Intraoperative Assessment of Reduction of the Ankle Syndesmosis

PURPOSE OF REVIEW

Postoperative malreduction of the ankle syndesmosis is common, poorly defined, and its assessment is controversial. In the absence of a gold standard method to evaluate the ankle syndesmosis, a variety of techniques have been described. As the knowledgebase expands, data illustrating caveats for such techniques has become available. The purpose of this review is to highlight literature-sourced technical pearls and their related caveats for the intraoperative assessment of the ankle syndesmosis.

RECENT FINDINGS

Although numerical criteria are commonly used to assess syndesmotic reduction, anatomical variation in the healthy population frequently exceeds proposed cutoffs. Patient-specific uninjured anatomy can be defined by comparing to the uninjured contralateral ankle; however, side-to-side variation is present for many anatomical relationships. Advanced imaging (e.g., lateral radiographs, 3-dimensional radiography) can influence intraoperative surgeon decision-making and improve syndesmosis reduction, but minute improvements in syndesmosis reduction may not outweigh increased operating time and costs. Intraoperative imaging is an adjunct, not a replacement for direct visualization or palpation when reducing the syndesmosis. Arthroscopy may benefit younger patients with high physical demands by improving identification of intra-articular pathology absent on MRI. Although anatomical reduction is important to restore pre-injury biomechanics, it is unclear whether differences in reduction quality influence patient-reported outcomes. In the absence of a gold standard, awareness of the options for intraoperative assessment of the syndesmosis and their respective accuracy and limitations reported herein could enhance surgeons' ability to intraoperatively reduce the syndesmosis with the tools currently available.

Ankle osteoarthritis: comprehensive review and treatment algorithm proposal

Ankle osteoarthritis (OA) is much less frequent than knee or hip OA, but it can be equally disabling, greatly affecting the quality of life of the patients.

Approximately 80% of ankle OA is post-traumatic, mainly secondary to malleolar fractures, being another of the main causes untreated in chronic instability. The average age of the patient affected by ankle OA is around 50 years, being therefore active patients and in working age who seek to maintain mobility and remain active.

The authors conducted a comprehensive review of the conservative, medical, and surgical treatment of ankle OA.

Initial conservative treatment is effective and should be attempted in any stage of OA. From a pharmacological point of view, non-steroidal anti-inflammatory drugs (NSAIDs) and intra-articular infiltrations can produce temporary relief of symptoms.

After the failure of conservative-medical treatment, two large groups of surgical treatment have been described: joint-preserving and joint-sacrificing procedures.

In the early stages, only periarticular osteotomies have enough evidence to recommend in ankle OA with malalignment. Both ankle arthrodesis and ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of the disease.

Finally, the authors propose a global treatment algorithm that can aid in the decision-making process.

Total Talar Replacement With Custom-Made Vitallium Prosthesis for Talar Avascular Necrosis

Background: The current study investigated the application of three-dimensional (3D) printing technology in the treatment of talar avascular necrosis (TAN). Custom-made Vitallium talar prostheses were designed and generated via 3D printing. We hypothesized that these talar prostheses would facilitate more stable positioning, better ergonomically fit the ankle joint surfaces, and promote favorable long-term prognoses. Material and Methods: Computed tomography scans of both ankle joints were acquired from three patients diagnosed with TAN. The talar on the unaffected side was used as the design blueprint. Hence, with the aid of 3D printing technology a customized talar prosthesis made from a novel Vitallium alloy could be manufactured for each individual patient. Results: In all three cases there were no signs of prosthesis loosening or substantial degenerative change in the surrounding area of the joint, but small osteophytes were observed on the tibial side and navicular side. No chronic infection or other prosthesis-related complications were observed in any of the patients. All three were able to walk without pain at the most recent follow-up. Conclusion: With the aid of 3D printing and a novel Vitallium alloy, total talar replacement achieved encouraging results in 3/3 patients. All patients were satisfied with their joint function, and were able to return to their daily activities without limitations. Although more cases and longer-term follow-up periods are required, the success rate reported herein is encouraging.

