bluuebunny/crossref_metadata_2025 huggingface dataset:
Influence of Topography on 3D printed Titanium Foot and Ankle Implants
Authors: Abar Bijan , Kelly Cambre N. , Allen Nicholas B. , Barber Helena , Kelly Alexander P. , Gall Ken , Adams Samuel B.
Published: November 2020

Category:

Basic Sciences/Biologics; Ankle; Trauma

Introduction/Purpose

Foot and ankle etiologies such as traumatic fractures, Charcot Arthropathy, nonunion after high risk arthrodesis and infectious debridement can result in critical sized bone defect (CSD). CSD is defined as bone loss greater than 1-2 cm in length or greater than 50% loss in circumference of bone. CSD remain a significant challenge in Orthopaedics. Custom 3D printed porous Titanium implants are currently being implemented when allograft is not an option. However, in a subset of cases, Titanium implants need to be removed due to infection or poor osseous integration where surrounding bone does not grow onto or through the scaffold. There is no one clear reason for poor osseous integration. This study explores effects of 3D printed topography on mechanical and biological properties.

Methods:

Titanium dog bones and discs were printed via laser powder bed fusion. Roughness groups were polished, blasted, as built, sprouts and rough sprouts. Roughness was measured with line measurement using a confocal microscope. To assess mechanical properties, tensile testing of samples from each roughness group produced stress strain curves. MC3T3 preosteoblast were seeded on discs. Samples were analyzed at 0, 2, and 4 weeks. A cell viability assay and confocal florescent microscopy assessed cell growth. Alkaline Phosphatase (ALP) assay and Quantitative Polymerase Chain Reaction (qPCR) examined cell differentiation. Extracellular matrix (ECM) was stained for collagen and calcium. Scanning Electron Microcopy (SEM) was done on sputter coated discs.

Results:

Rz, maximum peak to valley distance of the sample profile, for the polished, blasted, as built, sprouts and rough sprouts were 2.6, 22.6, 33.0, 41.4 and 65.1 µm respectively. The addition of printed roughness in the sprouts and rough sprouts group significantly diminished ductility resulting in early strain to failure during tensile testing. Cells adhered and proliferated on discs regardless of roughness group. There was no statically difference in ALP activity, but qPCR showed that rough groups (sprouts and rough sprouts) had diminished Osteocalcin gene expression at week 2 and 4. The ECM observed with SEM in the rough groups was more resistant to repeated washes and was more extensive compared to the less rough groups.

Conclusion:

The addition of 3D printed artificial roughness leads to inferior mechanical properties and confers no clear benefit regarding cellular proliferation. Printed topography increases the initiation of fractures resulting in diminished tensile strength and ductility. Concurrently, the resolution of LBF is not fine enough at this time to create surface features that enhance cell behavior. Therefore, data in this study suggest that artificially printing roughness is not an effective strategy to enhance osseous integration into Titanium implants for critical sized defects.
Mesenchymal Stem Cells Derived from Synovium and Fat Pad are Able to Treat Induced Ankle Osteoarthritis in Rats?
Authors: Ashkani-Esfahani Soheil , Lubberts Bart , Bhimani Rohan , DiGiovanni Christopher W.
Published: November 2020

Category:

Ankle Arthritis; Ankle; Basic Sciences/Biologics

Introduction/Purpose:

Osteoarthritis (OA) is a chronic disease and a significant cause of joint pain, tenderness, and limitation of motion. At present, no specific treatment is available and mesenchymal stem cells (MSCs) have shown promising potentials in this regard. Herein, we aimed to evaluate the repairing potentials of stem cells derived from synovium and fat pad in treatment of OA in ankle joint.

Methods:

Twenty-eight male rats (220+-20 g, aged 10-12 weeks), were randomly divided into four groups (n=7): C1: non- treated, C2: Hyalgan treated, E1: Adipose-tissue derived stem cell treated, and E2: synovial-membrane based stem cell treated groups. Collagenase type II enzyme was injected into the left ankle; after eight weeks, OA was developed. Then, stem cells were injected and rats were followed for three months. Afterwards, rats were euthanized and specimens and radiological images were provided. P-value<=0.05 was set as statistically significant.

Results:

Compared to C1, E1 and E2 groups showed significantly better results in all pathological criteria including surface, matrix, cell distribution, cell population viability, subchondral bone, and cartilage mineralization as well as joint space width and osteophytes developed in the joint (p<=0.001). Similarly, compared to C2 group, E1 and E2 had better scores regarding surface, matrix, cell distribution, and cell population viability (p<0.05). E2 showed considerably higher scores compared to C2 regarding subchondral bone and cartilage mineralization (p<0.05). Joint space width was similar between C2 and E groups.

Conclusion:

Treatment of OA of ankle with MSCs, particularly synovial-membrane derived stem cells, not only prevented but also healed OA to some extent in comparison to Hyalgan and non-treatment groups.
Tibial Torsion and Ankle Arthritis: Is External Tibial Rotation Associated with Varus Deformity in Patients with Ankle Arthritis?
Authors: Barber Collin C. , Hall Teresa , Madden Tyler , Kothari Parin D. , LaPointe Monica , Anderson John G. , Bohay Donald R. , Maskill John D. , Padley Michelle A.
Published: November 2020

Category:

Ankle; Ankle Arthritis; Hindfoot

Introduction/Purpose:

The effect of tibial torsion on lower extremity mechanical alignment has been well studied in the literature, including its effect on lower extremity osteoarthritis. It has been suggested that external tibial torsion is associated with cavus hindfoot deformity and may lead to varus osteoarthritis of the ankle. To our knowledge, there are no studies investigating this relationship. The purpose of this study is to characterize the relationship of tibial torsion with ankle coronal plane deformity in patients with ankle arthritis.

