The surgical treatment of end-stage tibiotalar arthritis continues to be a controversial topic. Advances in surgical technique and implant design have lead to improved outcomes after both ankle ...arthrodesis (AA) and total ankle arthroplasty (TAA), yet a clear consensus regarding the most ideal form of treatment is lacking. In this study, the outcomes and complications following AA and TAA are compared in order to improve our understanding and decision-making for care and treatment of symptomatic tibiotalar arthritis.
Studies reporting on outcomes and complications following TAA or AA were obtained for review from the PubMed database between January 2006 and July 2016. Results from studies reporting on a minimum of 200 total ankle arthroplasties or a minimum of 80 ankle arthrodesis procedures were reviewed and pooled for analysis. All studies directly comparing outcomes and complications between TAA and AA were also included for review. Only studies including modern third-generation TAA implants approved for use in the USA (HINTEGRA, STAR, Salto, INBONE) were included.
A total of six studies reporting on outcomes following TAA and five reporting on outcomes following AA met inclusion criteria and were included for pooled data analysis. The adjusted overall complication rate was higher for AA (26.9%) compared to TAA (19.7%), with similar findings in the non-revision reoperation rate (12.9% for AA compared to 9.5% for TAA). The adjusted revision reoperation rate for TAA (7.9%) was higher than AA (5.4%). Analysis of results from ten studies directly comparing TAA to AA suggests a more symmetric gait and less impairment on uneven surfaces after TAA.
Pooled data analysis demonstrated a higher overall complication rate after AA, but a higher reoperation rate for revision after TAA. Based on the existing literature, the decision to proceed with TAA or AA for end-stage ankle arthritis should be made on an individual patient basis.
Posterior malleolus fracture Irwin, Todd A; Lien, John; Kadakia, Anish R
Journal of the American Academy of Orthopaedic Surgeons
21, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Posterior malleolus fractures are a common component of ankle fractures. The morphology is variable; these fractures range from small posterolateral avulsion injuries to large displaced fracture ...fragments. The integrity of the posterior malleolus and its ligamentous attachment is important for tibiotalar load transfer, posterior talar stability, and rotatory ankle stability. Fixation of posterior malleolus fractures in the setting of rotational ankle injuries has certain benefits, such as restoring articular congruity and rotatory ankle stability, as well as preventing posterior talar translation, but current indications are unclear. Fragment size as a percentage of the anteroposterior dimension of the articular surface is often cited as an indication for fixation, although several factors may contribute to the decision, such as articular impaction, comminution, and syndesmotic stability. Outcome studies show that, in patients with ankle fractures, the presence of a posterior malleolus fracture negatively affects prognosis. Notable variability is evident in surgeon practice.
Acute rupture of the Achilles tendon is common and seen most frequently in people who participate in recreational athletics into their thirties and forties. Although goals of treatment have not ...changed in the past 15 years, recent studies of nonsurgical management, specifically functional bracing with early range of motion, demonstrate rerupture rates similar to those of tendon repair and result in fewer wound and soft-tissue complications. Satisfactory outcomes may be obtained with nonsurgical or surgical treatment. Newer surgical techniques, including limited open and percutaneous repair, show rerupture rates similar to those of open repair but lower overall complication rates. Early research demonstrates no improvement in functional outcomes or tendon properties with the use of platelet-rich plasma, but promising results with the use of bone marrow-derived stem cells have been seen in animal models. Further investigation is necessary to warrant routine use of biologic adjuncts in the management of acute Achilles tendon ruptures.
Depending on its unique advantages, 3D printing will lead a surgeon to precision medicine and provide patients with better treatment effects at lower cost 8, 9. The authors found that the diameter of ...the femoral ceramic head had no significant impact on the stability of the acetabular cup. X. Liu et al. evaluated the application of mixed reality (MixR) technology during transforaminal percutaneous endoscopic discectomy (TPED), and optical see-through head-mounted displays (OST-HMDs) were used to assist operation. Acknowledgments We would like to express our great gratitude to Xin Chen from the Center for Joint Surgery of Southwest Hospital for language support and appreciate all authors and editors who contributed to this special issue.