Association of Elevated Body Mass Index and Outcomes of Arthroscopic Treatment for Osteochondral Lesions of the Talus

Background:

Osteochondral lesions of the talus (OLTs) are a common condition found in patients with chronic ankle pain after previous ankle sprains. Surgical management is indicated after conservative management has failed.

Hypothesis/Purpose:

This study evaluates the influence of body mass index (BMI) on the early clinical outcomes of arthroscopic debridement and microfracture of OLTs.

Methods:

A total of 252 patients with symptomatic OLTs who failed conservative management underwent arthroscopic debridement and microfracture of OLTs over the affected ankle between 2007 and 2017. Patients from this cohort were divided into 2 groups based on BMI: the normal BMI group (NB Group) (BMI 18.5-25.0) and overweight and obese BMI group (OB Group) (BMI ≥25). Visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and the physical and mental component summaries of the 36-Item Short-Form Health Survey (PCS and MCS, respectively) were prospectively collected from the cohort during their standard postoperative outpatient follow-up.

Results:

The NB Group (n=105) and OB Group (n=147) were well matched demographically. The operative duration was significantly shorter for the NB Group compared to the OB Group. Patients from both groups had significant improvements in VAS, AOFAS, and PCS scores postoperatively at 6 and 24 months after surgery ( P < .05). Between both groups, patients had comparable VAS, AOFAS, and PCS scores at preoperation, 6 months postoperation, and 24 months postoperation ( P > .05). However, MCS in the OB Group was lower at 24 months postoperatively compared with the NB Group ( P < .05). The OB Group reported better satisfaction scores (82.4% vs 72.6%, P < .05), and a greater proportion had their expectations met (88.2% vs 77.9%, P < .05).

Conclusion:

A BMI ≥25 was not associated with worse postoperative pain and functional outcomes, but rather was found to be associated with greater satisfaction and fulfillment. However, patients with BMI ≥25 required longer procedure duration and had poorer MCS scores at 24 months after surgery. Level of Evidence: Level III, retrospective cohort study.

Mid-Term Functional and Radiological Outcomes of Total Ankle Replacement in an Asian Cohort

There are limited studies looking at longer-term outcomes of the total ankle replacement (TAR) in the Asian cohort. Asian ankles are smaller in size and are more varus compared to Western cohorts. Cultural differences also require increased ankle range of motion demands. Therefore, assessment of longer-term functional and radiological outcomes in the Asian cohort is warranted. Between 2007 and 2015, 43 consecutive patients received a 3-component, cementless, unconstrained, fully congruent TAR. Patients were followed up over a mean 8 (range 5-14 years). Preoperative and postoperative AOFAS ankle-hindfoot score (AOFAS-AHS), visual analogue score (VAS), physical and mental component scores of the SF-36 (PCS and MCS respectively) were calculated. European Foot and Ankle Score was also recorded at 8 years. Radiographs were reviewed postoperatively to assess implant position and study evidence of implant loosening and impingement. At 8 years, survivorship was 83.5%. Reasons for implant removal included infection (n = 2) and aseptic loosening (n = 5). AOFAS-AHS, VAS MCS at 8 years postoperatively were comparable to outcomes at 2 years postoperatively (p > .05). PCS at 8 years demonstrated improvement compared to 2 years postoperatively (49 ± 7 vs 42 ± 11, p = .048). Radiographic impingement was noted in 9 cases (20.9%). Radiological loosening was noted in 8 cases with 5 cases requiring revision surgery. At 8 years postoperatively, clinical outcomes, radiological outcomes and survivorship following TAR in an Asian cohort are satisfactory and comparable to that found in existing literature. Long-term studies are required to ascertain survivorship of TAR. Implant design with the Asian cohort in mind may yield improved outcomes.

Outcomes of Single-Stage Versus Staged Treatment of Osteochondral Lesions in Patients With Chronic Lateral Ankle Instability: A Prospective Randomized Study

Background:

There is controversy about whether treatment of chronic lateral ankle instability (CLAI) with osteochondral lesions of the talus (OLT) can be performed concurrently.