Methods:

The study is a retrospective, cohort of 223 patients who have undergone total ankle arthroplasty at a single institution. Preoperative computerized tomography was used to measure tibial torsion and coronal deformity. Descriptive statistics and regression analysis were used to analyze the data.

Results:

Descriptive analysis of all 223 patients demonstrated a maximum of 23.9 degrees varus and 20.5 degrees valgus among all patients. The mean for varus deformity was 6.86 degrees with a standard deviation of +- 6.39. Tibial rotation was calculated at an average of 20.8 degrees external rotation, with a maximum of 15.2 degrees internal rotation and 59.5 degrees external rotation in all patients. Plotting overall coronal ankle tilt versus tibial torsion revealed overall varus deformity with R2 of 0.016. Regression analysis of all varus deformities against external tibial torsion revealed a R2 of 0.02. Varus deformity 1 standard deviation above the mean against external tibial torsion demonstrated a R2 of 0.072. Valgus deformity against external tibial torsion revealed a R2 of 6.75 x10-5.

Conclusion:

An association between external tibial torsion and varus ankle arthritis has been proposed in the literature. The results of our study did not show an association between tibial torsion and coronal deformity in ankle arthritis in all patients undergoing total ankle arthroplasty at our institution. A difference may exist in certain subgroups, such as patients with neuromuscular disorders, but further investigation will be necessary to determine this relationship.
Dynamic Evaluation Of The Effect Of Syndesmotic Injury On Lateral Ankle Stability Using Fluoroscopy
Authors: Bhimani Rohan , Sato Go , Saengsin Jirawat , Hagemeijer Noortje , Lubberts Bart , Waryasz Gregory R. , Guss Daniel , DiGiovanni Christopher W.
Published: November 2020

Category:

Ankle; Sports; Trauma

Introduction/Purpose:

There is a high incidence of concomitance between lateral ankle ligament injuries and syndesmotic ligamentous injuries. However, it is unclear whether syndesmotic ligaments directly contribute toward the stability of the lateral ankle. Stress radiographs are an accepted technique to assess the degree of lateral ankle instability by providing a static view of the ankle when subjected to the anterior drawer (AD) and talar tilt (TT) tests. The aim of this study is to assess the effect of syndesmotic injury as well as combined syndesmotic and lateral ankle injury on the stability of the lateral ankle.

Methods:

Sixteen fresh frozen above-knee amputated cadaveric specimens, divided into two groups, underwent fluoroscopic evaluation for lateral ankle stability. In both the groups, the assessment was first done with all ligaments intact and later with sequential transection of anterior inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), posterior inferior tibiofibular ligament (PITFL), anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). In all scenarios, two loading conditions were considered: (1) Anterior drawer test: 50N and 80N and (2) Talar tilt and Lateral clear space (LCS): 1.7Nm torque. The talar translation, talar tilt, and LCS were measured using Image J. Wilcoxon rank-sum test was used to compare the findings of each ligamentous transection state to the intact state. A p-value <0.05 was considered statistically significant.

Results:

In group 1 after transection of the AITFL and IOL, an increase in the anterior drawer, talar tilt, and lateral clear space values was found as compared to the intact state. Similarly, in group 2 the anterior drawer, talar tilt, and lateral clear space values significantly increased after transection of the AITFL and ATFL as compared to the intact state (p-values = 0.001).

Conclusion:

Lateral ankle instability appears after injury to two syndesmotic ligaments (AITFL and IOL), or after one syndesmotic ligament rupture (AITFL) with a concomitant anterior talofibular ligament rupture (ATFL). These findings suggest that surgeons should lower their threshold for stabilizing the syndesmosis if there is a concomitant lateral ankle ligament injury.
Using 3D Volume Measurements on Weightbearing Computed Tomography Scan to Diagnose Syndesmotic Instability
Authors: Bhimani Rohan , Ashkani-Esfahani Soheil , Lubberts Bart , Guss Daniel , Hagemeijer Noortje , Waryasz Gregory R. , DiGiovanni Christopher W.
Published: November 2020

Category:

Ankle

Introduction/Purpose:

Diagnosing syndesmotic instability, especially when subtle, remains challenging. Weight bearing computed tomography (WBCT) offers a unique opportunity to evaluate the distal syndesmosis under physiologic load while simultaneously comparing the injured and uninjured side. We hypothesized that WBCT volumetric measurements of the distal syndesmosis were increased on the injured side as compared to the contralateral uninjured side among patients with syndesmotic instability. Our secondary hypothesis was that these 3-dimensional calculations were an even more sensitive determinant of instability as compared to 2-dimensional methodology.

