bluuebunny/crossref_metadata_2025_split huggingface dataset:
Density and tailored breast cancer screening: practice and prediction – an overview
Authors: Wengert Georg J , Helbich Thomas H , Kapetas Panagiotis , Baltzer Pascal AT , Pinker Katja 
Published: September 2018

Mammography, as the primary screening modality, has facilitated a substantial decrease in breast cancer-related mortality in the general population. However, the sensitivity of mammography for breast cancer detection is decreased in women with higher breast densities, which is an independent risk factor for breast cancer. With increasing public awareness of the implications of a high breast density, there is an increasing demand for supplemental screening in these patients. Yet, improvements in breast cancer detection with supplemental screening methods come at the expense of increased false-positives, recall rates, patient anxiety, and costs. Therefore, breast cancer screening practice must change from a general one-size-fits-all approach to a more personalized, risk-based one that is tailored to the individual woman’s risk, personal beliefs, and preferences, while accounting for cost, potential harm, and benefits. This overview will provide an overview of the available breast density assessment modalities, the current breast density screening recommendations for women at average risk of breast cancer, and supplemental methods for breast cancer screening. In addition, we will provide a look at the possibilities for a risk-adapted breast cancer screening.
Effects of Exposure to New Car Interiors in Patients With Asthma and Allergic Rhinitis
Authors: Pepper Amber N. , Bulkhi Adeeb , Smith Catherine R. , Colli Matthias , Bergmann Karl-Christian , Zuberbier Torsten , Casale Thomas B. 
Published: September 2018

Rationale Vehicle interiors are an important microenvironment for atopic subjects. This study evaluated the subjective and objective physiologic and clinical effects of exposing subjects with asthma and allergic rhinitis to new 2017 Mercedes vehicles during 90-minute rides. Methods Ten adult asthmatics with allergic rhinitis were assessed before and 45 and 90 minutes into rides in a 2017 Mercedes-Benz S-Class sedan and GLE-Class SUV on 2 separate days. Assessments included spirometry, fractional exhaled nitric oxide, peak nasal inspiratory flow, asthma symptom scores, and physical examinations. Results Of the 10 subjects, 6 were women, mean age was 32 years, and 6 and 4 were using chronic asthma controllers or intranasal corticosteroids, respectively. None of the subjects had worsening of asthma or rhinitis symptoms during the rides. There were no statistically significant changes from baseline in forced expiratory volume in 1 second, forced expiratory volume in 1 second:forced vital capacity ratio, forced expiratory flow at 25%–75% of vital capacity, fractional exhaled nitric oxide, or peak nasal inspiratory flow at 45 or 90 minutes into the rides with either Mercedes vehicle (all P values > .1 using generalized linear mixed model). Conclusion The interior environment of the tested Mercedes vehicles did not cause changes in subjective or objective measures of asthma and allergic rhinitis. We suggest that this model system can be used to test other vehicles for putatively adverse effects on patients with allergic respiratory disorders.
Does Patient-specific Instrumentation Yield Better Component Position than Standard Instrumentation in Total Ankle Arthroplasty?