Purpose:

To investigate the midterm results of arthroscopic treatment of CLAI combined with OLT in different surgical settings. It was hypothesized that the outcomes of treating both injuries at the same time would not be inferior to those of staged surgery.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

Included were 103 patients with both CLAI and OLT who underwent arthroscopic microfracture surgery and an open, modified Broström-Gould procedure for ligament repair from January 2015 to December 2016. The patients were assigned randomly to a staged group (51 patients) and a single-stage group (52 patients). The staged group underwent arthroscopic debridement of the OLT and microfracture, then rehabilitation for 4 to 6 months before undergoing modified Broström-Gould ligament repair. The single-stage group underwent both procedures simultaneously. Clinical evaluations were performed on the day before surgery and at 12-month, 24-month, and final follow-up periods using the Karlsson-Peterson score, American Orthopaedic Foot & Ankle Society (AOFAS) score, and pain visual analog scale. The Karlsson-Peterson score at 24 months postoperatively was considered the primary outcome. The predefined noninferiority margin for the primary outcome was −5 points.

Results:

At the final follow-up, 50 patients in the single-stage group and 48 patients in the staged group completed the study. The median lesion size was 0.72 cm² (interquartile range [IQR], 0.5-1.12 cm²) in the single-stage group and 0.84 cm² (IQR, 0.7-1.05 cm²) in the staged group. At 12-month follow-up, the single-stage group had a significantly higher median Karlsson-Peterson score (79 [IQR, 70-85] vs 75 [IQR 65-80] for staged; P = .024) and median AOFAS score (85 [IQR, 76-89] vs 79.5 [IQR, 70-87] for staged; P = .045). At 24-month follow-up, the median difference in the Karlsson-Peterson score for single-stage versus staged surgery was 2 points (95% CI, −2 to 5 points), and the confidence interval was greater than the predefined value.

Conclusion:

At midterm follow-up, there was no clinical difference between single-stage versus staged surgery to treat CLAI with OLT. Single-stage surgery achieved better clinical outcomes than staged surgery at short-term follow-up.

Structural validity of the foot and ankle outcome score for orthopaedic pathologies with Rasch Measurement Theory

BACKGROUND

The Foot and Ankle Outcome Score (FAOS) is one of the most frequently used patient-reported outcome measures for foot and ankle conditions. The aim is to test the structural validity of the Finnish version of the FAOS using Rasch Measurement Theory.

METHODS

FAOS scores were obtained from 218 consecutive patients who received operative treatment for foot and ankle conditions. The FAOS data were fitted into the Rasch model and person separation index (PSI) calculated.

RESULTS

All the five subscales provided good coverage and targeting. Three subscales presented unidimensional structure. Thirty-eight of the 42 items had ordered response category thresholds. Three of the 42 items had differential item functioning towards gender. All subscales showed sufficient fit to the Rasch model. PSI ranged from 0.73 to 0.94 for the subscales.

CONCLUSIONS

The Finnish version of the FAOS shows acceptable structural validity for assessing complaints in orthopaedic foot and ankle patients.

A feature-based statistical shape model for geometric analysis of the human talus and development of universal talar prostheses

Statistical data pertaining to anatomic variations of the human talus contain valuable information for advances in biological anthropology, diagnosis of the talar pathologies, and designing talar prostheses. A statistical shape model (SSM) can be a powerful data analysis tool for the anatomic variations of the talus. The main concern in constructing an SSM for the talus is establishing the true geometric correspondence between the talar geometries. The true correspondence complies with biological and/or mathematical homologies on the talar surfaces. In this study, we proposed a semi-automatic approach to establish a dense correspondence between talar surfaces discretized by triangular meshes. Through our approach, homologous salient surface features in the form of crest lines were detected on 49 talar surfaces. Then, the point-wise correspondence information of the crest lines was recruited to create posterior Gaussian process morphable models that non-rigidly registered the talar meshes and consequently established inter-mesh dense correspondence. The resultant correspondence perceptually represented the true correspondence as per our visual assessments. Having established the correspondence, we computed the mean shape using full generalized Procrustes analysis and constructed an SSM by means of principal component analysis. Anatomical variations and the mean shape of the talus were predicted by the SSM. As a clinically related application, we considered the mean shape and investigated the feasibility of designing universal talar prostheses. Our results suggest that the mean shape of (the shapes of) tali can be used as a scalable shape template for designing universal talar prostheses.