Methods:

Twelve patients with unilateral syndesmotic instability requiring operative fixation who underwent preoperative bilateral foot and ankle WBCT were included in the study group. The control group comprised of 24 patients without ankle injury who underwent similar imaging. For each WBCT scan, 2-dimensional measurements of the interspace between the distal fibula and tibia were measured 1cm above the joint line in the axial plane, namely the syndesmosis area and the direct anterior, middle and posterior difference. Furthermore, three volumetric measurements of the interspace between the distal fibula and tibia were evaluated: 1) from the tibial plafond extending until 3cm proximally, 2) 5cm proximally, and 3) 10cm proximally from the joint line.

Results:

In patients with unilateral syndesmotic instability, all weightbearing volumetric measurements were significantly larger on the injured side as compared to the contralateral, uninjured side (p<0.001). In the control group, there was no difference between syndesmotic volumes at any level. Of the three anatomic reference points, the volumetric measurement spanning from the tibial plafond to a level 5cm proximally had the highest relative volumetric ratio between the injured and uninjured side, suggesting it is more sensitive in distinguishing stable and unstable syndesmotic injuries (median ratios (IQR) 1.3(1.2-1.4), 1.8(1.6-2.1), 1.4(1.3-1.5), respectively; p<0.001). Additionally, this relative volumetric ratio was also more sensitive than 2-dimensional measurements (p=0.001).

Conclusion:

Volumetric measurement of the distal tibiofibular interspace using WBCT appears to be the most effective way to diagnose syndesmotic instability. The measurement from the tibial plafond extending until 5cm proximally is more sensitive to detect syndesmotic instability than using either more traditional 2D WBCT syndesmosis measurements or using more distal (3cm) or proximal (10cm) 3D volumetric measurements. This does not seem surprising given the overall spectrum and 3D nature of the syndesmotic injury across the injured population.

Tables

[Table: see text][Table: see text]
Prescribing Fewer Opioid Pills to Patients Undergoing Foot and Ankle Surgery: A Prospective Comparative Study
Authors: Caolo Kristin C. , Day Jonathan , Marion Celia , Ray Gabrielle S. , Johnson A. Holly
Published: November 2020

Category:

Ankle; Ankle Arthritis; Arthroscopy; Basic Sciences/Biologics; Bunion; Diabetes; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; Trauma; Other

Introduction/Purpose:

This study aims to compare a novel opioid prescribing protocol aimed at reducing the number of opioid pills prescribed and consumed with an established, previously published protocol for foot and ankle surgery. We hypothesized that patients in the novel group would consume fewer opioids and report similar satisfaction with pain management compared with the established group.

Methods:

This study is a single center prospective study of 59 patients undergoing foot and ankle surgery who received a novel opioid prescribing protocol used by the senior author. Preoperatively, patients were counseled on the expectations of pain after surgery, received a take home pamphlet, and were prescribed opioids based on a sliding scale of procedures designated as minor (0-5 pills), moderate (5-10 pills) or major (15-20 pills). These patients were then compared to 84 patients from a previous prospective study from the same institution who received an opioid prescribing protocol with a maximum of 40-60 opioid pills. Patients were excluded if they used opioids or muscle relaxants preoperatively or had a known history of a substance use disorder. Patients completed surveys postoperatively for eight weeks reporting pain level, number of opioid pills consumed, refill requests, and satisfaction with their pain management plan.

Results:

There was a significant difference (p< 0.001) in mean pills consumed between the novel and established prescribing protocols at all time points (Table 1). During the entire postoperative period patients in the novel group had taken 21% of their prescribed pills compared to 40% in the established group (p=0.03). Patients had comparable levels of pain throughout the study (p>0.05 at POD 3, POD 7 and POD 14) and only differed significantly at POD 56 (p=0.005). Patients in the novel group did not request any refills, whereas patients in the established group requested a total of 9 refills over the course of the study.

Conclusion:

Patients receiving fewer opioid medications, along with preoperative coaching and take home materials, achieved equivalent analgesic effect when compared to patients receiving approximately double the amount of opioids. This study demonstrates that a sliding scale protocol with a maximum prescription of 20 opioid pills provides appropriate pain relief for most patients. This study confirms that patients on average take far fewer opioid pills than prescribed, and likely an even more limited prescribing protocol would be adequate for the majority of patients. This novel prescribing protocol ensures less opioids are both consumed and leftover for potential diversion in the community. [Table: see text]
Cartiva: A Retrospective Multicenter Report
Authors: Casscells Nicholas , Dean Daniel M. , Cooper Paul S. , Miller Stuart D. , Guyton Gregory P.
Published: November 2020

Category:

Midfoot/Forefoot; Other

Introduction/Purpose:

Arthritis of the 1st metatarsophalangeal (MTP) joint is a common condition. Traditionally, advanced disease has been treated with arthrodesis. In 2016, Cartiva, a cylindrical polyvinyl 1st MTP implant, was approved for use in this condition by the FDA upon the basis of a company-sponsored, nonblinded, randomized controlled trial (MOTION) that reported noninferiority to arthrodesis at a -15% difference of proportions margin using a multipart ad hoc definition of surgical success. A subsequent independent level IV case series reported poor PROMIS score outcomes for the procedure but lacked any preoperative data. We report the short-term reoperation rate and pre- and postoperative VAS pain score outcomes for Cartiva in an independent multicenter series.

