Category:
Ankle; Hindfoot
Introduction/Purpose:
Tibiotalocalcaneal (TTC) arthrodesis is a treatment option for several pathologies of the hindfoot and ankle. Traditional fixation options include ...intramedullary nailing or plate-screw constructs. In certain patients, for example when bone quality or post-operative compliance are of concern, more robust fixation may be desired. Charcot neuroarthropathy (CN) patients in particular often have complex deformities, poor bone quality, and impaired sensation. New trauma literature shows hybrid nail-plate constructs (NPCs) may permit early weight bearing in osteoporotic distal femur fractures. We report early results of TTC arthrodesis using NPCs in patients with complex deformities of the ankle and hindfoot.
Methods:
Patients undergoing TTC arthrodesis via intramedullary nail fixation plus plating by a single surgeon from September 2020 to December 2022 were included in our study. Indications included CN, post-traumatic deformities, and advanced arthritis. Age, comorbidities, Hemoglobin A1c, presence of an ulcer, implants, bone graft used, and postoperative complications were retrospectively recorded.
Results:
Fifteen patients met inclusion criteria. Six patients had CN; eight patients had post-traumatic complications; and one patient had an arthritic cavovarus deformity. Average age was 55 years (range 31-72). Eleven patients were treated with a lateral TTC locking plate; three were treated with an anterior tibiotalar arthrodesis plate; and one was treated with a 3.5mm reconstruction plate. All patients were treated with a TTC arthrodesis nail. In all cases, cellular bone matrix was used; in fourteen cases, autograft was also used. Average follow-up was 35 weeks (min. 12). Three patients underwent below-knee amputation, two for infection and the other for hardware failure. Two others required postoperative debridements but subsequently cleared their infections. Twelve patients have a stable, non-infected, ulcer free foot at latest follow-up.
Conclusion:
TTC arthrodesis can be used for a variety of indications, and many of these patients present complex challenges. Patients with CN in particular often have severe deformities and poor bone quality. Hybrid fixation methods provide added stability in complex cases, possibly allowing for more powerful deformity correction and earlier weight-bearing. We report a 80% favorable outcome rate in our case series, with major complications confined to patients with significant medical comorbidities (poorly controlled diabetes, peripheral vascular disease). We believe that TTC arthrodesis with hybrid nail-plate constructs represents an attractive solution to complex ankle and hindfoot deformities.
The role of genetic and environmental factors, as well as their interaction, in the natural history of asthma, allergic rhinitis and chronic obstructive pulmonary disease (COPD) is largely unknown. ...This is mainly due to the lack of large-scale analytical epidemiological/genetic studies aimed at investigating these 3 respiratory conditions simultaneously. The GEIRD project is a collaborative initiative designed to collect information on biomarkers of inflammation and oxidative stress, individual and ecological exposures, diet, early-life factors, smoking habits, genetic traits and medication use in large and accurately defined series of asthma, allergic rhinitis and COPD phenotypes. It is a population-based multicase-control design, where cases and controls are identified through a 2-stage screening process (postal questionnaire and clinical examination) in pre-existing cohorts or new samples of subjects. It is aimed at elucidating the role that modifiable and genetic factors play in the occurrence, persistence, severity and control of inflammatory airway diseases, by way of the establishment of a historical multicentre standardized databank of phenotypes, contributed by and openly available to international epidemiologists. Researchers conducting population-based surveys with standardized methods may contribute to the public-domain case-control database, and use the resulting increased power to answer their own scientific questions.
Objective We aimed to characterize the effect of vaginal or abdominal mesh insertion and of different collagen augmentation of polypropylene mesh in a sheep model. Outcome measures were passive and ...active biomechanical properties and semiquantitative morphometry. Study Design Forty-two Texel sheep were used: 6 were nonimplanted controls (n = 6), the rest were implanted with polypropylene mesh (n = 12; Avaulta Solo; Bard Medical, Covington, GA) or collagen-coated meshes: Avaulta Plus (n = 12; Bard Medical) and Ugytex (n = 12; Sofradim International, Trevoux, France). Through a single incision, the rectovaginal septum was dissected and a 35 × 35–mm mesh was sutured to the underlying tissues. Abdominally, a 50 × 50–mm mesh was laid over a primarily sutured full thickness 40-mm longitudinal incisional defect. Animals were explanted after 60 or 180 days (n = 6 per group). Outcome measures were passive biomechanics by biaxial tensiometry, active contractility of vaginal explants, and histologic evidence. Results Vaginal explants were 2.4 times stiffer compared with native vaginal tissue ( P < .001), but without differences in comfort zone stiffness or slope of the load-elongation in the physiologic range between the products that were tested. Collagen coating was associated with a 16-fold reduction in contractile force at 180 days, compared with native vaginal tissue, both for Avaulta Plus ( P = .032) and Ugytex ( P = .015). Abdominal explants were 1.3-times stiffer compared with native abdominal wall tissue ( P < .001) and were 1.9-times stiffer compared with vaginal explants. Conclusion Vaginal mesh implantation yields less stiff explants compared with abdominal explants. Vaginal mesh implantation also alters the passive and active biomechanical properties compared with native vaginal tissues. Collagen matrices did not reduce the number of graft-related complications.