[Conservative treatment options for arthritis of the ankle : What is possible, what is effective?]

In this article the causes of arthritis in the region of the ankle are introduced and the conservative treatment options are described and discussed more extensively. The risks of treatment with nonopioid analgesics (NOPA) are presented in detail. The topical use of nonsteroidal anti-inflammatory drugs (NSAID) should always be considered in the clinical routine. If contraindications for oral NSAIDs are present, intra-articular treatment is a meaningful option. The best evidence is currently available for viscosupplementation but the study situation for the use of platelet-rich plasma (PRP) is still not sufficiently comprehensive and there are only a few case reports on the use of mesenchymal stem cells..

The Prevalence of Osteoporosis in Patients Older than 50 Years with Distal Radius Fractures in an Institutional Registry of 2,572 Patients in Singapore

Background: The distal radius is one of the common sites for fragility fractures. A fracture of the distal radius in the elderly is often associated with low bone mineral density (BMD). It is an early predictor of osteoporosis and increased risk of subsequent fragility fractures of the hip and the spine with greater morbidity. Osteoporosis is becoming an increasing cause for concern in the elderly population. The aim of this study is to determine the prevalence of osteoporosis in patients aged 50 years and above with distal radius fractures in our local population. Methods: This is a retrospective study of all patients aged 50 years and above who were treated for a distal radius fracture at our institution over a 4-year period. Data regarding gender, mechanism of injury (low or high energy), and outcome of BMD scans were collected. The data were analyzed to look at the prevalence of osteoporosis and osteopenia and the relation amongst BMD, gender, and the mechanism of injury. Results: About 2,572 patients aged 50 years and above were treated at our institution over a 4-year period from 2013 to 2016. The average age of the patients was 67.7 years old and 1,938 (75.3%) were women. A total of 1,034 patients had BMD scans and of these 56.0% had osteoporosis and 37.4% had osteopenia. There was no correlation between the prevalence of osteoporosis and gender or the mechanism of injury. Conclusions: The prevalence of osteoporosis in patients aged 50 and above with distal radius fractures is a significant cause for concern in Singapore. Routine assessment for osteoporosis is recommended for all patients above 50 years old with distal radius fractures. Level of Evidence: Level III (Therapeutic).

Polka dot cementless talar component in enhancing total ankle replacement fixation: A parametric study using the finite element analysis approach

The primary stability of a total ankle replacement (TAR) is essential in preventing long-term aseptic loosening failure and could be quantified based on micromotion at the bone-prosthesis interface subjected to physiological loading during the normal walking. A 3D finite element analysis was conducted to investigate the current commercial STAR™ Ankle TAR bone-prosthesis interface relative micromotion (BPIRM) with addition of the talus bone minimum principal bone stresses (MPBS). Comparison was made to the proposed polka dot designs with the hemispheric feature that was demonstrated to enhance BPIRM. Parametric studies were conducted on the hemispheric features with changes in its diameter, length and shape. The FE results indicated high BPIRM at the talar component was primarily contributed by de-bonding (in the normal direction) between the talus bone and talar component. The MPBS were found to be most significant in the superior anterior and superior medial regions of the talus bone. When the pin length was increased from 1.5 to 3 mm, the BPIRM was predicted to fall below 50 μm in favour of bone in-growth. Based on the practicality of the prosthesis implantation during the surgical procedure, the final design that incorporated both the initial polka dot and 3 mm pin length in a crisscross manner was deemed to be a favorable design with reduced BPIRM and MPBS hence lowering the risk of long-term aseptic loosening.