Methods:

A retrospective, multicenter review was performed of patients who had a Cartiva hemiarthroplasty placed from 2016- 18 and who had at least 6 months of follow-up. Demographic information, surgical data, and prospectively collected VAS pain scores on a 0-100 point scale on were reviewed. The primary endpoint was reoperation of the implant, defined as removal or revision during the follow-up period. Implant subsidence was measured by comparing early postoperative radiographs with final radiographs. Subgroup analysis was performed comparing Cartiva failures to the remainder of the group.

Results:

Fifty-three patients with 56 operated toes were included. Forty-seven (88.7%) females and 6 (11.3%) males had a mean age of 57.7 +- 7.14 years (range 43-73). At an average follow-up of 11.1 +- 4.24 months, there were 6 (10.7%) reoperations. Younger age was the only factor found to be associated with failure of the implant (p=.043). Radiographic subsidence >1 mm was identified in 26.6% of patients but did not correlate with failure. VAS pain scores improved from a preoperative average of 49.7 +/- 24.8 to a postoperative average of 33.1 +- 23.3 at final follow-up. Despite this improvement, 40.4% of patients failed to show a 30% improvement, the MCID, in their VAS pain score, and 42.6% of patients had residual pain scores above 30.

Conclusion:

Our cohort had a 10.7% reoperation rate for the Cartiva implant which is comparable to the results of the MOTION trial. Although aggregate results demonstrated a statistically significant improvement in VAS pain scores, many patients failed to have a satisfactory outcome as demonstrated by the large standard deviation and low achievement of the MCID. Compared to the 1-year results of the MOTION study, our final VAS pain scores were slightly worse, but the very high variance mirrored that reported in the company-sponsored trail (17.8 +- 23.0). This suggests that use of Cartiva does not reliably produce satisfactory pain outcomes.
Comparison of Outcomes of Cheilectomy with and without Synthetic Hydrogel Interposition (Cartiva®)
Authors: Ford Samuel E. , Scott Daniel J. , Alejandro Shannon F. , Vier David D. , Zide Jacob R. , Brodsky James W.
Published: November 2020

Category:

Midfoot/Forefoot; Other

Introduction/Purpose:

Cheilectomy and arthrodesis are the primary surgical treatments of hallux rigidus. While cheilectomy preserves limited motion, that motion can be the source of persistent pain that later requires arthrodesis. Cheilectomy with interposition arthroplasty using a synthetic hydrogel implant (Cartiva) has been proposed as an alternative to arthrodesis. Previous studies compared Cartiva to arthrodesis, but Cartiva is really a modification of cheilectomy, meant to improve its results by distracting the bony surfaces of the first MTP joint. This study compared outcomes of cheilectomy with Cartiva to cheilectomy alone.

Methods:

A retrospective cohort study assessed the results at 1-year minimum follow-up, identifying patients by CPT code for cheilectomy with (28291) and without (28289) Cartiva interposition. There were forty-five patients: 26 in the Cartiva group and 19 in the cheilectomy group. Tabulated data included: age, gender; preoperative, 6-month, and final postoperative total first MTP ranges of motion (ROM); preoperative and final postoperative VAS and SF-36 scores; and reoperation information. Hallux rigidus grade was assessed by Coughlin and Shurnas criteria. First MTP joint space was measured at the medial, midline, and lateral portions of the joint on both AP and lateral radiographs before, immediately following, and at maximum postoperative follow-up (16 month mean). For analysis, medial, midline, and lateral joint measurements were averaged to generate a composite measure of radiographic joint space. Follow-up means were 23 months for all patients, 18 for Cartiva and 28 for cheilectomy.

Results:

Mean age was 54. Mean preoperative grade was 2.6 for Cartiva and 2.1 for cheilectomy (p=0.037). Mean preoperative ROM was 44°. At 1 year follow-up, ROM was 39° for Cartiva and 47° for cheilectomy (p=0.95). Mean VAS improved from 5.8 to 2.0 and 3.0 for Cartiva and cheilectomy, respectively, at final follow-up (p=0.002, p=0.004). Following Cartiva, two week postoperative joint space means increased: AP midline 1.4 to 2.6 mm, AP composite 1.4 to 2.2 mm, and lateral midline 1.3 to 2.7 mm (p<0.001). At final follow-up, joint space measures returned to levels similar to cheilectomy: AP midline 1.3 vs. 1.2 mm, AP composite 1.1 vs. 1.2 mm, and lateral midline 1.6 vs. 1.2 mm (p>0.3). Five patients in each group (22%) underwent revision.

Conclusion::

Cartiva offers similar intermediate-term ROM preservation and pain relief as cheilectomy in a cohort with higher grade hallux rigidus. Joint distraction gained by synthetic hydrogel interposition subsides with time to levels similar to cheilectomy. Revision surgery for persistent pain is common in both groups.
Extensile Anteromedial Approach for Total Ankle Arthroplasty
Authors: Kayum Shahin , Khan Ryan M. , Lee Jong Min , Daniels Timothy R.
Published: November 2020

Category:

Ankle

Introduction/Purpose:

Wound complications can lead to devastating outcomes in major ankle procedures such as total ankle arthroplasty. Up to 28% wound healing complications have been reported with anterior approach to the ankle. Anteromedial approach is an angiosome based approach for ideal wound healing especially in those with high risk factors.

