Post-Traumatic Ankle Arthritis

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Bulletin of the Hospital for Joint Diseases 2013;71(1):104-12
Post-Traumatic Ankle Arthritis
Justin M. Weatherall, M.D., Kenneth Mroczek, M.D., Toni McLaurin, M.D., Bryan Ding, M.D.,
and Nirmal Tejwani, M.D.
Abstract
Post-traumatic ankle arthritis can be a very disabling condition especially in young patients. Localization of the pain
is important to allow appropriate treatment. Non-surgical
treatment options include anti-inflammatory medications
and use of bracing. Multiple surgical options range from
joint sparing procedures for the younger patient to total
ankle replacement for the older, less active patient. Arthrodesis remains the gold standard and is the procedure
of choice for younger patients who are heavy laborers and
in patients with severe arthritis who are not candidates
for a total ankle replacement. Joint sparing operations
include allograft resurfacing, arthroscopic debridement
and osteophyte resection, joint distraction arthroplasty, and
supramalleolar osteotomy. In older low demand patients,
the surgeon may consider a total ankle arthroplasty as an
alternative to arthrodesis.
A
nkle arthritis is a very common problem, and treatment decisions can be a challenge in young patients.
Fifty-percent of elderly patients have some form
of arthrosis involving the foot or ankle. Post-traumatic
arthritis is the most common cause,1 representing 70% of
cases among patients who present with osteoarthritis.2 The
three most common causes of post-traumatic arthritis are
rotational ankle fractures (37%), recurrent ankle instability(14.6%), and history of a single sprain with continued
pain (13.7%).2
Justin M. Weatherall, M.D., Kenneth Mroczek, M.D., Toni McLaurin, M.D., Bryan Ding, M.D., and Nirmal Tejwani, M.D., are in
the Department of Orthopaedic Surgery, NYU Hospital for Joint
Diseases, New York, New York.
Correspondence: Nirmal Tejwani, M.D., Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th
Street, 14th Floor, New York, New York 10003; nirmal.tejwani@
nyumc.org.
Osteoarthritis in the knee is 8 to 10 times more common
than osteoarthritis in the ankle.3,4 A cadaver study examined
the prevalence of knee and ankle arthritis with an average age
of 76, and the investigators found the prevalence of grade 3
and 4 degenerative changes in the knee was 66% compared
to 18% in the ankle.5 Nonetheless, a substantial number of
patients require treatment for debilitating ankle arthritis. According to industry experts, approximately 4,400 total ankle
replacements and approximately 25,000 ankle fusions were
performed in the United States in 2010.6 Thus, this condition
has come to have significant orthopaedic relevance.
Anatomy
The bony anatomy of the ankle confers a high degree of
stability and congruence when the joint is loaded. The ankle
has firm anterior and posterior ligaments that bind the distal
tibia and fibula together. Stability of the tibiotalar joint is
provided by the joint capsule, the medial deltoid ligament,
and the three lateral ligaments: the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the
posterior talofibular ligament (PTFL). The dome of the talus
is wider anteriorly, which allows some rotatory movement
in the ankle joint when the foot is plantarflexed. Conversely,
only minimal tibiotalar rotation can occur when the foot is
in maximal dorsiflexion.
The ankle has a smaller area of contact compared to
the knee and the hip (350 mm2 compared to 1,120 mm2
and 1,100 mm2 in the knee and hip, respectively).7-11 This
results in higher forces per area when the lower extremity
is loaded. Ankle cartilage thickness ranges from less than 1
mm to slightly less than 2 mm12 compared to the thickness
of the cartilage in the hip and knee, which is at least 3 mm
in the load bearing areas.13 Despite ankle cartilage being
thinner than hip and knee cartilage, a study by Kempson and
coworkers found that the tensile fracture stress and stiffness
of ankle cartilage deteriorates less rapidly with age than the
Weatherall JM, Mroczek K, McLaurin T, Ding B, Tejwani N. Post-traumatic ankle arthritis. Bull Hosp Jt Dis. 2013;71(1):104-12.
