Background
Nonunion is one of the most common and devastating complications following midfoot joint arthrodesis. Many different types of bone grafts and bone substitutes have been used to promote ...osseous fusion. However, there is no consensus on the gold standard bone grafting material and whether biologic materials should be used alone or in combination. The purpose of this study is to investigate the efficiency of highly porous β-tricalcium phosphate (β-TCP) with bone marrow aspirate concentrate (BMAC) in midfoot joint arthrodesis.
Methods
This retrospective comparative study included patients who underwent midfoot joint arthrodesis using compression screws. Patients were classified into 2 groups: arthrodesis with highly porous β-TCP and BMAC (group A) and arthrodesis without them (group B). The osseous union rate was compared between the 2 groups. A total of 44 patients (46 feet) including 89 joints were included in this study.
Results
There was a significant difference in the union rate between the 2 groups: 91.5% (43/47 joints) in arthrodesis with highly porous β-TCP and BMAC (group A) and 76.2% (32/42 joints) in arthrodesis without highly porous β-TCP and BMAC (group B; P = .048).
Conclusion
This study investigated the efficiency of highly porous β-TCP and BMAC to promote bony healing in midfoot joint arthrodesis. A significantly higher union rate was shown when arthrodesis was performed with highly porous β-TCP and BMAC, compared with arthrodesis performed without them. We suggest that highly porous β-TCP and BMAC can be a viable and effective adjunct to the fixation in midfoot joint arthrodesis.
Level of Evidence:
Level III: Retrospective comparative analysis
Background
The most common indications for revision of first metatarsophalangeal joint (MTPJ) arthrodesis are symptomatic failures of prior arthrodesis, failed hallux valgus correction, and failed ...MTPJ arthroplasty implants. However, the outcomes of revision MTPJ arthrodesis have rarely been studied. The purpose of this study was to compare the clinical, radiographic, and patient-reported outcomes of revision MTPJ arthrodesis following different primary procedures.
Methods
A retrospective review of revision MTPJ arthrodesis cases between January 2015 and December 2019 was performed. The radiographic results, patient-reported outcomes, and rates of complications, subsequent revisions, and nonunions, were analyzed and compared preoperatively and postoperatively. A multivariate analysis was utilized to determine risk factors for complications and reoperations.
Results
This study yielded a total of 79 cases of revision MTPJ arthrodesis. The mean follow-up time was 365 days (SD ± 295). The overall complication rate was 40.5%, of which the overall nonunion rate was 19.0%. Seven cases (8.9%) required further revision surgery. The multivariate analysis revealed that Diabetes mellitus was associated with significantly higher overall complication rates (
p
= 0.016), and nonunion was associated with “in-situ” joint preparation techniques (
p
= 0.042). Visual Analog Scale (VAS) significantly improved postoperatively (
p
< 0.001); However, PROMIS-10 physical health and PROMIS-10 mental health did not change significantly during the study period.
Conclusion
Treatment of MTPJ surgery failures is a clinical challenge in orthopedic surgery. In our study, revision of first MTPJ surgery resulted in higher nonunion rates and overall complication rates compared to typical outcomes from primary MTPJ arthrodesis. Diabetes, Tobacco use, and “in-situ” joint preparation technique were found to be independent risk factors for complications and reoperations.
Level of evidence
III—Retrospective Cohort Study.
Th17 cells have been investigated in mice primarily for their contributions to autoimmune diseases. However, the pathways of differentiation of Th17 and related Th cells (type 17 cells) and the ...structure of the type 17 memory population in humans are not well understood; such understanding is critical for manipulating these cells in vivo. By exploiting differences in levels of surface CCR6, we found that human type 17 memory cells, including individual T cell clonotypes, form an elongated continuum of type 17 character along which cells can be driven by increasing RORγt. This continuum includes cells preserved within the memory pool with potentials that reflect the early preferential activation of multiple over single lineages. The phenotypes and epigenomes of CCR6+ cells are stable across cell divisions under noninflammatory conditions. Nonetheless, activation in polarizing and nonpolarizing conditions can yield additional functionalities, revealing, respectively, both environmentally induced and imprinted mechanisms that contribute differentially across the type 17 continuum to yield the unusual plasticity ascribed to type 17 cells.