Background:
Weightbearing computed tomography (WBCT) is becoming a valuable tool in the evaluation of foot and ankle pathology. Currently, cost analyses of WBCT scanners in private practice are ...lacking in the literature. This study evaluated the costs of acquisition, utilization, and reimbursements for a WBCT at a tertiary referral center, information of particular interest to practices considering obtaining such equipment.
Methods:
All WBCT scans performed at a tertiary referral center over the 55-month period (August 2016 to February 2021) were retrospectively evaluated. Patient demographics, pathology location, etiology, subspecialty of the ordering provider, and whether the study was unilateral or bilateral were collected. Reimbursement was calculated based on payor source as a percentage of Medicare reimbursement for lower extremity CT. The number of total scans performed per month was evaluated to determine revenue generated per month.
Results:
Over the study period, 1903 scans were performed. An average of 34.6 scans were performed each month. Forty-one providers ordered WBCT scans over the study period. Foot and ankle fellowship-trained orthopaedic surgeons ordered 75.5% of all scans. The most common location of pathology was the ankle, and the most common etiology was trauma. The device was cost neutral at 44.2 months, assuming reimbursement for each study was commensurate with Medicare rates. The device became cost neutral at approximately 29.9 months when calculating reimbursement according to mixed-payor source.
Conclusion:
As WBCT scan becomes more widely used for evaluation of foot and ankle pathology, practices may be interested in understanding the financial implications of such an investment. To the authors’ knowledge, this study is the only cost-effectiveness analysis of WBCT based in the United States. We found that in a large, multispecialty orthopaedic group, WBCT can be a financially viable asset and a valuable diagnostic tool for a variety of pathologies.
Level of Evidence:
Level III, diagnostic.
Category:
Other
Introduction/Purpose:
Weightbearing Computed Tomography (WB CT) is becoming a valuable tool in the evaluation and understanding of foot and ankle pathology. With this, more practices ...may be interested in acquiring WB CT scanners and understanding cost effectiveness of acquisition. To date there are currently no US based reports of cost analysis of WB CT scanners. Our study is a cost analysis of WB CT at tertiary referral physician owned practice.
Methods:
Data was collected for all patients who underwent imaging utilizing a weight bearing CT scanner at our institution from the date of acquisition in 2016. For ease of analysis and applicability of information across orthopedic practices, Medicare reimbursement was used as a uniform estimation of reimbursement across all insurances at a rate of $163.50 per scan. We then compared the number of scans obtained per month to total costs related to acquiring and maintaining the WB CT machine. Secondary variables collected included patient demographic information, pathology location (forefoot, midfoot, hindfoot), and utilization of the device by subspecialty.
Results:
A WB CT scanner was acquired by a private group in 2016. A proforma analysis demonstrated $179,000 to acquire the machine, $30,000 for extended warranty, $995 for additional licenses. Between August 2016 and February 2021, 1702 unilateral studies and 100 bilateral studies were performed. Patients ranged in age from 6 to 92. Average age was 45 years with 45.9% male and 54.1% female. Forty-one staff utilized the CT scanner from various subspecialties with 5 Foot and Ankle (F&A) surgeons ordering 80% of scans. When dividing total costs by number of months since acquisition the monthly cost of the device is $3,318 which requires 20 scans per month when using Medicare reimbursement rates. Over a 55 month the average number of scans per month is 34. When dividing the cost of acquisition by reimbursement per scan, the breakeven point was 1,284 scans which occurred at approximately 3 years.
Conclusion:
As WB CT scans become a valuable tool for the analysis of foot and ankle pathology, groups may be interested in understanding the financial implications of such an investment. Our study is the only cost analysis based in the United States of WB CT. We found that WB CT is a cost-effective tool that can be used to evaluate a number or pathologies in the foot and ankle.