Polycarbonate-urethane coating can significantly improve talus implant contact characteristics

Talus implants can be utilized in cases of talus avascular necrosis and has been regarded as a promising treatment method. However, existing implants are made of stiff materials that directly oppose natural cartilage. The risk of long-term cartilage wear and bone fracture from the interaction between the cartilage and stiff implant surfaces has been documented in post-hemiarthroplasty of the hip, knee and ankle joints. The aim is to explore the effects of adding a layer of compliant material (polycarbonate-urethane; PCU) over a stiff material (cobalt chromium) in talus implants. To do so, we obtained initial ankle geometry from four cadaveric subjects in neutral standing to create the finite element models. We simulated seven models for each subject: three different types of talus implants, each coated with and without PCU, and a biological model. In total, we constructed 28 finite element models. By comparing the contact characteristics of the implant models with their respective biological model counterparts, our results showed that PCU coated implants have comparable contact area and contact pressure to the biological models, whereas stiff material implants without the PCU coating all have relatively higher contact pressure and smaller contact areas. These results confirmed that adding a layer of compliant material coating reduces the contact pressure and increases the contact area which in turn reduces the risk of cartilage wear and bone fracture. The results also suggest that there can be clinical benefits of adding a layer of compliant material coating on existing stiff material implants, and can provide valuable information towards the design of more biofidelic implants in the future.

Effect of Platelet-Rich Plasma Injections vs Placebo on Ankle Symptoms and Function in Patients With Ankle Osteoarthritis: A Randomized Clinical Trial

IMPORTANCE

Approximately 3.4% of adults have ankle (tibiotalar) osteoarthritis and, among younger patients, ankle osteoarthritis is more common than knee and hip osteoarthritis. Few effective nonsurgical interventions exist, but platelet-rich plasma (PRP) injections are widely used, with some evidence of efficacy in knee osteoarthritis.

OBJECTIVE

To determine the effect of PRP injections on symptoms and function in patients with ankle osteoarthritis.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, block-randomized, double-blinded, placebo-controlled clinical trial performed at 6 sites in the Netherlands that included 100 patients with pain greater than 40 on a visual analog scale (range, 0-100) and tibiotalar joint space narrowing. Enrollment began on August 24, 2018, and follow-up was completed on December 3, 2020.

INTERVENTIONS

Patients were randomly assigned (1:1) to receive 2 ultrasonography-guided intra-articular injections of either PRP (n = 48) or placebo (saline; n = 52).

MAIN OUTCOMES AND MEASURES

The primary outcome was the validated American Orthopaedic Foot and Ankle Society score (range, 0-100; higher scores indicate less pain and better function; minimal clinically important difference, 12 points) over 26 weeks.

RESULTS

Among 100 randomized patients (mean age, 56 years; 45 [45%] women), no patients were lost to follow-up for the primary outcome. Compared with baseline values, the mean American Orthopaedic Foot and Ankle Society score improved by 10 points in the PRP group (from 63 to 73 points [95% CI, 6-14]; P < .001) and 11 points in the placebo group (from 64 to 75 points [95% CI, 7-15]; P < .001). The adjusted between-group difference over 26 weeks was -1 ([95% CI, -6 to 3]; P = .56). One serious adverse event was reported in the placebo group, which was unrelated to the intervention; there were 13 other adverse events in the PRP group and 8 in the placebo group.

CONCLUSIONS AND RELEVANCE

Among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. The results of this study do not support the use of PRP injections for ankle osteoarthritis.

TRIAL REGISTRATION

Netherlands Trial Register: NTR7261.

Conservative Treatment of Ankle Osteoarthritis

Despite the disabling nature of ankle osteoarthritis (OA), there is poor scientific evidence for a conservative treatment compared to the hip and knee OA. In this regard, most of the treatment options in use are not based on clinical studies of the ankle, and they are extracted from evidence obtained from clinical studies of other lower limb joints. However, this does not seem to be a good idea, since the aetiology of ankle OA is quite different from that of the hip or knee. Nonpharmacological and pharmacological treatments such as nonsteroidal anti-inflammatory drugs, hyaluronic acid, corticosteroid, platelet-rich plasma injection and mesenchymal stem cells injections have been reported. However, further research is required in this field to obtain a specific clinical practice guideline for the conservative treatment of ankle OA.

