Large-volume osteochondral lesions of the talus present a difficult dilemma for the treating physician. The purpose of this study was to evaluate the clinical outcomes of talar lesions with a volume ...of >3000 mm(3) treated with fresh bulk osteochondral allograft transplantation.
Fifteen patients (mean age, 41.9 years) who had symptomatic osteochondral lesions of the talus with a mean volume of 6059 mm(3) underwent fresh matched osteochondral allograft transplantation. All patients were followed prospectively for a minimum of two years and were evaluated with use of the pain score on a visual analog scale, which ranged from 0 to 10, and the American Orthopaedic Foot and Ankle Society ankle-hindfoot score, which had a maximum of 100 points. Patient satisfaction and radiographic stability of the graft were also assessed.
All patients were available for follow-up at an average fifty-four months after surgery. Two ankles subsequently underwent conversion to an ankle arthrodesis at thirty-two and seventy-six months, respectively. With the scores for these patients included (at the time of arthrodesis), the mean pain score had improved from 8.5 to 3.3 and the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score had improved 45 points, from 38 to 83 points. Overall, five patients rated the result as excellent, six as good, two as fair, and two as poor.
Bulk fresh osteochondral allograft transplantation to the talus is a viable reconstructive option for patients with large-volume cystic lesions of the talar dome. Graft stability and viability are maintained both structurally and functionally over a mean follow-up period of 4.5 years (minimum, two years).
The overall rate of complications after ankle fracture fixation varies between 5% and 40% depending on the population investigated, and wound complications have been reported to occur in 1.4% to ...18.8% of patients. Large studies have focused on complications in terms of readmission, but few studies have examined risk factors for wound-related issues in the outpatient setting in a large number of patients. A review was performed to identify risk factors for wound complications tracked in the hospital and outpatient setting.
Four hundred and seventy-eight patients underwent open reduction and internal fixation of an ankle fracture between 2003 and 2010 by a single surgeon at a single institution. Demographic characteristics, time to surgery, comorbidities, and postoperative care were tracked. Wound complications were defined as those requiring dressing care and oral antibiotics or requiring further surgical treatment.
Of the 478 patients who were followed, six (1.25%) had wounds requiring surgical debridement. Fourteen patients (2.9%) required further dressing care or a course of oral antibiotics. There were significant associations between wound complications and a history of diabetes (p < 0.001), peripheral neuropathy (p = 0.003), wound-compromising medications (p = 0.011), open fractures (p = 0.05), and postoperative noncompliance (p = 0.027). There was a significant difference in age between patients with and without wound complications (p = 0.045). We did not identify a relationship between time to surgery and complications.
These results highlight the difficulty of treating medically complex and noncompliant patient populations. With careful preoperative monitoring of swelling, time to surgery does not affect wound outcome. The failure of the patient to adhere to postoperative instructions should be a concern to the treating surgeon.
Background:
Three-dimensional custom cages can be used to treat complex ankle and hindfoot pathology and bone loss with potentially better patient satisfaction and higher fusion rates than ...tibiotalocalcaneal (TTC) fusion alone or in combination with bulk femoral head allograft. Yet there is limited literature to support this procedure. The purpose of this study is to objectively quantify the clinical and radiologic outcomes of patients undergoing patient-specific 3D-printed custom cage implantation to fill large defects around the ankle joint region as part of a limb-salvaging TTC fusion.
Methods:
This is a retrospective review of 21 patients (mean age 59.3 years) who underwent custom cage implantation with a TTC retrograde fusion nail by a single surgeon for massive bone loss of the ankle and hindfoot. Patient charts were reviewed for pain and functional outcomes, complications, and various demographics, including number of previous surgeries to the ipsilateral ankle. Mean follow-up was 32 months. All 21 patients had preoperative and postoperative pain and function scores available for analysis.
Results:
A total of 20 (95.2%) of the 21 patients had their cage in situ at final follow-up. Overall, with the numbers available, visual analog scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, and the 12-Item Short Form Health Survey (SF-12) mental and physical health scores significantly improved from preoperative to final follow-up. However, when compared to the overall US population of age-matched 55- to 64-year-old individuals, patients still remained relatively disabled. There were 2 failures, one of which required amputation and the other was treated nonoperatively with bracing.