Bulletin of the Hospital for Joint Diseases 2013;71(1):104-12
Table 1 Causes of Post-Traumatic Ankle Arthritis
Ankle Fracture
Pilon Fracture
Tibia or Fibula Fracture
Talus Fracture
Ankle Dislocations
Recurrent Sprains
Persistent Ankle Instability
Osteochondritis Dessicans of the Talus or Distal Tibia
hip,14 and Aurich and colleagues found that when ankle cartilage is stressed it undergoes a higher turnover of cartilage
matrix material making it more resistant to degradation than
knee cartilage.15
Etiology
Typical causes of post-traumatic arthritis of the ankle
include ankle, pilon, tibia, fibula, and talus fractures. Several factors have been implicated in the development of
post-traumatic ankle arthritis, including fracture severity,
extent of cartilage damage, and a non-anatomic reduction.16
Soft tissue injuries can contribute as well, including ankle
dislocations, recurrent sprains, persistent ankle instability,
and osteochondritis dissecans lesions (Table 1). Atraumatic
causes include inflammatory arthritides, infection, Charcot,
hemophilia, and crystalline arthropathies. Ankle arthritis can
be idiopathic, as well.
Clinical Presentation
The cause of ankle arthritis can nearly always be identified
from the patient’s history. Pain with uphill walking may indicate anterior ankle or talonavicular joint bony impingement.
Pain with downhill walking may be related to a problem
in the posterior ankle including soft tissue impingement,
105
trigonal problems, or synovial chondromatosis. Pain with
walking on uneven ground felt in the posterior or lateral
ankle may be subtalar arthritis. If the patient complains of
sub-fibular pain, it may be due to bony impingement from
the calcaneus on the lateral process of the talus, the peroneal
tendons, or the fibula.
A thorough clinical examination will help isolate the
ankle pathology along with radiological investigations.
Weightbearing radiographs are essential (Fig. 1). The hindfoot alignment view is important when the heel is in varus
or valgus or when the ankle has coronal plane tilting. A CT
scan may be beneficial in patients with an ankle or hindfoot
deformity. It is less useful in patients with flexible deformities since it is a non-weightbearing exam. In patients with
a history of trauma, an MRI can be useful to evaluate for
the presence of subtle arthritic changes or other soft tissue
pathology and may assist with identifying the source of the
patient’s pain.
Non-Surgical Treatment
In most cases of post-traumatic ankle arthritis, it is critical
to exhaust an extensive course of non-surgical treatments
prior to offering surgical options. The basic options in the
physician’s armamentarium include NSAIDs, a cane, orthotics, orthoses, and injections, which include corticosteroids,
hyaluronic acid, and platelet-rich plasma. A corticosteroid
injection will be most beneficial to the patient who requires
short-term relief. Hyaluronic acid is most commonly used in
the knee, but it may be used in the ankle also, as the literature
has shown that some patients do receive benefit from injections of this compound into an arthritic ankle.17,18 A study
published in 2010 found favorable results with PRP injections in patients with osteoarthritis of the knee19; however,
its efficacy for ankle arthritis remains unproven. A variety
of either custom or off the shelf braces may be prescribed
initially. Braces can be a mechanical aid to limit painful motion and may function to correct flexible deformities. Some
Figure 1 Mortise and lateral ankle radiographs of a patient with ankle osteoarthritis.
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Bulletin of the Hospital for Joint Diseases 2013;71(1):104-12
patients may benefit from shoe wear modifications, such as
a wide heel or rocker bottom sole. Custom orthotics may
be prescribed to improve the foot-shoe interface and relieve
pressure from sensitive areas.
Surgical Treatment
The primary goals of any surgery on the foot or ankle are
to establish a painless, plantigrade foot that fits in a shoe.
Currently, surgical options include allograft resurfacing,
arthroscopic debridement and osteophyte resection, joint distraction arthroplasty, supramalleolar osteotomy, total ankle
replacement, and ankle arthrodesis. For the young patient
who is a heavy laborer, the option with the most consistent
results is ankle arthrodesis. In the older patient population,
the two surgical options most commonly used are total ankle
replacement and ankle arthrodesis. The most difficult patient
to treat is the young adult with painful ankle arthritis who
is not a heavy laborer but desires an active lifestyle. The
surgical options for this patient include allograft resurfacing, arthroscopic debridement and osteophyte resection,
joint distraction arthroplasty, and supramalleolar osteotomy.
Allograft Resurfacing
Allograft resurfacing is indicated for young active patients.