Authors: Escudero Mario , Wing Kevin , Waly Feras , Bemenderfer Thomas , Davis W. Hodges , Anderson Robert , Penner Murray 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: The unique anatomy and biomechanics of the ankle joint have made total ankle arthroplasty (TAA) challenging over the past few decades. Final implant position and successful soft tissue balancing are key components to the longevity of total ankle implants. Preoperative computer navigation, templating, and patient-specific instrumentation (PSI) have shown promising results in total ankle replacement with accurate and reproducible radiographic outcomes. Recent data has also suggested that even experienced surgeons benefit from the improved time efficiency of PSI. The purpose of this study is to determine if radiographic outcomes differ between patients undergoing TAA with PSI and those who undergo TAA with standard instrumentation (SI). Methods: The first 67 consecutive patients who underwent primary Infinity total ankle arthroplasty (TAA) at 2 North American sites between 2013 and 2015 were reviewed in a prospective observational study. All TAA’s were performed by one of four fellowship-trained foot and ankle surgeons. Demographic, radiographic, and functional outcome data was collected preoperatively, at 6-12 months postoperatively, and annually thereafter. The radiographic variables measured were the medial distal tibial angle (MDTA), talar tilt angle (TTA), lateral talar station (LTS), sagittal distal tibial articular angle (sDTAA), and the gamma angle. Acceptable intervals for each parameter were selected and TAAs were then categorized as being “correctly aligned” or “not correctly aligned” for all the parameters described. The rate of “correctly aligned” TAA’s was compared between cases with PSI and those with SI. Fisher’s exact test was used to analyze difference by groups. A significance of 5% was used. Results: Of a total of 67 TAAs included, 51 were in the PSI group and 16 in the SI group. No significant statistically differences were found between PSI and NPSI regarding MDTA (p=0.174), LTS (p=0.922), sDTAA (p=0.986), gamma angle (p=0.252) and TTA (p=0.145). We did not find a significant statistical difference in the rate of “correctly aligned TAR” when we compared both groups (p=0.35). Conclusion: This study suggests that both PSI and SI provide accurate and reproducible TAA radiographic alignment when performed by experienced surgeons. In view of previously published data demonstrating high levels of reproducibility for PSI in TAA, these data also suggest that PSI may offer a means for less experienced surgeons to achieve radiographic results similar to those achieved by experienced surgeons. It also suggests that experienced surgeons may not need to use PSI to achieve satisfactory implant alignment, though improved time efficiency with PSI, as demonstrated in other studies, may still be of benefit for experienced surgeons.
Predicting Failure in Total Ankle Arthroplasty. A COFAS study
Authors: Escudero Mario , Le Vu (Brian) , Veljkovic Andrea , Wing Kevin , Younger Alastair , Penner Murray 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) and ankle arthrodesis (AA) are standard treatment modalities for end-stage ankle osteoarthritis. The total ankle arthroplasty (TAA) anatomical alignment is critical for the longevity of total ankle components. Coronal and sagittal malalignment results in altered joint mechanics and reactive forces that result in implant failure. Also, to our knowledge, tibial component sizing in the sagittal plane has been addressed in knee arthroplasty literature, but not in ankle arthroplasty literature. Based on these parameters, we developed a novel radiographic predictive score for failure in TAA (RPSFT). Methods: A retrospective review performed on the COFAS database, selecting for all total ankle replacements done at a single institution between September 2004 and June 2015. Those with complete series of anteroposterior and lateral standing ankle radiographs, both preoperative and postoperative and a minimum of 1 year of follow-up, were included. We performed a multivariate logistic regression, using the medial distal tibial component angle, lateral talar station, talar tilt angle, and the absence of posterior under= or overhang of the tibial component in the first post-operative radiographs. These parameters were used to develop a RPSFT. Binomial regression was used to determine each variable’s weight in the RPSFT and assigned a corresponding score value. A univariate logistic regression was estimated, using the RPSFT as the independent variable and mechanical failure as the dependent variable. Then a Receiver-Operating Characteristic curve was constructed and the probability of failure for each possible score was estimated. Results: Of a total of 296 TAAs, 146 were included, and 8 TAAs required revision (5%). TAA revision was defined as a reoperation to remove one or both metal components, or amputation. According to our predictive score, if all the parameters are within established normal ranges (17 points) the TAA failure probability (TFP) is 2% [0-0.1] p<0.01. If none of them are obtained (0 points) the TFP rise to 42% p<0.01 (see attached table). Time to TAA failure averaged 4.4 years and ranged from 1.4 to 9.6 years. Conclusion: Our model suggests that a coronal and sagittal alignment and absence of tibial implant under/overhang are of vital importance to prevent TAA failure. To our knowledge, this is the first study that presents a predictive score for failure in TAA using postoperative ALSAR. Further data analyses are ongoing and may expand our predictive model to include other radiographic parameters.