Incorporating 3D Printing Into Your Practice: Lessons Learned

Three-dimensional (3D) printing has greatly benefited medicine, manufacturing vital organs like skin, hearts, kidneys, and livers. Early studies on 3D printing in surgery have consistently reported decreased operative time and improved precision. This technology has gained popularity with orthopaedic surgeons in knee, hip, and shoulder surgeries because 3D printing is associated with enhancing osseointegration. However, this innovation is still not commonly used among foot and ankle surgeons; one reason is that whereas the literature on 3D printing-assisted surgery is populated with studies on operative techniques and clinical outcomes, there exists an ambiguity on how to incorporate this feature into the clinic. Thus, the aim of this technology column is to consolidate and standardize a workflow to guide foot and ankle surgeons on integrating 3D printing into one's practice. We describe a model developed by a single surgeon at one institution who directs a large caseload of 3D-printed foot and ankle surgeries. From the initial patient visit to the interaction between the surgeon and the implant engineering team, to documentation of data adding to the preliminary literature, this work has great implications on streamlining the assimilation of a highly successful technology to improve foot and ankle surgery for both surgeons and patients.Level of Evidence: Level V.

Mesenchymal stem cells: ideal seeds for treating diseases

Mesenchymal stem cells (MSCs), a kind of multipotent stem cells with self-renewal ability and multi-differentiation ability, have become the “practical stem cells” for the treatment of diseases. MSCs have immunomodulatory properties and can be used to treat autoimmune diseases, such as systemic lupus erythematosus (SLE) and Crohn’s disease. MSCs also can be used in cancer and aging. At present, many clinical experiments are using MSCs. MSCs can reduce the occurrence of inflammation and apoptosis of tissue cells, and promote the proliferation of endogenous tissue and organ cells, so as to achieve the effect of repairing tissue and organs. MSCs presumably also play an important role in Corona Virus Disease 2019 (COVID-19) infection.

Efficacy and Safety of a Single Intra-articular Injection of Platelet-rich Plasma on Pain and Physical Function in Patients With Ankle Osteoarthritis-A Prospective Study

Ankle osteoarthritis (OA) can cause disabling symptoms, and some patients prefer to be treated with minimally invasive procedures. The aim was to evaluate the efficacy and safety of a single intraarticular injection of platelet-rich plasma (PRP) for patients with ankle OA. In a prospective study done in a university-affiliated tertiary care medical center, 44 patients with symptomatic ankle OA for at least 6 months were recruited. Patients received a single injection of PRP (3 mL) into symptomatic ankles. The primary outcome was the change from baseline in the visual analog scale (VAS) pain (0-10 cm) at 6 months. Secondary outcomes included the Ankle Osteoarthritis Scale (AOS) score, American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle score, single-leg stance test (SLS), rescue analgesics consumption and patient satisfaction. Thirty-nine participants (88.64%) completed the study. Significantly improvement in the VAS and AOS was noted at 1-, 3-, and 6-month follow-ups (p < .001). The mean VAS pain decreased significantly from 4.1 ± 1.7 at baseline to 2.2 ± 1.9, 1.7 ± 1.5, and 1.8 ± 1.6 at 1, 3, and 6 months (p < .001). The mean total AOS score reduced by 1.5, 2.2, and 2.1 from baseline respectively postinjection (p < .001). The mean AOFAS hindfoot-ankle score improved from 80.3 points at baseline to 87.2, 91.6, and 89.7 points at 1, 3, and 6 months (p < .001). SLS tests improved significantly (p < .001) at each follow-up. Acetaminophen consumption dropped significantly (p < .001) and no serious adverse events occurred. The study showed promise for a single intraarticular injection of PRP in the treatment of ankle OA.

Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region

Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care.

PURPOSE

Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development.

METHODS

We conducted a structured comparative analysis of existing CPGs in the AP region using a "5IQ" model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards.

RESULTS

Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines.

CONCLUSION

The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.