Resurfacing involves the use of fresh allografts to replace
damaged articular surfaces. Two important considerations
are the necessity of anatomic matching of the allograft to the
host bone and the limited supply of donor ankles.20-22 Hahn
and colleagues in 2010 reported on 18 patients with 13 completing 4 years of follow-up. The investigators concluded
that fresh talar allograft transplantation for osteochondral
lesions is a reasonable procedure in younger patients with
a focal defect.23 Another recent study reviewed 12 ankles
in 11 patients with an average patient age of 35.5 years that
underwent osteochondral grafting with fresh talar allografts
with significant improvement in outcome scores, and 5 of
12 patients reported good to excellent results. They had
two graft failures, and one patient went on to arthrodesis.24
Similarly, Raikin and colleagues published a series of 15
patients with a minimum of 2 years of follow-up, and the
investigators found 2 of 15 patients were converted to
arthrodesis, and 11 patients reported good to excellent results with significant improvement in post-op AOFAS and
pain scores.25 It is contraindicated in patients with vascular
disease, varus or valgus malalignment of greater than 10°,
ankle joint instability, and obesity.22
Arthroscopic Debridement and Osteophyte
Resection
Arthroscopic debridement and osteophyte resection may be
helpful in patients with mild arthritis with a large osteophyte
restricting motion or causing painful impingement at the
extremes of motion. Patients with soft tissue impingement
can also benefit from arthroscopic debridement.26 Prior to
undergoing the procedure, patients should be counseled that
any pain they have at rest will most likely not be relieved
by this operation. In a study of 105 patients who underwent
arthroscopic debridement for either anterior bony or soft tissue impingement, the investigators reported that 65 patients
at 2-year follow-up were pain free, and another 28 had their
level of pain improved. Thirty-three had resumed sports,
and 92 out of 105 reported good to excellent results.27 A
more recent study examined 105 patients with osteochondral lesions that underwent arthroscopic debridement and
microfracture. The investigators reported zero failures in
lesions smaller than 15 mm and found that lesions larger
than 15 mm, older age, higher BMI, a history of trauma,
and presence of osteophytes were all predictors of a negative outcome. Overall, arthroscopic debridement can be a
successful operation in patients with isolated bony or soft
tissue impingement and mild ankle arthritis.
Joint Distraction Arthroplasty
Joint distraction arthroplasty, also referred to as arthrodiastasis, employs an external fixator to mechanically unload
the joint. It is theorized that mechanical unloading of the
joint allows for intermittent flow of intra-articular synovial
fluid when the patient bears weight on the extremity, which
gives the articular cartilage a chance to repair itself.28 Joint
distraction arthroplasty is a joint sparing alternative for
young patients with a congruent and painful arthritic joint.
Typically, the external fixator is kept on for 3 months. The
procedure may also be combined with adjunctive procedures
such as osteophyte resection and Achilles lengthening.29
Tellisi and associates published a retrospective review in
2009 looking at 25 patients with an average follow-up of
30 months who had undergone joint preservation using
distraction arthroplasty in patients with ankle osteoarthritis.