Should 15° of Valgus Coronal-Plane Deformity Be the Upper Limit for a Total Ankle Replacement?
Authors: Halai Mansur , Mann Matthew , Khan Ryan , Pinsker Ellie , Daniels Timothy 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: Preoperative talar valgus deformity increases the technical difficulty of total ankle replacement (TAR) and is associated with an increased failure rate. Deformity of ≥15° has been reported to be a contraindication to arthroplasty. The goal of the present study was to determine whether the clinical outcomes of TAR for treatment of end-stage ankle arthritis were comparable for patients with preoperative talar valgus deformity of ≥15° as compared to those with <15°. Methods: Fifty ankles with preoperative coronal-plane tibiotalar valgus deformity of ≥15° (“valgus” group) and 50 ankles with valgus deformity of <15° (“control” group) underwent TAR. The cohorts were similar with respect to demographics and components used. All TARs were performed by a single surgeon. The mean duration of clinical follow-up was 5.5 years (minimum two years). Preoperative and postoperative radiographic measurements of coronal-plane deformity, Ankle Osteoarthritis Scale (AOS) scores and Short Form (SF)-36 scores were prospectively recorded. All ancillary (intraoperative) and secondary procedures, complications and measurements were collected. Results: The AOS pain and disability subscale scores decreased significantly in both groups. The improvement in AOS and SF-36 scores did not differ significantly between the groups at the time of the final follow-up. The valgus group underwent more ancillary procedures during the index surgery (80% vs 26%). Tibio-talar deformity improved significantly toward a normal weight-bearing axis in the valgus group. Secondary postoperative procedures were more common in the valgus group (36%) than the controls (20%). Overall, re-operation was not associated with poorer patient outcome scores. Metal component revision surgery occurred in seven patients (three valgus and four controls). These revisions included two deep infections (2%), one in each group, which were converted to hindfoot fusions. Therefore, 94% of the valgus group retained their original components at final follow-up. Conclusion: Satisfactory midterm results were achieved in patients with valgus mal-alignment of ≥15°. The valgus cohort required more procedures during and after their TAR, as well as receiving more novel techniques to balance their TAR. Whilst longer term studies are needed, valgus coronal-plane alignment of ≥15° should not be considered an absolute contraindication to TAR if the associated deformities are addressed.
Outcomes of Acute Hematogenous Periprosthetic Joint Infection in Total Ankle Arthroplasty Treated with Irrigation, Debridement, and Polyethylene Exchange
Authors: Lachman James , Ramos Jania A. , Nunley James , DeOrio James , Adams Samuel 
Published: September 2018

Category: Ankle Introduction/Purpose: Acute hematogenous periprosthetic joint infection(PJI) is defined in the literature as infection diagnosed and treated within two to four weeks from the onset of symptoms. In total hip and knee arthroplasty, irrigation, debridement(I&D) and polyethylene exchange with component retention is the treatment of choice. There is minimal literature evaluating this treatment method for PJI in total ankle arthroplasty (TAA), however, with four patients being the largest sample size. The purpose of this study was to evaluate both the clinical and patient reported outcomes and survivorship of treating PJI in TAA with I&D and polyethylene exchange in patients with acute hematogenous PJIs. Methods: A single center, retrospective chart review of prospectively collected data in patients with TAA PJI who subsequently underwent I&D and polyethylene exchange with retention of metal components was conducted. The primary outcome was failure rate of I&D and polyethylene exchange where failure was defined as subsequent removal of all components and two-stage revision or arthrodesis. Patient reported outcomes collected before primary arthroplasty, after primary arthroplasty and after polyethylene exchange were also analyzed. Results: We identified 11 patients with acute hematogenous PJI who underwent I&D/ polyethylene exchange with retention of metal components. The average time from onset of symptoms to I&D/ polyethylene exchange was 11.55 days +/-5.57. The mean follow-up after this surgery was 2.8 years +/-1.45. The long-term failure rate was 50%. The most common bacteria isolated in patients who failed was Methicillin Resistant Staphylococcus Aureus (MRSA). The most common bacteria isolated in patients who retained their implants was Methicillin Sensitive Staphylococcus Aureus(MSSA). Visual Analog Scale (VAS), Short Musculoskeletal Function Assessment (SMFA), Short Form-36 (SF36), and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale showed significant improvement when compared to preoperative scores in patients who retained their implants both after primary and after I&D and polyethylene exchange. Conclusion: I&D and polyethylene exchange with retention of metal components has comparable long-term survivorship to those reported in the Knee and Hip Arthroplasty literature. Patient reported outcomes after I&D and polyethylene exchange were comparable to those collected after primary arthroplasty in patients who ultimately retained their implants. Two variables which were independent predictors of failure of this surgery include duration of symptoms prior to I&D as well as organism isolated on culture. With a failure rate of 50%, the authors recommend thorough evaluation on a case by case basis prior to indicating a patient for single stage I&D with polyethylene exchange.