Total Talus Replacement: Case Series and Literature Review

Custom 3D printed total talus implants have been used successfully as a functional alternative to arthrodesis or amputation in cases of severe talar destruction or loss. However, the ideal material and construct still remains to be elucidated. Current models have been made from aluminum ceramic, cobalt chrome, stainless steel, titanium, or metal combinations. The implants may be constrained (subtalar arthrodesis) or unconstrained (press fit within mortise). They may also be combined with a tibial prosthesis or used in isolation. The majority of currently published case studies examine unconstrained and isolated implants. This case study presents satisfactory 1-y outcomes in 3 cobalt chrome constrained total talar implants used in combination with a tibial prosthesis, and a literature review of total talus replacements.

Patient-Perceived Recovery and Outcomes after Bipolar Radiofrequency Controlled Ablation with Platelet-Rich Plasma Injection for Refractory Plantar Fasciosis

Previous studies have documented persistent postoperative symptoms and limitations following plantar fasciotomy using patient-reported outcome measures (PROMs). The incomplete recovery (resolution) has been theorized to occur from altered foot biomechanics, and alternative treatment methods have continued to gained popularity for addressing refractory plantar fasciosis (RPF). The purpose of the present study was to assess patient-perceived recovery (PPR) and outcomes after bipolar radiofrequency controlled ablation (BRC) with platelet-rich plasma (PRP) injection for RPF. From July 2006 to July 2016, 43 patients (52 procedures) were enrolled. PROMS were prospectively obtained and compared between patients who perceived themselves as recovered without/residual deficits (recovered-resolved, recovered-not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure were recorded. Overall, 67.4% perceived themselves as recovered-resolved, 23.3% as recovered-not resolved, and 9.3% as not recovered. Holistic and procedure specific satisfaction were high (90.7% and 88.4%), with a mean modified Foot Function Index of 11.65, visual analog scale for pain 1.5, and failure rate of 9.3% at a median of 53 months (interquartile range 33 to 83). In the present study, outcomes with BRC with PRP injection compared favorably to the long-term outcomes reported for partial and complete plantar fasciotomy. Although 14 patients (32.6%) continued to have some postoperative symptoms, 71% indicated that they were satisfied with their symptoms, and 64% would undergo a similar procedure again. Therefore, despite the study's shortcomings, a patient's ability to cope appears to have a role in recovery from RPF.

Total Ankle Total Talus Replacement Using a 3D Printed Talus Component: A Case Report

The 3D custom total talus replacement is a novel treatment for avascular necrosis of the talus. However, patients who require a total talus replacement often have concomitant degenerative changes to the tibiotalar, subtalar, or talonavicular joints. The combined 3D custom total ankle-total talus replacement (TATTR) is used for patients with an unreconstructable talus and adjacent tibial plafond involvement. The goal of performing a TATTR is to provide pain relief, retain motion at the tibiotalar joint, maintain or improve the patient's functional status, and minimize limb shortening. TATTR is made possible by 3D printing. The advent of 3D printing has allowed for the accurate recreation of the native talar anatomy with a talar dome that can be matched to a total ankle replacement polyethylene bearing. In this article, we will discuss a case of talar avascular necrosis treated with a combined TATTR and review the current literature for TATTR.

Clinical Use of Talar Prostheses

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The blood supply to the talus is vulnerable to damage, making the talus susceptible to osteonecrosis, with limited treatment options.

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Talar bone replacement has been investigated as a treatment option to preserve ankle function and maintain limb length.

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Successful talar bone replacements have been performed for the past >35 years, with variations in design, methods of fixation, materials, and manufacturing techniques.

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The designs of talar prostheses range from custom-made partial (talar body) or total prostheses to prefabricated universal (non-custom-made) prostheses.

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Total talar prostheses have been demonstrated to function better than partial talar prostheses; however, there is a need for long-term studies regarding custom-made total talar prostheses and prefabricated universal talar prostheses in order to determine their long-term effectiveness.

Medium-Term Outcomes of Chevron Osteotomy for Hallux Valgus Correction in a Spanish Population: Radiologic and Clinical Parameters and Patient Satisfaction

BACKGROUND

Chevron osteotomy for mild and moderate hallux valgus obtains good effects. It is suitable for a variety of cases, allowing for a significant degree of correction. This study aimed to investigate chevron osteotomy for the correction of hallux valgus in the medium-term by podiatric surgeons. It considers clinical and radiologic findings and patient perspectives and level of satisfaction.