Methods:

The procedure includes the following steps: 1. Make the Incision along the medial border of the anterior angiosome fed by anterior tibial artery and dorsalis pedis 2. Create full thickness lateral flap by dissecting through the extensor retinaculum, along the course of the tibialis anterior tendon 3. Stay sutures are placed full thickness through the retinaculum and EHL, the full thickness flap is then retracted laterally with the anterior neurovascular bundle 4. The interval between the tibialis anterior tendon and lateral flap is used to perform the total ankle replacement 5. Adequate and full exposure of the distal tibia and ankle joint is achieved. Retrospective chart review of patients who underwent anteromedial approach for elective ankle procedures from Jan 2012 to 2018 was performed. Patient demographics (age, BMI), medical comorbidities, smoking status, pertinent trauma history, follow up duration, and wound complications were collected.

Results:

Total 73 patients underwent extensile anteromedial approach. Mean age was 48, mean follow up was 24 (range 12 to 73) months. There were no instances of skin flap necrosis. One patient with chronic venous insufficiency developed a small superficial wound infection that healed with dressing changes alone.

Conclusion:

Anteromedial approach to ankle is a reasonable alternative to standard anterior approach to achieve optimal wound healing in ankle procedures in a high-risk patient for wound healing. The approach allows complete access to the ankle joint keeping the angiosomes intact which helps in excellent wound healing. [Figure: see text]
Biomechanical Comparison of FiberTape Device Repair Techniques of Ligamentous Lisfranc Injury in Cadaveric Model
Authors: Koroneos Zachary , Vannatta Emily , Kim Morgan S. , Fritsche Madelaine W. , Cowman Trevin , Kunselman Allen , Lewis Gregory , Aynardi Michael C.
Published: November 2020

Category:

Trauma; Basic Sciences/Biologics; Midfoot/Forefoot; Sports

Introduction/Purpose:

Lisfranc ligamentous injuries are complex. Controversy exists regarding their treatment and preferred method of fixation. Fixation methods employing a FiberTape device and interference screw fixation have been described as an alternative to traditional screw fixation. The purpose of this biomechanical study was to evaluate two methods of fixation utilizing interference screw fixation with FiberTape augmentation in a cadaveric model.

Methods:

9 paired cadaveric feet (mid tibia/fibula) were separated into two groups based on fixation method: FiberTape alone and FiberTape with supplementary limb into the middle cuneiform via anchor. At three joints of the midfoot (second metatarsal - medial cuneiform, intermediate cuneiform - medial cuneiform, second metatarsal - intermediate cuneiform), the diastasis and relative angular displacement between bones in the coronal plane were measured for static and cyclic loading. Measurements were obtained for the native (pre-injured), injured, and post-fixation in static loading. Fixed specimens then underwent stepwise increases in cyclic loading performed at 1 Hz and 100 cycles, at 100 N intervals from 500 to 1800 N ground reaction force. The Achilles tendon was also loaded to simulate postoperative weightbearing. Failure of fixation was defined as diastasis at the second metatarsal - medial cuneiform joint greater than 2 millimeters.

Results:

FiberTape specimens demonstrated diastasis failures of 3 of 9 (33%) specimens at cyclic loads of 1000 N. Conversely, FiberTape with supplementary limb specimens all survived past this loading magnitude, with 1 failing at supraphysiologic loads (>1200 N). The difference in diastasis at the second metatarsal-medial cuneiform joint was statistically significant between the two groups at forces of 1600N (p = 0.019) and 1800N (p = 0.029). There were no significant differences between the other joint diastases and relative angular displacements.

Conclusion:

The use of FiberTape for fixation of ligamentous Lisfranc injuries appears to provide a biomechanically viable alternative for withstanding early post-operative protected weightbearing. Furthermore, the use of a supplementary limb in addition to the FiberTape fixation method appears to enhance its biomechanical efficacy under cyclic loading especially at higher loads.
Two Year Follow-Up of Patient Reported Outcomes Following Third Generation Minimally Invasive Chevron Akin Osteotomies (MICA) in Hallux Valgus Surgery
Authors: Lewis Thomas L. , Ray Robbie , Gordon David
Published: November 2020

Category:

Bunion

Introduction/Purpose:

The aim of this study was to explore the 2 year results of third generation (using screw fixation) Minimally Invasive Chevron and Akin osteotomies (MICA) for hallux valgus correction. There is a paucity of published data regarding the outcomes of this relatively new technique. We present the largest series in the literature, using three separate validated patient-reported outcome measures (EQ-5DL, VAS Pain and Manchester Oxford Foot Questionnaire (MOXFQ), for this time point.

Methods:

A single surgeon case series of patients with hallux valgus underwent primary third generation minimally invasive chevron and akin osteotomies for hallux valgus correction. Between August 2015 and January 2018, 290 MICAs were performed in 203 patients that were eligible for 2 year follow up. Baseline and 2 year post-operative patient reported outcomes were collected for 164 feet in 130 patients (124 females; 6 males). Paired t-tests were used to determine the statistical significance of the difference between pre- and post-operative scores.