Conclusion:
In conclusion, in this relatively small, single-surgeon series, we found that 3D-printed custom cage technology offered a viable option for complex TTC fusion procedures performed in the presence of significant bone loss, with good fusion rates, however relatively modest improvement in functional outcomes.
Level of Evidence:
Level IV, retrospective case series.
Background:
Minimum clinically important difference (MCID) defines a threshold when determining clinically significant treatment improvement. Visual analog scale (VAS) and Foot and Ankle Ability ...Measure activities of daily living (FAAM-ADL) are commonly used for measuring hallux valgus correction. This study aimed to determine MCID in VAS pain and FAAM-ADL scores for hallux valgus correction and additionally, to identify variables influencing achievement of the VAS pain MCID.
Methods:
Patients undergoing hallux valgus surgery were retrospectively included. VAS pain, FAAM-ADL, and pain satisfaction surveys were collected preoperatively and minimum 1-year postoperatively. Using a 6-point Likert-type pain satisfaction scale, patients reporting low postoperative satisfaction scores 1 through 3 were categorized as “dissatisfied,” and high satisfaction scores 4 through six as “satisfied.” One distribution-based method and 2 anchor-based methods were used to calculate MCID. Further, a logistic regression was calculated to determine if one group (defined by sex, pain satisfaction, preoperative VAS pain, concomitant lesser toe deformity correction, and specific hallux valgus correction procedure) had a greater likelihood of achieving the VAS pain MCID threshold. This study included 170 patients with postoperative follow-up averaging 23.6 months.
Results:
Calculated MCID scores ranged from 1.8 to 5.2 points for VAS pain and 11.1 to 22.7 points for FAAM-ADL. Moderate deformity correction with proximal first metatarsal osteotomy (Ludloff) (OR=2.236, P = .036) or severe deformity correction with first tarsometatarsal arthrodesis (Lapidus) (OR=3.145, P = .046); and higher preoperative pain scores (OR=1.045, P < .010) had significantly higher odds of meeting VAS pain MCID.
Conclusion:
This study demonstrated MCID values that may indicate significant pain and function improvement after hallux valgus correction. Higher preoperative pain, and utilization of proximal metatarsal osteotomy or first tarsometatarsal arthrodesis for moderate or severe deformity correction resulted in significantly greater likelihood of reaching the VAS pain MCID than utilizing distal metatarsal and/or proximal phalanx osteotomy for mild deformity treatment.
Level of Evidence:
Level IV, validating outcome measures.
Background:
Most studies on Achilles tendon ruptures involved US military or European populations, which may not translate to the general US population. The current study reviews 406 consecutive ...Achilles tendon ruptures occurring in the general US population for patterns in a tertiary care subspecialty referral setting.
Methods:
An institutional review board–approved, retrospective review of the charts of 331 (83%) males (6 bilateral, nonsimultaneous) and 69 (17%) females diagnosed with Achilles tendon ruptures over a 10-year period was undertaken. Average age was 46.4 years with 310 (76%) ruptures diagnosed and managed acutely (less than 4 weeks), whereas 96 (24%) were chronic (more than 4 weeks since the injury). Patients were assessed for mechanism of injury and previously described underlying risk factors. Results were assessed according to age (greater or less than 55 years), body mass index (BMI), and time to diagnosis.
Results:
Sporting activity was responsible for 275 ruptures (68%). This was higher in patients younger than 55 years of age (77%) than those older than 55 years (42%). Basketball was the most commonly involved sport, accounting for 132 ruptures (48% of sports ruptures, 32% of all ruptures), followed by tennis in 52 ruptures (13%, 9%), and football in 32 ruptures (12%, 8%). In all, 20 ruptures were reruptures of the same Achilles tendon, of which 17 had previously been treated nonsurgically. In this study, recent quinolone use (2%) and African American race (31%) were not major risk factors for rupture as described in other studies. Older patients and patients with a BMI greater than 30 were more likely to be injured in nonsporting activities and more likely to have their diagnosis initially not recognized resulting in their presentation more than 4 weeks following the injury.