Posterior Malleolar Ankle Fractures
Authors: Mason Lyndon , Widnall James , Redfern James , Swanton Eric , Molloy Andrew 
Published: September 2018

Category: Ankle Introduction/Purpose: There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. In creating a treatment guiding classification and algorithm, we report our results in a system change in management of posterior malleolar fractures in our unit. Methods: All fractures were classified according to Mason and Molloy classification (Foot Ankle Int. 2017 Nov;38(11):1229-1235) based on CT scans obtained pre-operatively. This dictated the treatment algorithm. Type 1 fractures underwent syndesmotic fixation. Type 2A fractures underwent ORIF through a posterolateral incision, and type 2B and 3 fractures underwent ORIF through a posteromedial incision. The patient remained NWB for 6 weeks postoperative. Data was collected prospectively from December 2014 to July 2017. Results: Patient-related outcome measures were obtained in 50 patients with at least 1 year follow up (mean 18 months). The overall OMAS score for all posterior malleolar fractures in this cohort was 74.1 (range 35-100). According to Mason and Molloy classification, the mean OMAS for type 1 was 75.9 (Range 30-100), type 2A 75.0 (range 35-100), type 2B 74.0 (range 55-100) and type 3 70.5 (Range 35-100). Using one way ANOVA test, there was no significant difference (p=.886) between groups or within groups. There was a trend, however, that the lower the Mason and Molloy classification had higher OMAS outcomes. The overall 1-year EQ-5D index for this cohort was 0.88 (SD 0.22). The average visual analogue score for this patient group was 77.5 (SD 26.2). Conclusion: We have been able to demonstrate an improvement in functional scores for all posterior malleolar fractures with the treatment algorithm applied using the Mason and Molloy classification. This is compared to our previous study where traditional posterior malleolar management was undertaken. Our OMAS scores have now improved to what would be expected from unimalleolar fractures, illustrating the importance of understanding the injury mechanism and patterns of injury. Mason and Molloy type 3 fractures have marginally poorer outcomes, which correlates with a more significant injury.