Lateral ankle sprains and instability are an increasingly identified pain point for patients, accounting for 20 to 25% of musculoskeletal injuries. Lateral ankle injuries are especially concerning ...given the propensity for patients to develop chronic lateral ankle instability and for the high risk of reinjury on an unstable ankle. With the complex articulation of the tibiofibular syndesmosis, subtalar, and talocrural joints, pinpointing ankle dysfunction remains difficult. Multiple reviews have evaluated management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Although multiple surgical options exist, many nonsurgical functional options have also been developed for patients that may help patients prevent the development of chronic lateral ankle instability. In recent times, many new options have come up, including in-office needle arthroscopy and continual advancements in diagnosis and our understanding of this difficult topic. Multiple reviews have evaluated the management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Given this, this review will help to highlight new diagnostic and nonsurgical therapeutic options for the management of lateral ankle instability.
As the cost of health-care delivery rises in the era of bundled payments for care, there is an impetus toward minimizing hospitalization. Evidence to support the safety of open reduction and internal ...fixation (ORIF) of ankle fractures in the outpatient setting is largely anecdotal.
Patients who underwent ORIF from 2005 to 2013 were identified via postoperative diagnoses of ankle fracture and Current Procedural Terminology codes; patients with open fractures and patients who were emergency cases were excluded. Patients undergoing inpatient and outpatient surgical procedures were propensity score-matched to reduce differences in the baseline characteristics. Primary tracked outcomes included medical and surgical complications, readmission, and reoperation within 30 days of the procedure. Binary logistic regression models were created that determined the risk-adjusted relationship between admission status and primary outcomes.
Outpatient surgical procedures were associated with lower rates of urinary tract infection (0.4% compared with 0.9%; p = 0.041), pneumonia (0.0% compared with 0.5%; p = 0.002), venous thromboembolic events (0.3% compared with 0.8%; p = 0.049), and bleeding requiring transfusion (0.1% compared with 0.6%; p = 0.012). Outpatient status was independently associated with reduced 30-day medical morbidity (odds ratio, 0.344 95% confidence interval, 0.201 to 0.589). No significant differences were uncovered with respect to surgical complications (p = 0.076), unplanned reoperations (p = 0.301), and unplanned readmissions (p = 0.358).
In patients with closed fractures and minimal comorbidities, outpatient ORIF was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, reoperations, and readmissions relative to inpatient. Factors unaccounted for when creating matched cohorts may impact our results. Our findings lend reassurance to surgeons who defer admission for low-risk patients.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Achilles tendon rupture is a common injury to the lower extremity that requires appropriate treatment to minimize functional deficit. Available treatments of Achilles tendon ruptures include ...nonoperative, open surgical repair, percutaneous repair, and minimally invasive repair. Open surgical repair obtains favorable functional outcomes with significant potential for deep soft tissue complications, calling into question the value of open repair. Percutaneous repair is an alternative option with comparable functional results and minimal soft tissue complications; however, sural nerve injury is a complication. Minimally invasive Achilles repair offers optimal results with superior functional outcomes with minimal soft tissue complications and sural nerve injury.
•Isolated sustentaculum tali fractures are rare injuries.•Cases with Mal-union of sustentaculum tali with tarsal tunnel syndrome have been reported in the literature.•Cases with talo-calcaneal ...coalition have been reported in the literature.•This is a rare case with a combination of mal-union sustentaculum tali fracture in the presence of talo-calcaneal coalition leading to symptoms of tarsal tunnel syndrome.•A combination of S. tali mal-union with talo-calcaneal coalition and tarsal tunnel syndrome makes this case unique
Displaced isolated fractures of sustentaculum tali are rare. Inadequate treatment of these injuries can rarely lead to non-union or mal-union and in most cases are treated non-surgically. We report a unique case of undiagnosed mal-union of sustentaculum tali in the setting of underlying tarsal coalition that resulted in symptoms of tarsal tunnel. Osteotomy and excision of the mal-united fragment and coalition along with decompression of the tarsal tunnel was performed. The patient had immediate improvement in pain and the paraesthesia recovered by the end of 6 weeks post-operatively. The Foot and Ankle disability score (FADI) score improved from 26.0 pre-operatively to 96.2 at 3 years’ follow-up. This case highlights that isolated fractures of sustentaculum tali warrant advanced imaging and surgical reduction and fixation may be appropriate to avoid long-term disability where displacement compromises the tarsal tunnel or function of the subtalar joint.