Conclusion:
In this study, sports participation was the most common mechanism, but not to the same extent seen in the European or US military studies. Basketball was the most commonly involved sport, as compared to soccer in Europe. Age and BMI had a directly proportional correlation with time to diagnosis.
Level of Evidence:
Level II, epidemiologic study.
Background:
Total ankle replacement (TAR) and ankle fusion (AF) are the 2 major operative options for treatment of advanced ankle arthropathy; there is, however, no large epidemiologic study ...comparing nationwide trends of these 2 procedures. The current study used a nationwide database to compare epidemiologic profiles of TAR and AF.
Methods:
Data collected for the Nationwide Inpatient Sample (NIS) from 2000 to 2010 were reviewed. Procedures were identified by searching for ICD-9-CM codes 81.11 (AF) and 81.56 (TAR). Patients’ demographics and comorbidities, geographic distribution, and cost of procedures were compared.
Results:
The NIS analysis identified 2666 TAR and 16 419 AF cases which was extrapolated to 13 145 TAR and 80 426 AF nationwide. Spearman’s ρ showed an increase in the number of AF per year while the number of TAR cases remained relatively flat per year until 2006, after which there was a steady increase in the number of TAR performed. Patients receiving a TAR tended to be older, female, and white. Patients who underwent AF were more likely to be obese or diabetic than TAR patients. Both TAR and AF were performed more frequently in private urban hospitals through 2007. However, in 2010, the number of TAR procedures was greater in academic centers compared to private urban hospitals.
Conclusions:
Despite recent increases in the number of TAR implanted, AF was still performed more than 6 times more frequently for advanced ankle arthropathy. A trend was demonstrated toward an increasing number of TAR being implanted in academic centers, and in patients with more underlying comorbidities than was previously seen.
Level of Evidence:
Level II, prognostic study.
Recurrence of hallux valgus: a review Raikin, Steven M; Miller, Adam G; Daniel, Joseph
Foot and ankle clinics,
06/2014, Letnik:
19, Številka:
2
Journal Article
Recenzirano
Recurrence of hallux valgus deformity can be a common complication after corrective surgery. The cause of recurrent hallux valgus is usually multifactorial, and includes patient-related factors such ...as preoperative anatomic predisposition, medical comorbidities, compliance with postcorrection instructions, and surgical factors such as choice of the appropriate procedure and technical competency. For a successful outcome, this cause must be ascertained preoperatively. Although the algorithm to determine which intervention should be used is not unlike that of primary hallux valgus surgery, operative correction of hallux valgus recurrence can be challenging. This article discusses these challenges, complications, causes, and techniques.
Background
Fractures to the fifth metatarsal metaphyseal-diaphyseal junction (Jones fracture) have high nonunion rates. Surgical intramedullary screw fixations have excellent results but a high ...refracture rate. This has been associated with inadequate screw size and too early return to activity.
Hypothesis
Varus hindfoot alignment overloads the lateral column of the foot and acts as a predisposing factor to the development of and failure of treatment of Jones fractures.
Study Design
Case series; Level of evidence, 4.
Methods
Twenty-one primary Jones fractures (20 patients) treated surgically with a 4.5-mm cannulated screw were retrospectively reviewed. Detailed clinical and radiographic data and outcomes were recorded, including measurements of hindfoot alignment.
Results
A 100% union rate with return to prior activity level and no refractures were found at a mean follow-up of 49 months. Clinical varus was present in 16 feet, whereas radiographic measurements revealed 18 of 21 hindfeet to be in varus. The mean calcaneal pitch angle was 28.5°, and the mean Meary angle was 13° convex upward. Patients with varus alignment were fitted postoperatively with lateral hindfoot and forefoot posted orthotic inserts to correct alignment.
Conclusion
The majority of patients sustaining Jones fractures have evidence of varus hindfoot alignment. This may be a predisposing factor to developing the fracture or refracture after fixation. Postoperative varus unloading (lateral hindfoot and forefoot posting) orthotic insert appears to be helpful in preventing reinjury or refracture of Jones fractures.
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