Results:

The mean age was 56.6 (range 29.5-81.0, standard deviation (s.d.) 10.9). At two year follow up, mean MOXFQ scores improved for each domain: Pain; baseline 40.6 (range 0-100, s.d. 22.8), reduced to 11.3 (range 0-75, s.d. 16.0, p<0.001); Walking; 36.0 (range 0-100, s.d. 25.9) reduced to 8.2 (range 0-75.0, s.d. 16.0, p<0.001); Social interaction; 46.7 (range 0-100, s.d. 24.3), reduced to 7.7 (range 0-75.0, s.d. 13.9, p<0.001). Mean VAS Pain score improved from 30.4 (range 0.0-90.0, s.d. 23.6) to 9.4 (range 0.00-70.0, s.d. 15.6, p<0.001). Mean EQ-5D index score improved from 0.750 (range 0.066-1.000, s.d. 0.148) to 0.892 (range 0.410-1.000, s.d. 0.135, p<0.001). Mean EQ-5D VAS score did not significantly improve from 81.9 (range 0-100, s.d. 17.1) to 83.0 (range 0-100, s.d. 18.0, p=0.559).

Conclusion:

This is the largest prospective case series of short-term patient reported outcomes using a validated assessment method for hallux valgus, following third generation MICA to date. These data show that this technique is effective at improving foot and ankle specific patient reported outcomes at 2 years. This cohort is being followed over the longer term.
Assessing Hallux Valgus using Automatically Segmented Weight Bearing CT Datasets: A Case-Control Study
Authors: Lintz Francois , Bernasconi Alessio , Fernando Céline , Netto Cesar de Cesar
Published: November 2020

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

Hallux Valgus (HV) is a complex 3D deformity. Coronal rotation of the first column has been advocated as a key component of its pathophysiology. Cone Beam Weightbearing CT (CB-WBCT) provides 3D images of the foot and ankle bones under physiological load and may provide any absolute or relative measurements. However, the fact that numerous bones and joints are concerned makes analysis time-consuming and results difficult to render and interpret. Artificial Intelligence based Automatic Segmentation (AIAS) is a new tool which allows for volumetric identification and localization of bones. The objective of this study was to use this tool to obtain exhaustive measurements of the whole first column relative to the second and third columns in HV and compare them to the normal population.

Methods:

Retrospective comparative, level III study including 16 HV cases and 16 controls matched for age, sex and BMI. Bilateral CB-WBCT images performed as standard care were available for each patient. Inclusion criteria were clinically identified HV cases with first intermetatarsal angle (IMA) >10° and HV angles (HVA) >15° as measured on digitally reconstructed radiographs. Patients under 18 years of age, history of trauma or surgery resulting in a potential modification of the forefoot were excluded. Datasets were analyzed using AIAS software which provided: 3D coordinates for spatial position and orientation and angles of the first, second and third metatarsals and cuneiforms, sesamoids, first phalanx of the first ray, navicular, talus, calcaneus. Normality was assessed using a Shapiro-Wilk test and differences between means were calculated using Welch’s unequal variances t-test.

Results::

Mean age and BMI were respectively 57.25 +- 9.65 years and 22.23 +- 2.85 kg.m2; 93.75% (31/32) feet came from women. The mean IMA was 12.9° +- 3° in HV and 8.7° +- 1.4° in controls. In the axial plane, the following measurements were found to be significantly different: IMA (p<0.001), first tarsometatarsal angle (p<0.001) and first-fifth metatarsal angle (p=0.001). In the coronal plane, sesamoid angle (p<0.001), sesamoid shift (p<0.001) and sesamoid rotation (p<0.001) were found significantly different, while first metatarsal torsion was similar in the two groups (p=0.347).

Conclusion::

The main finding of this study is that AIAS provided an exhaustive series of measurements in the 3 planes of space which were efficient in discriminating between HV and controls with highly significant figures, even when small numerical differences were observed. The introduction of CB-WBCT, which provides images taken during physiological standing stance, followed by the elaboration of data through AIAS (in order to determine absolute or relative positions of bones in space) may help increase efficiency in clinical daily practice.
Adverse Events Related to Polyvinyl Alcohol Hydrogel Hemiarthroplasty of 1st Metatarsal: An Analysis of Reports to the United States Food and Drug Administration
Authors: Metikala Sreenivasulu , Khamis Karim Mahmoud , O’Connor Kathryn , Chao Wen , Wapner Keith L. , Farber Daniel C.
Published: November 2020

Category:

Midfoot/Forefoot

Introduction/Purpose:

Polyvinyl Alcohol Hydrogel (PAH) hemiarthroplasty has gained popularity in the operative management of symptomatic hallux rigidus since its introduction to the US in July 2016. Despite encouraging initial results, any implant has the potential for complications that may not become apparent until it is in widespread use. Also, the series of publications supporting the effectiveness of PAH have come from a limited group of institutions and surgeons which creates an opportunity for observational bias. Other complications or unsatisfactory outcomes may be under-reported, such as those experienced in community centers due to the challenges in publishing lower volume work. In order to look at a broader range of potential complications, we reviewed the United States Food and Drug Administration’s (FDA) database and compared with published literature.

Methods:

The Manufacturer and User Facility Device Experience (MAUDE) database of the US Food and Drug Administration (FDA) was retrospectively reviewed between July 2016 and October 2019 using the assigned product code: PNW for the PAH implant. All the reported adverse events, implant-related complications, and secondary procedures were analyzed.