“Cup-shaped power reamers” and “flat cuts” (FC) are common joint preparation techniques in first metatarsophalangeal (MTP) joint arthrodesis. However, the third option of an “in situ” (IS) technique ...has rarely been studied. This study aims to compare the clinical, radiographic, and patient-reported outcomes (PROMs) of the IS technique for various MTP pathologies with other MTP joint preparation techniques. A single-center retrospective review was performed for patients who underwent primary MTP joint arthrodesis between 2015 and 2019. In total, 388 cases were included in the study. We found higher nonunion rates in the IS group (11.1% vs 4.6%, p = .016). However, the revision rates were similar between the groups (7.1% vs 6.5%, p = .809). Multivariate analysis revealed that diabetes mellitus was associated with significantly higher overall complication rates (p < .001). The FC technique was associated with transfer metatarsalgia (p = .015) and a more first ray shortening (p < .001). Visual analog scale, PROMIS-10 physical, and PROMIS-CAT physical scores significantly improved in IS and FC groups (p < .001, p = .002, p = .001, respectively). The improvement was comparable between the joint preparation techniques (p = .806). In conclusion, the IS joint preparation technique is simple and effective for first MTP joint arthrodesis. In our series, the IS technique had a higher radiographic nonunion rate that did not correlate with a higher revision rate, and otherwise similar complication profile to the FC technique while providing similar PROMs. The IS technique resulted in significantly less first ray shortening when compared to the FC technique.
Background
There is still a controversy regarding the most optimal fixation instruments and bone graft materials for midfoot joint arthrodesis. We present the results of midfoot joint arthrodesis ...using compression plate with lag screw augmenting with highly porous β-tricalcium phosphate (β-TCP) and bone marrow aspirate concentrate (BMAC).
Methods
We performed a retrospective review of patients undergoing midfoot joint arthrodesis using compression plate with lag screw augmenting with highly porous β-TCP and BMAC from January 2014 to May 2019. The radiographic bony union rate was investigated. Postoperative complications and reoperations were also reviewed. A total of 36 patients (37 feet) including 75 joints were available in this study.
Results
A high union rate was achieved as of 97.3% in 73 of 75 joints. Nonunion occurred in 2 patients including 2 joints. Other than nonunion, there were no major complications such as deep infection. Minor complications (5 of 75 joints, 6.7%) included hardware irritations. Reoperations were required in 1 patient for revision of arthrodesis and symptomatic hardware removal was performed in all 5 hardware irritation cases.
Conclusion
Based on our results, the fixation construct of compression plate with lag screw augmenting with highly porous β-TCP and BMAC is safe and effective for midfoot joint arthrodesis with an excellent union rate and a low complication rate.
Level of Evidence:
IV, retrospective case series
Category:
Bunion; Midfoot/Forefoot
Introduction/Purpose:
The majority of hallux valgus (HV) corrections have been historically performed via a two-dimensional, transverse plane-focused approach, ...which has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of HV deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two-dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion historically entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near- immediate weightbearing.
Methods:
A prospective multicenter study that will continue for 60 months post-operatively. Patients 14-58 years old with symptomatic HV (intermetatarsal and HV angles between 10-22° and 16-40°, respectively) and no prior HV surgery on the operative foot were eligible for this study. Patients were treated with an instrumented TMTA procedure using a biplanar plating system with protected early weightbearing. The primary endpoint of this study is radiographic recurrence of HV deformity at 24 months for subjects with successful correction (defined as IMA < 9°, HVA < 15° and TSP ≤ 3 at 6 weeks post-procedure).
Recurrence is defined by any two of the three conditions: IMA of ≥12°, HVA ≥20° and TSP ≥4. Secondary outcomes (return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) were evaluated post-operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data.
Results:
173 patients underwent TMTA with mean age of 41.0 (range:14-58) years; 92% females. Median (range) time-to-follow-up is 25 (1.5-49.2) months. Eighteen (10.4%) patients have discontinued. Mean (SD) days to protected weightbearing in CAM boot and return to full work were 8.4 (7.4) and 57.9 (46.2), respectively. At 24 months post-procedure, 99.3% (134/135) of patients were recurrence-free. Statistically significant improvements from baseline in HVA, IMA, and TSP (Table 1), VAS score, MOxFQ and PROMIS domains were observed as early as 6 weeks post-operatively and maintained over time. In 143 patients, mean (95% CI) 24-month improvements were VAS: 3.9 (3.5, 4.2); Walking/Standing (MOxFQ): 39.2 (34.9, 43.4); Physical Function (PROMIS): 9.7 (8.3, 11.2). Nineteen (11.0%) patients experienced hardware complications yet maintained radiographic correction.
Conclusion:
The results of this study’s primary and secondary endpoints provide supporting evidence that TMTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing and low recurrence while demonstrating favorable clinical and patient-reported outcomes. Patients exhibited meaningful pain reduction after surgery and were able to return to full, unrestricted work and activities in less than two months, on average. Statistically significant improvements in patients’ health-related quality-of-life were observed through 36 months, post-operatively. Patients will continue to be followed for up to 60 months with additional evaluations for complications, recurrence, and patient satisfaction.
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