Background:
Substantial attention has recently been placed on fractures of the posterior malleolus. Fracture extension to the posteromedial rim (“posterior pilon variant”) may result in articular ...incongruity and talar subluxation. Current classification systems fail to account for these fractures. The relative frequency of this fracture, its associated patient characteristics, and the reliability of its diagnosis have never been reported in such a large series.
Methods:
We retrospectively identified 270 patients who met our inclusion criteria. Basic demographic data were collected. The fractures were classified according to Lauge-Hansen and AO/OTA. Additional radiographic data included whether the fracture involved the posterior malleolus and whether the fracture represented a posterior pilon variant. Univariate statistical methods, chi-square analysis, and interobserver reliability were assessed.
Results:
The relative frequency of posterior malleolus fracture was 50%. The relative frequency of the posterior pilon variant was 20%. No significant difference was noted with respect to the frequency of posterior malleolar or posterior pilon variant between the subgroups of the AO/OTA and Lauge-Hansen classification systems when compared to the overall fracture distribution. Patients with posterior malleolar fractures and posterior pilon variants were significantly older. Females were significantly more likely than men to sustain posterior malleolar fractures and posterior pilon variants. Patients with diabetes trended toward a greater risk of both types of fractures. Interobserver reliability data revealed substantial agreement for posterior malleolar fractures and posterior pilon variants.
Conclusion:
These data represent the highest reported rate of posterior malleolar involvement in operatively treated ankle fractures and is the first to describe the percentage of the posterior pilon variant in such a large series. The interobserver reliability data demonstrate substantial agreement in identification of posterior malleolar fractures and the posterior pilon variant based on plain radiographs. Certain patient characteristics such as age, sex, and diabetes may be associated with these fractures.
Level of Evidence:
Level III, retrospective cohort study.
Given the trend toward value-based care, there has been increased interest in minimizing hospital length of stay (LOS) after orthopedic procedures. Outpatient total ankle arthroplasty (TAA) has ...become more popular in recent years; however, research on surgical outcomes of this procedure has been limited. This study sought to employ large sample, propensity score-matched analyses to assess the safety of outpatient and short-stay discharge pathways following TAA.
The ACS NSQIP database was used to identify 1141 patients who underwent primary and revision TAA between 2007 and 2017. Propensity score matching was used to match patients based on several factors, including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and several comorbidities. The incidence of various 30-day complications was compared between the short and standard LOS groups to assess for any differences in short-term outcomes.
A total of 892 patients were included in the final propensity score-matched analysis, with 446 patients in each group. The short LOS group had a significantly lower rate of medical complications (0.2% vs. 2.5%, p = 0.006) and non-home discharge (1.3% vs. 12.1%, p < 0.001). There was no significant difference in operative complications (0.4% vs. 1.8%, p = 0.107), unplanned readmission (0.4% vs. 1.1%, p = 0.451), reoperation (0.2% vs. 0.4%, p > 0.999), return to the OR (0.2% vs. 0.9%, p = 0.374), or mortality (0.7% vs. 0.0%, p > 0.249) between the short and standard LOS groups.
Outpatient and short-stay hospitalization had comparable safety to standard inpatient hospitalization after TAA. Outpatient or short-stay TAA should be considered for patients with low risk of short-term complications.
PDF