Results:

A total of 49 events have been reported to this voluntary database over the past 3 years while over 22,000 Cartiva devices have been implanted. Implant subsidence was the most common with 16 reported instances. Fragmentation of the device was observed in nine and four reports were related to infection in which two were deep infections needing antibiotic spacers. Bone erosion managed by grafting was documented in three reports and foreign body reaction was noted in one. Persistent pain and swelling were common presentations. Thirty-five of 49 reported events required additional operative procedures performed at a mean interval of 4.75 months following the index procedure while four more were awaiting further surgery. Conversion to fusion was the most common procedure, featured in 10 reports.

Conclusion::

The analysis of the MAUDE database disclosed certain device-related dysfunctions that have been under-reported in the published literature. Also, complications such as fragmentation, bone erosion and foreign body reaction have not been previously described. Awareness of these details will assist in decision-making and quality control. Due to the voluntary nature of reporting, the true incidence of each complication is unknown with the above data representing a baseline. Nonetheless, the MAUDE database serves as an illuminating source of information which would further be strengthened by a more robust and mandatory reporting of device-related complications. [Table: see text][Table: see text]
Arthroscopic Bone Marrow Stimulation for the Treatment of Osteochondral Lesions of the Talus Shows Promising Clinical Outcomes Over 10 Years
Authors: Park Jae Han , Lee Jin Woo , Park Kwang Hwan , Kim Sang B. , Park Yoo Jung , Han Seung Hwan
Published: November 2020

Category:

Arthroscopy; Ankle

Introduction/Purpose:

Arthroscopic bone marrow stimulation (BMS) has been considered as the 1st-line treatment for osteochondral lesions of the talus (OLT) with its simplicity, cost-effectiveness, low complication rate and successful clinical results in numerous studies. However, there were few studies which had investigated long-term clinical outcomes about the arthroscopic BMS. The purpose of this study is to evaluate the long-term outcomes of arthroscopic BMS for OLT and to identify prognostic factors that affect the outcomes.

Methods:

A retrospective analysis was performed for 202 ankles (189 patients) who underwent arthroscopic BMS as a primary surgery for the OLT between January 2001 and December 2008 with more than 10 years of follow-up. Visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scales, Foot and Ankle Outcome Score (FAOS) were assessed as clinical outcomes and re-operation data were collected. The clinical scores were compared along the stream of time. Kaplan-Meier plot and log rank test showed survival outcomes of OLT in the long-term follow-up. Factors associated with revision surgery were evaluated with multivariate Cox proportional hazard regression model.

Results:

The VAS scales were improved from 7.11 +- 1.73 (preoperatively) to 1.51 +- 1.61 (3 to 6 years after BMS), and 2.00 +- 1.67 (over 10 years after BMS) (P < 0.001). Also the AOFAS ankle-hindfoot scale were also improved from 58.39 +- 13.7373 (preoperatively) to 85.85 +- 10.31 (3 to 6 years after BMS), and 82.56 +- 11.62 (over 10 years after BMS) (P < 0.001). FAOS at final follow-up was compatible with those of other literatures with short- and mid-term follow-up. Re-operation rate was 5.94 % (12 / 202 ankles). According to multivariate regression analysis, significant factors associated with the revision surgery were large- size (greater than 150mm2) OLT (P = 0.009) and body mass index greater than 25 kg/m2 (P = 0.014).

Conclusion::

Arthroscopic bone marrow stimulation is an effective and reliable operative procedure for the primary treatment of osteochondral lesions of the talus with favorable long-term outcomes at a mean follow-up of 13.9 years. Therefore, we recommend this procedure for the 1st-line treatment of the OLT. Success of arthroscopic BMS depends on the size of the OLT and the body mass index of patients.
A Propensity Score Matched Analysis Comparing Outpatient and Short-Stay Hospitalization to Standard Inpatient Hospitalization Following Total Ankle Arthroplasty
Authors: Plantz Mark A. , Sherman Alain E. , Kadakia Anish R.
Published: November 2020

Category:

Ankle

Introduction/Purpose:

The number of total ankle arthroplasties (TAAs) performed annually has continued to increase over the last two decades. Given the current challenges of healthcare cost-control, the trend towards minimizing hospitalization and length of stay (LOS) after various procedures, including joint replacement, has become an area of interest. Currently, there are no large sample, propensity score matched analyses to assess the safety of ‘short-stay’ versus standard inpatient hospitalization following TAA.

Methods:

The American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP) was used to identify 1,141 patients who underwent primary and revision TAA between 2007 and 2017. Propensity score matching was used to compare the risk of 30-day unplanned readmission, reoperation, mortality, discharge destination, and several medical and surgical complications in patients with outpatient or short-stay inpatient hospitalization (LOS <= 1 day) versus standard inpatient hospitalization (LOS > 1 day). Patients were matched in a 1:1 ratio based on several factors, including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and several comorbidities (diabetes, smoking, COPD, congestive heart failure, hypertension, dialysis, and chronic steroid use). The incidence of various 30-day complications were compared between the two propensity score matched groups to assess for any differences in short-term outcomes after controlling for confounding risk factors.