Mechanical and Anatomical Axis in Total Ankle Arthroplasty
Authors: Najefi Ali-Asgar , Goldberg Andrew 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: Inadequate correction of alignment in the coronal, sagittal or axial planes will inevitably lead to failure of the Total Ankle Arthroplasty (TAA). The mechanical axis of the lower limb (MAL), the mechanical axis of the tibia (MAT) and the anatomical axis of the tibia (AAT) are three recognized coronal plane measurements using plain radiography. The relationship between anatomical and mechanical axes depends on the presence of femoral or tibial deformities from trauma or inherited conditions, or previous corrective or replacement surgery. Ankle arthroplasty relies heavily on preoperative radiographs or CT scans and the purpose of this study was to assess whether MAL, MAT and AAT are the same in a cohort of patients upon which placement of TAA is considered. Methods: We analysed 75 patients operated on between 2015 and 2016 at a specialist tertiary centre for elective orthopaedic surgery. All patients had a pre-operative long leg radiograph. They were split into 2 groups. The first group had known deformity proximal to the ankle (such as previous tibial or femoral fracture, severe arthritis, or previous reconstructive surgery) and the second group had no clinically detectable deformity. The MAL, MAT and AAT were assessed and the difference between these values was calculated. Results: There were 54 patients in the normal group, and 21 patients in the deformity group. Overall, 25 patients(33%) had a difference between all three axes of less than 1 degree. In 33 patients(44%), there was a difference in one of the axes of ≥2 degrees. There was no significant difference between MAT and AAT in patients in the normal group(p=0.6). 95% of patients had a difference of <1 degree. There was a significant difference between the MAT and AAT in patients in the deformity group(p<0.01). In the normal group, 39 patients(73%) had a difference of <2 degrees between the AAT and MAL. In the deformity group, only 10 patients (48%) had a difference of <2 degrees.In fact, 24% of patients had a difference ≥3 degrees. Conclusion: Malalignment in the coronal plane in TAA may be an issue that we have not properly addressed. Up to 66% of patients without known deformity may have a TAA that is placed at least 1 degree incorrectly relative to the MAL. We recommend the use of full-length lower limb radiographs when planning a TAA in order to plan the placement of implants. The decision to perform extramedullary referencing, intramedullary referencing, or patient specific Instrumentation must be part of the pre-operative planning process.
Restoration of Talar Height using a Modular Revision Prosthesis after Failed Total Ankle Arthroplasty
Authors: Steginsky Brian , Haddad Steven 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: Talar component subsidence is the most common indication for revision total ankle replacement. The management of talar bone loss and alteration in the ankle joint center of rotation is challenging following component subsidence. Unfortunately, ankle arthrodesis as a salvage procedure for failed ankle arthroplasty has been associated with high rates of nonunion and collapse. Equally unfortunate, there is paucity in the literature on revision total ankle arthroplasty. The purpose of this study was to report the early outcomes of revision total ankle replacement using a modular prosthesis and metal/cement augmentation to reconstitute talar height following catastrophic failure of the index total ankle arthroplasty. Methods: A retrospective review was performed on sixteen patients who underwent revision total ankle replacement for failed arthroplasty associated with talar component subsidence and subsequent talar bone loss. Demographic data, postoperative complications, index implant, and concomitant procedures were recorded. Radiographic measurements were performed at three time-points (preoperative, immediately postoperative, and most recent follow-up) to evaluate alignment of the prosthesis, talar height restoration, and range of motion. Results: Patient follow-up ranged from 9.3 –19.1 months, with a mean follow-up period of 12.2 months. The maximum preoperative and postoperative talar coronal misalignment was 16.2° and 3.5°, respectively. The mean preoperative and immediate postoperative talar height was 28.7 mm and 33.3 mm, respectively. There was a significant improvement in talar height of 4.6 mm after revision total ankle replacement (P<0.001). There was no difference in talar height between the immediate postoperative visit and latest follow-up visit (33.2 mm). The mean preoperative and postoperative radiographic arc of motion was 19.5° and 24.0°, respectively. Ten patients (62.5%) did not sustain complications post surgical. Three patients developed a superficial wound complication that healed without additional surgery. One patient required a transmetatarsal amputation. Other complications included neuritis and DVT. Conclusion: Revision ankle replacement using a modular prosthesis with metal/cement augmentation allows restoration of talar height. Though we recognize this data constitutes a very early follow up, this cohort has utilized the revision ankle implant with significant repetitive load after which older generation implants underwent secondary subsidence due to poor talar bone stock. Early outcomes demonstrate a predictable method to salvage catastrophic prosthesis failure associated with severe talar subsidence and deformity. The risk of postoperative complications, although moderate, is an acceptable alternative to lower limb amputation/arthrodesis. Further follow up is warranted to determine functional outcomes and longevity of revision implant systems.