankle arthritis should be made on an individual patient basis.

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Background: Osteosarcoma and other primary bone malignancies are relatively common in skeletally immature patients. Current literature features case series with disparate complication rates, making it difficult for surgeons to educate patients on outcomes after limb salvage with expandable prostheses. This study aims to provide an update on complication rates, mortality, and functional outcomes in patients who undergo limb salvage with expandable prostheses for primary bone malignancies. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An exhaustive PubMed/Medline and Cochrane search of peer-reviewed published literature from 1997 to 2017 was performed, yielding a total of 1350 studies. After multiple rounds of review for inclusion and exclusion criteria, 28 retrospective studies were included. All were level IV evidence of case series and retrospective studies. Overall, this included 634 total patients and 292 patients with individual patient data. The primary outcomes studied were complication rates, mortality, and Musculoskeletal Tumor Society (MSTS) functional score. Secondary outcomes included complication rate subtypes, number of lengthening procedures, mean amount lengthened, and prevalence of limb length discrepancies. Results: A total of 292 patients with individual patient data averaged 10.1 years at the surgery and had a mean follow-up of 67 months. Two hundred sixteen patients (74%) had tumors of the distal femur. MSTS scores averaged 80.3 and overall mortality was 22%. Patients with distal femur tumors averaged 4.4 lengthening procedures and 43 mm lengthened. Leg length discrepancy (LLD) was 36% overall, which increased with longer periods of follow-up (P<0.001). Overall complication and revision rate was 43%, increasing to 59% in patients with 5 to 10 years of follow-up, and 89% in patients with >10 years of follow-up. Minimally invasive prostheses had lower rates of complications than noninvasive prostheses (P=0.024), specifically mechanical complications (P=0.028), mostly because of increased rates of lengthening and device failure in the noninvasive models (21% vs. 4%, P=0.0004). Conclusions: Despite its limitations, which include entirely heterogenous and retrospective case series data, this systematic review provides clinicians with pooled summary data representing the largest summary of outcomes after reconstruction with expandable prostheses to date. This analysis can assist surgeons to better understand and educate their patients and their families on functional outcomes, mortality, and complication rates after limb-sparing reconstruction with expandable prostheses for primary bone malignancies. Level of Evidence: Level IV—retrospective case series with pooled data.

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Summary: The Judet and Letournel acetabular fracture classification system, based on the idea of bicolumnar support of the acetabulum, was first described in a landmark article published in the 1960s. It has stood the test of time and continues to be the preferred method for describing acetabular fractures for the majority of orthopaedic trauma surgeons. Still, there have been attempts to modify or replace Letournel system since its introduction for a variety of reasons, chief among them a perceived inability of the classification system to account for a number of transitional fracture patterns and injury modifiers that may affect surgical decision making and patient outcomes. In this review, we present the literature related to the Judet and Letournel acetabular fracture classification system, over 50 years after its first formal description. We summarize its strengths, weaknesses, and its place in our current understanding of acetabular fractures and their recommended management.