Results:

A total of 892 patients were included in the propensity-score matched analysis, with 446 patients per group. The shorter LOS group had a significantly lower rate of medical complications (0.2% vs. 2.8%, p = 0.004) and non-home discharge (1.3% vs. 12.1%, <0.001). Additionally, the shorter LOS group had lower rates of unplanned readmission (0.4% vs. 1.1%, p = 0.256), reoperation (0.2% vs. 0.4%, p = 0.564), return to the OR (0.2% vs. 0.9%, p = 0.179), and surgical complications (0.4% vs. 2.0%, p = 0.057), although these results were not statistically significant.

Conclusion:

Propensity score matched comparative analysis demonstrated that outpatient and short-stay inpatient hospitalization can be just as safe as standard inpatient hospitalization after TAA. Length of stay should be dictated by the overall risk of complication. Outpatient or short-stay TAA should be considered for patients with low risk of short-term complications. [Table: see text]
Do Total Ankle Replacements have Worse Outcomes when Compared to Total Knee and Hip Replacements at 10 Years Post-Operatively? A Prospective Clinical Study
Authors: Ramaskandhan Jayasree Ramas , Siddique Malik S. , Smith Karen
Published: November 2020

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

There is paucity of literature comparing patient reported outcomes (PROMs) between total joint arthroplasties. There is a need to study the PROMS data to understand outcomes of treatment and factors affecting outcomes. We aimed to to study the PROMs data for total ankle replacement (TAR) to 10 years. To study how PROMS outcomes of TAR compare to total hip replacement (THR) and total knee replacement (TKR) at 10 years

Methods:

This is a prospective data collection from local hospital joint registry. 10 year follow up data was collected from patients who underwent a total joint replacement (Hip, Knee or ankle), provided informed consent for their data. Patients who refused consent, or had cognitive language problems were not approached for participation in the registry. Self-administered questionnaire data included WOMAC scores, Foot and ankle outcomes scores (FAOS), SF-36 scores and patient satisfaction data. Data was collected at pre-op, 3 years, 5 years and 10 years post operatively. Statistical tests including ANOVA, GLM univariate tests and chi-square tests were used for analysis.

Results:

There were 119 patients who underwent TAR for the duration of 2006-2009. 74 patients were male (62.18%). Average age of patients was 59.1 yrs. Data was available on 2672 THR and 3520 TKR patients. At 5 years, TAR patients reported lower scores for stiffness, similar outcomes to THR and TKR for mental health score, similar to TKR for ¾ physical domains (p<0.05), but lower satisfaction rates for ADL and recreation when compared to THR (p<0.05). We are currently processing the questionnaires for 10 year mailing returns (completion expected March 2020).

Conclusion:

The outcomes for TAR were similar to outcomes reported by TKR patients at 10 years but lower than THR. The lower score of TAR was due to stiffness and recreational activity comparing to THR. We aim to present the complete set of results if the abstract is accepted (data completion March 2020).
2020 IFFAS Award for Excellence Winner: Outcomes and Complications of Open versus Posterior Arthroscopic Subtalar Arthrodesis: A Prospective Randomized Controlled Multicenter Study
Authors: Rungprai Chamnanni , Jaroenarpornwatana Aekachai , Sripanich Yantarat , Chaiprom Nusorn
Published: November 2020

Category:

Hindfoot

Introduction/Purpose:

Open subtalar arthrodesis is a standard treatment for subtalar joint arthritis. Recently, posterior arthroscopic subtalar arthrodesis (PASTA) has been introduced and gained increasing popularity due to fasten recovery time and better cosmesis. However, there is limited current studies to report outcomes and complications between the two techniques. The purpose of this study is to compare outcomes and complications between open and PASTA techniques.

Methods:

A prospective, randomized collected data of 56 consecutive patients who were diagnosed with isolated subtalar arthritis and underwent either open (28 patients) or PASTA (28 patients) between 2016 and 2019 were enrolled in this study. The minimum follow-up time to be included in this study was 12 months. The primary outcome was union rate which was confirmed by post-operative CT scan. The secondary outcomes were union time, VAS, SF-36, FAAM, tourniquet times, and complications. A paired sample t-test was used to assess statistical differences between pre- and post-operative functional outcomes (VAS, SF-36, and FAAM) in the same group of both open and PASTA techniques while an independent t-test was used to compare functional outcomes (VAS, SF-36, and FAAM) between the two techniques. Results were significance at p < 0.05. Descriptive statistics were used for the demographic variables.

Results:

There were 56 patients (44 male and 12 female) with mean follow-up time was 17.7 months and 17.5 months for open and PASTA. The union time was significantly shorter in PASTA (9.4 vs 12.8 weeks, p<0.05). PASTA demonstrated significantly fasten recovery times (p<0.05 all) including time to return to ADL (8.4 vs 10.8 weeks), work (9.4 vs 12.8 weeks), and sports (9.4 vs 12.8 weeks). Both Open and PASTA techniques demonstrated significant improvement of all functional outcomes (FAAM, SF- 36, and VAS (p<0.01 all)); however, there was no significant difference between the two techniques. Other outcomes were not significant difference including tourniquet times (55.8 vs 67.2 minutes) and union rates (96.3 vs 100%) and complications.

Conclusion:

Both open and PASTA techniques demonstrated significant improvement of pain and function for treatment of patients with isolated subtalar joint arthritis. Although there was no significant difference of short-term of functional outcomes and complications, PASTA technique was better in term of shorten time to union and fasten time to return to sports.