Category:
Hindfoot; Diabetes
Introduction/Purpose:
Charcot arthropathy is a disorder known to have poor outcomes with a high risk of amputation. Life expectancy, lifetime amputation rates and ...five-year mortality rates approach 50%. Patients often present with multiple medical comorbidities, poor bone quality and severe deformity. They have difficulty following non-weight bearing precautions postoperatively leading to fixation failure, recurrent instability and wound problems. Recent trauma literature has shown that a nail plate construct (NPC) provides a good option for elderly patients with poor bone quality sustaining distal femur fractures. This intervention has afforded these low demand patients increased stability allowing early weightbearing while maintaining good clinical results. Implementing this concept, we report early results with a novel application of NPCs in patients with charcot arthropathy of the ankle and hindfoot.
Methods:
Patients with Charcot arthropathy undergoing tibiotalocalcaneal fusion via combination of intramedullary nail fixation and lateral variable angle locked plating by a single surgeon from September 2020 to August 2021 were included in our study. Age, comorbidities, Hemoglobin A1c, smoking status, ambulatory status, presence of an ulcer, history of infection, implants used, bone graft used, tourniquet time, and postoperative complications were retrospectively recorded.
Results:
Four patients with hindfoot charcot deformities were included in our case series. Two men and two women with an average age of 58 years (range, 45-67 years) were treated. Three patients were diabetic with an average Hemoglobin A1C of 6.9 (range 5.2-10.7). Three patients had an active or impending ulcer. All patients were treated with a tibiotalocalcaneal variable angle locked plate around a hindfoot fusion nail with fibular autograft and biologic adjunct. Follow-up ranged from 4-12 months. All patients were made non-weight bearing, but all reported weightbearing in the perioperative period. Three of the four patients have a stable, non-infected, ulcer free foot and are ambulating in commercially available footwear (75% favorable outcome). One patient suffered a deep infection which was ultimately treated with below-knee amputation. This patient was morbidly obese, failed prior ORIF of the ankle, and was on vancomycin at time of presentation.
Conclusion:
Charcot arthropathy is a difficult pathologic process to treat surgically with high rates of complications. This difficult patient population often is unable to follow non-weight bearing precautions putting them at increased risk for failure. NPCs, as described in new trauma literature, promote encouraging results in patients with poor bone quality permitted early weight bearing. Hindfoot nail with variable angle locked plate combination for unstable ankle and hindfoot charcot arthropathy yields a 75% favorable outcome with early results consisting of 3 patients with functional limb salvage and 1 patient with below knee amputation.
Category:
Diabetes; Hindfoot; Trauma
Introduction/Purpose:
Tibio-talar-calcaneal (TTC) fusion nails are commonly used to treated acute ankle fractures in patients with diabetes, Charcot arthropathy ...or other comorbidities. Recently, Paragon28 released the Phantom Hindfoot Fusion Nail (Phantom nail) with a unique design feature-a proximal coil.
Methods:
We present the case of a diabetic patient with an ankle fracture-dislocation treated with the Paragon28 nail who experienced early implant failure.
Results:
A 48-year-old male with HIV, end-stage renal disease requiring hemodialysis, and insulin-dependent diabetes mellitus with severe peripheral neuropathy presented a trimalleolar ankle fracture-dislocation treated with a TTC nail. At his first follow- up, he presented with early implant failure at the nail-coil interface.
Conclusion:
The integrity of the Phantom nail, appropriate length, and placement of the flex coil require further evaluation. Unstable pathologies such as fractures may be better stabilized with a solid nail construct.
Primary heart tumors in fetuses are rare and mainly represent rhabdomyomas. The tumors have a variable expression and can be associated with arrhythmias, including both wide and narrow QRS ...tachycardia. Although multiple Doppler techniques exist to assess fetal heart rhythm, it can be difficult to record precise electrophysiological abnormalities in fetal life.
Investigations defining precise electrophysiological diagnosis were performed by using fetal magnetocardiography (fMCG).
In addition to routine fetal echocardiography, fMCG was used to investigate electrophysiological rhythm patterns in a series of 10 fetuses with cardiac rhabdomyomas.
The mean gestational age of the fetuses was 28.6 ± 4.7 weeks. The multiple rhabdomyomas were mainly located in the right and left ventricles as well as around the atrioventricular groove. Arrhythmias or conduction abnormalities were diagnosed in all 10 patients, although only 6 of them were referred due to that indication. Remarkably, 80% (8 of 10) had associated Wolff-Parkinson-White pre-excitation. In addition, we found prominent P waves in 4 fetuses.