The investigators reported that 91% of the patients had improvement in their pain, with a significant number of patients
having an improvement in their AOFAS scores. Two out of
25 patients had undergone fusion.30
Supramalleolar Osteotomy
Patients with mild to moderate osteoarthritis with tibiotalar
malalignment and reasonable ankle range of motion may be
indicted for a supramalleolar osteotomy. This may also be
the first stage procedure prior to undergoing a total ankle
replacement or arthrodesis.31 A study in 2003 reviewed 13
feet in 12 patients with a distal tibial deformity and ankle
arthritis that underwent a supramalleolar osteotomy. The
patients had an average follow-up of 33.6 months, and the
osteotomies healed at a mean of 14 weeks. The investigators reported that there was no radiographic progression of
arthritis, and the AOFAS score improved from 56.7 to 82.32
Total Ankle Arthroplasty
Total ankle replacements were first approved by the FDA in
the mid-1980s. Total ankles are indicated in patients with
painful ankle arthritis secondary to a significant loss of artic-
Bulletin of the Hospital for Joint Diseases 2013;71(1):104-12
107
Table 2 Indications for Total Ankle Arthroplasty
Indications
Relative Contraindications
Absolute Contraindications
Post-traumatic OA
Inflammatory Arthritis
Arthritis secondary to chronic ankle
instability
Younger Patients
Extremely active patients
Overweight patients
Prior ankle infection
Skin ulcers
Large areas of Osteonecrosis
Charcot Arthropathy
Absence of muscle function in the lower
leg or foot
Uncorrectable tibiotalar malalignment
Vascular insufficiency
Severe loss of bone stock
Severe osteoporosis
Current infection
ular cartilage caused by trauma, inflammatory arthropathy, or
joint instability. Relative contraindications include younger
patients, extremely active or heavy individuals, prior ankle
infection, or skin ulcers. Absolute contraindications include
large areas of osteonecrosis, Charcot arthropathy, absence
of muscle function in the lower leg and foot, uncorrectable
tibiotalar malalignment, vascular insufficiency, severe loss
of bone stock, osteoporosis that may lead to inadequate component fixation, and current infection (Table 2). Short-term
results were initially encouraging,33 but subsequent studies
with long-term follow-up showed rates of radiographic
loosening to be in the range of 22% to 75%.34 Other reported
complications included superficial and deep infections, resection arthroplasty, attempted re-implantations or fusions
and below-knee amputations.34-39
Recently, there has been a resurgence in the use of total
ankle replacements secondary to improved designs, better
fixation, and a better understanding of the modes of failure from the previous generation of implants. Performing
an adequate medial and lateral gutter debridement is of
paramount importance. Intra-operative malleolar fracture
and deltoid ligament insufficiency are potential pitfalls.
It is important to have solid bony support. Post-operative
complications of total ankle replacement include infection,
loosening, progressive intra-component instability or deformity, subsidence, and polyethylene failure.40 Proper patient
selection is a critical factor in reducing the rate of infection.
Caution is advised in patients with a history of prior ankle
infection or skin problems. During surgery, meticulous
handling of the soft tissues, hemostasis, and a multilayer
closure are critical in preventing infection and wound complications. Patients should be immobilized postoperatively
and instructed to elevate the extremity to assist in wound
healing. Weightbearing may be initiated at approximately
6 weeks postoperatively or when bony consolidation is
seen. As in total hip and knee arthroplasty, deep acute (less
than 6 weeks) infections can be treated with irrigation and
debridement and poly exchange whereas deep chronic infections should be treated with resection arthroplasty with
placement of a cement spacer and possible subsequent
revision total ankle replacement or arthrodesis. The rate of
subsidence of the talar component has decreased with the
use of non-cemented components. In cases of severe subsidence, treatment includes revision of the talar component
or fusion. The polyethylene component may fail by either
catastrophic fracture, wear, or particle induced osteolysis.
Thin bearings have the highest risk of catastrophic fracture.
Patients should be appropriately counseled about the risk of
acute fracture and should refrain from high impact activities
on the implant. Patients should be followed regularly with
radiographic evaluation to observe for the development of
osteolysis.41 Multiple studies have been published which
Figure 2 Immediate postoperative anteroposterior and lateral radiographs after a STAR
(Scandinavian Total Ankle Replacement,
Small Bone Innovations, Inc, New York, NY,
USA) total ankle arthroplasty.
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Bulletin of the Hospital for Joint Diseases 2013;71(1):104-12
indicate that, as with many procedures, there is a learning
curve with performing total ankle replacements.40,42,43
Currently, the STAR (Scandinavian Total Ankle Replacement, Small Bone Innovations, Inc, New York, NY, USA)
is the only FDA-approved mobile bearing device with bony
in-growth potential (Fig. 2), and several studies have been
published recently on its results. Saltzman and coworkers
in 2009 performed a prospective multicenter trial comparing the STAR total ankle replacement and ankle fusion with
2-year follow-up. The investigators concluded that, at two
years postoperatively, patients with a total ankle replacement
had better function and equivalent pain relief compared to
fusion.44 A study in 2004 looked at the STAR total ankle replacement in patients with 3 to 8 year follow-up and reported
the estimated 5 year survival rate was 70% with 12 out of 51
ankles that had to be revised and another 8 with radiographic
signs of loosening.45 More recently, Bonnin and colleagues
in a 7 to 11 year follow-up on the Salto Total Ankle Replacement (Tornier, Inc., Montbonnot, Rhone-Alpes, France)
reported an initial implant survival rate of 65% with 6 out
of 85 patients converted to arthrodesis.46
Arthrodesis
Arthrodesis currently remains the gold standard and the
most common treatment of ankle arthritis. Arthrodesis is a
successful operation in patients whose pain is isolated to the
ankle joint. The results and complication rates have greatly
improved through modern surgical techniques. Secondary
operations, such as hardware removal, are rare while initial
fusion rates have been reported to range between 60% and
100%.7,26,47-57 Despite this, patients may have persistent pain
postoperatively if other sources of pain were not treated by
the fusion. Postoperative functional limitations are common
after arthrodesis, and postoperative shoe modifications may
be necessary to improve the mechanics of the gait cycle.
Over time adjacent joints, such as the sub-talar and talona-
vicular joints, may become arthritic.48 Patients should be told
that they may need bracing or more surgery in the future
especially in young patients.
To have a successful outcome, it is imperative that the
surgeon establishes the proper alignment of the entire
lower leg including the foot. The optimal position for ankle
fusion is neutral dorsiflexion, 5° of valgus, and rotation
equal to the other side (or slightly more externally rotated
than the other side). The anterior aspect of the talar dome
should be brought to the anterior aspect of the tibia. Occasionally, selective osteotomies or fusion of the forefoot
may be required to make the foot plantigrade. Multiple
surgical options are available including a standard open
or mini-open approach, arthroscopy, and external fixation.
The classic approach is trans-fibular with or without an
accessory medial portal. Some surgeons reattach the fibula
to act as a buttress against lateral talar migration (Fig. 3).
The optimal screw pattern is controversial, but the typical pattern is parallel or crossed screws with or without
a homerun screw (Fig. 4). The “homerun” screw is a lag
screw that travels from the posterior malleolus into the
plantar medial talar head and neck. The addition of a lateral
plate, such as a blade plate or locking plate, is optional.
Other approaches include the anterior and posterior approaches.58 The anterior approach allows anterior plating,
which in theory uses the Achilles tendon as a tension band.
One advantage is that the incision can be re-used in the
future to convert the fusion to a total ankle replacement.
It also maintains the fibula, which is necessary for future
conversion to a total ankle. However, a drawback of the
anterior approach is that it carries the risk of anterior talar
subluxation.59 The posterior approach is used when the
patient has poor blood supply or the skin in the region of
other approaches has been compromised. With the posterior approach, though, the surgeon must be mindful of the
neurovascular structures.60
Figure 3 Anteroposterior and lateral postoperative ankle radiographs of a patient statuspost ankle arthrodesis.
Bulletin of the Hospital for Joint Diseases 2013;71(1):104-12
109
Figure 4. Postoperative radiographs of a patient
who required revision left ankle fusion. The patient
originally underwent bilateral ankle arthrodesis
for post-traumatic arthritis, which developed from
prior pilon fractures. Because of failure of bony
fusion on the left side, he was indicated for the
revision procedure.
Buchner and coworkers in a study of patient statuspost ankle fusion with an average follow-up of 9.3 years
found that 92% of patients had good subjective results.
Patients did worse with greater than 5° of plantar flexion.