In fetuses with rhabdomyomas, a disease where rhythm pathology is common, precise electrophysiological diagnosis can now be made by fMCG. fMCG is complimentary to echocardiography for rhythm assessment and can detect conduction abnormalities that are not possible to diagnose prenatally with M-mode or pulsed Doppler ultrasound. Risk factor assessment using fMCG can support pregnancy management and postnatal treatment and follow-up.
Category:
Other; Ankle Arthritis; Hindfoot; Midfoot/Forefoot
Introduction/Purpose:
Allograft is routinely used to enhance bone healing in foot and ankle surgery. One allograft in particular employs ...viable cells and bone scaffolding in a gel base. There is little evidence that compares how this material effects rate of fusion (ROF) and time to fusion (TTF) when compared to autograft in routine forefoot, midfoot, and hindfoot fusions. Our study investigates the use of a viable cellular allograft and its effect on these two variables in a population of patients undergoing fusions in the foot and ankle.
Methods:
A retrospective review was conducted over a five-year span of patients undergoing fusions in the foot and ankle where the cellular allograft was used. We compared the ROF and TTF between the following three graft groups: cellular allograft alone, autograft alone, and combined allograft + autograft. Data was retrieved from the patients' electronic medical record and TTF was recorded as the time, in days, it took for a solid radiographic fusion to form. Secondary variables collected included etiology of disease (post-traumatic, inflammatory, or diabetic arthropathy) and also analyzed for effect on ROF and TTF.
Results:
Two hundred and twenty-five patients underwent a fusion in the foot or ankle over a five-year period. Autograft alone was used in 101 patients, the cellular allograft alone was used in 88 patients, and a combination of autograft and the cellular allograft was used in 36 patients. Each group were similar in their comorbid conditions and demographics. The ROF of the autograft only group was 88% (89/101), compared to the cellular allograft group's ROF of 89% (78/88), and the combination graft group's ROF of 75% (27/36). The average TTF between each group varied slightly, with the cellular allograft group fusing the fastest at 86, followed by the autograft alone group at 97 days, and the combined group at 112 days.
Conclusion:
Our study investigated the use of a viable cellular allograft and its effect on ROF and TTF compared to autograft alone and autograft combined with said cellular allograft. We found no significant difference in ROF between autograft alone and the cellular allograft alone but did find a significant difference in ROF for the combined group resulting in lower rate of fusion. Additionally, use of the cellular allograft resulted in fastest time to fusion compared to autograft alone or a combination of the graft types.
Category:
Hindfoot; Ankle
Introduction/Purpose:
Total talus replacement (TTR) has emerged as a novel treatment for talar avascular necrosis and severe trauma to the talus. Despite TTR first being ...described over 35 years ago, many questions still remain regarding the procedure.
The objective of this study was to summarize the evidence on third-generation TTR's, focusing on surgical indications, surgical technique, prosthesis design, clinical outcomes, and postoperative complications.
Methods:
MEDLINE and EMBASE were queried and data abstraction was performed by 2 independent reviewers. Inclusion criteria for the articles were (1) peer-reviewed clinical studies with levels of evidence from I to IV, (2) with at least 5 patients, (3) reporting clinical outcomes of third-generation TTR's that were not done in conjunction with a total ankle arthroplasty, and (4) with a minimum clinical follow-up of at least 6 months.
Results:
Five studies met inclusion criteria for analysis including 101 ankles in 97 patients. The mean reported patient age was 52.8 years. The most common indication for TTR was avascular necrosis (86%), followed by trauma (10%), and tumor (4%). The mean follow up was 40 months. 98% of TTR's were performed through an anterior approach. There was significant variation in implant material, with 60% alumina ceramic, 27% cobalt chromium, 9% titanium, and 4% stainless steel. Only 3 studies obtained preoperative outcome measures, but these all demonstrated improvement at final follow up. Average dorsiflexion after TTR was 6.1 degrees and average plantarflexion was 35.1. Only 5% of ankles had complications requiring return to the operating room and only 2% of the total taluses were revised.
Conclusion:
While evidence is limited, short-term and mid-term results are promising for TTR as it demonstrates improvement in ankle function and has a low rate of revision. As the consequences of failure of a TTR are significant, including pantalar fusion or below knee amputation, higher quality studies and long-term results are needed to further evaluate this procedure.
PDF