Also, patients had a high incidence of adjacent arthrosis
with subsequent decreased mobility in their adjacent tarsal
joints. Forty-seven percent of patients had moderate to
severe subtalar osteoarthritis.48 Other investigators looking
at long-term follow-up in patients with ankle fusion for
post-traumatic arthritis also found an increased incidence
of adjacent foot joint arthritis as well as significant differences between the fusion and normal side in regards
to activity, pain, and disability.61 A retrospective database
review compared 4,705 ankle fusions versus 480 total ankle
replacements, and the investigators reported that major
revision was required in 9% of the total ankles after one
year and 23% by 5 years compared to 5% and 11% for ankle
fusions, respectively, but patients who underwent ankle
replacement had a decreased rate of subsequent subtalar
fusion (0.7%) compared to arthrodesis (2.8%).62
Ankle fusion may be successfully performed arthroscopically in the patient with tibiotalar arthrosis but no significant deformity. Patients with inflammatory, hemophilic, or
post-septic arthritis, or patients who have a poor vascular
supply or compromised soft tissue are not good candidates.26
Myerson and colleagues in a comparison of 17 patients
that underwent arthroscopic fusion versus 16 patients that
underwent open fusion reported an average fusion time of
8.7 weeks in the arthroscopic group compared to 14.5 weeks
in the open group.63
External fixation may be the best choice for fusion in
patients with complex hindfoot deformities, soft tissue
compromise, significant shortening, or septic arthritis. A
circular or hybrid fixator is often used. External fixation
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offers the advantage of gradual correction of complex
deformities that minimizes soft tissue complications. High
union rates have been reported, though pin site complications
are common.64-66 Typically, external fixation is performed
by surgeons with experience in this technique. Of the 17
patients that underwent Ilizarov ankle arthrodesis for either
post-traumatic arthritis or a Charcot ankle joint, the investigators reported that all ankles fused, and 11 of 17 patients
reported good to excellent results.64
The three most common postoperative complications of
ankle arthrodesis are non-union, mal-union, and secondary
subtalar arthritis. Non-union rates have been reported to
range between 0% and 40%.57,63,67-73 Non-union is more
common in smokers, the elderly, the non-compliant, and
those with neuroarthopathy, history of open trauma, or poor
soft tissues.49,71 The most common position of malunion
is varus or valgus with equinus. Malunion may be treated
with either an opening or closing wedge osteotomy, double
osteotomy, dome shaped osteotomy, or a circular external
fixator.74
The subtalar joint is the most common joint to develop
arthritis after an ankle fusion. Degenerative changes occur
secondary to increased stress on the subtalar joint. After
ankle fusion, most patients will walk with the foot externally rotated in order to vault over the foot at the end of the
stance phase of gait. To vault over the foot, a patient will roll
through the subtalar joint in an unnatural medial to lateral
direction. This unnatural motion may result in localized area
of increased load on the articular cartilage, which ultimately
leads to arthritic changes. After 20 years, all patients can be
expected to have radiographic evidence of subtalar arthritis,
but the rate of symptomatic arthritis is low.61
gastrocnemius alone such as a Strayer procedure.78
Bone Grafting
The need for bone grafting is controversial. However,
since non-union can be a devastating complication, most
surgeons use bone grafting with primary arthrodesis.75-77
Potential sites to obtain autograft are iliac crest, proximal
tibia, distal tibia, and calcaneus.76-78 To date, no large studies
have been published comparing primary fusion with and
without bone graft.
1.
Achilles Contracture
Patients with tibiotalar arthritis may develop an isolated
gastrocnemius or Achilles contracture secondary to altered
joint motion or gait mechanics. It is essential to recognize a
contracture preoperatively, so that it can be addressed at the
time of surgery, thus ensuring the patient has a plantigrade
foot postoperatively. Patients with an isolated gastrocnemius
contracture will lack dorsiflexion only with the knee extended, but an equinus position in both knee flexion and extension
indicates a combined gastrocnemius-soleus contracture.
An open or percutaneous release of the Achilles tendon is
necessary in this situation. When an isolated gastrocnemius
contracture is present, it can be treated with a release of the
4.
Summary
Post-traumatic ankle arthritis can be a challenging problem
to treat, especially in younger patients. Isolating the exact
location of the patient’s pain and in what positions of motion
is critical in determining the correct treatment option. Nonsurgical treatment options should be exhausted prior to proceeding with surgical treatment. Many surgical procedures
have been described, and the surgeon should be familiar
with the indications and contra-indications of each before
proceeding with a specific operation. Ankle arthrodesis remains the gold standard for the treatment of ankle arthritis,
especially in young laborers, but total ankle replacement
may be a good option in older, less active, patients. Ankle
arthroplasty may avoid the development of adjacent joint
arthritis almost always seen after ankle fusion. In young
patients with ankle arthritis, joint sparing operations, such
as arthroscopic debridement, joint distraction arthroplasty,
or supramalleolar osteotomy, may be performed. Bone grafting as an adjunct to ankle fusion is commonly used, despite
there being no clinical trials showing an advantage to using
bone graft. In all cases, Achilles tendon contracture should
be addressed at the time of surgery to enable the surgeon to
achieve a plantigrade foot.
Disclosure Statement
None of the authors have a financial or proprietary interest
in the subject matter or materials discussed, including, but
not limited to, employment, consultancies, stock ownership,
honoraria, and paid expert testimony.
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