METHODS

Forty-five patients (50 feet) were assessed preoperatively, postoperatively, and at final follow-up. Mean patient age was 59.43 years (range, 32-80 years). The protocols include medical record review, clinical examination, and radiologic assessment. Anteroposterior weightbearing radiographs were analyzed preoperatively and at final follow-up. Clinical effects were analyzed with visual analog scale and American Orthopaedic Foot and Ankle Society (AOFAS) scores.

RESULTS

Interobserver and intraobserver reliability were evaluated. Mean ± SD hallux valgus angle decreased at final follow-up (25.30° ± 7.21° versus 17.25° ± 10.32°; P = .041). There was no significant reduction in mean ± SD intermetatarsal angle at final follow-up (13.13° ± 3.03° versus 7.65° ± 3.47°; P = .078). Final AOFAS score was 82.08 ± 17.66. This study showed the relevance of magnet therapy, nail surgery, and other procedures. No patient was dissatisfied with the aesthetic scarring.

CONCLUSIONS

The radiologic results at final follow-up were not compatible with relapse of the deformity. The definitive clinical results and the degree of patient satisfaction achieved with this technique were favorable from the patients' point of view.

Propensity Score-Matched Analysis of Arthroscopically Assisted Ankle Facture Treatment Versus Conventional Treatment

BACKGROUND

The aim of this study was to assess the prospective, longitudinal outcome after arthroscopically assisted open reduction and internal fixation (AORIF) and to compare the results with open reduction and internal fixation (ORIF) in complex ankle fractures.

METHODS

Acute, closed, bimalleolar equivalent, bimalleolar, or trimalleolar ankle fractures were included. The AORIF cohort was enrolled prospectively. The ORIF group was identified from a retrospective database. The same inclusion and exclusion criteria were applied. The only difference was the additional arthroscopy in the AORIF cohort. The patient-reported outcome measurement (PROM) following AORIF was assessed at 1 and 4 years of follow-up using the Olerud and Molander Ankle Score (OMAS) and Tegner activity scale (TAS). The AORIF cohort was propensity score matched (nearest-neighbor matching) to the ORIF database. The OMAS and Foot and Ankle Ability Measure (FAAM) were compared between the resulting groups. Nonparametric statistics were applied; values are presented as median (interquartile range). Twenty-six AORIF patients had a prospective 4-year follow-up.

RESULTS

No significant differences (1 year vs 4 years) were identified for the OMAS (90 [10] vs 90 [11]) and TAS (4 [2] vs 5 [2]). The severity of the cartilage lesions (International Cartilage Repair Society [ICRS] grade <4 vs ICRS of 4) had no significant influence on the PROMs. Twenty-five patients per cohort (AORIF vs ORIF) were matched. The OMAS (90 [13] vs 75 [40]; P = .008) and FAAM Activities of Daily Living (ADL; 96 [11] vs 88 [30]; P = .034) revealed significantly better outcomes for AORIF. More patients in the AORIF cohort returned to sport (96% vs 77%; P = .035), with a higher FAAM Sports score (88 [37] vs 56 [47]; P = .008).

CONCLUSION

AORIF for complex ankle fractures led to consistently good to excellent results. The propensity score-matched analysis revealed a significantly better outcome 4 years after surgery for AORIF compared with ORIF.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Limitations of accessibility of the talar dome with different open surgical approaches

PURPOSE

The aim of this study is to systematically review the current, relevant literature and provide a thorough understanding of the various open surgical approaches utilized to gain access to the talar dome for treatment of osteochondral lesions. Realizing the limits of access from soft tissue exposures and osteotomies, with and without external distraction, will help surgeons to select the appropriate approach for each individual clinical situation.

METHODS

A literature search was performed using three major medical databases: PubMed (MEDLINE), Scopus, and Embase. The Quality Appraisal for Cadaveric Studies (QUACS) scale was used to assess the methodological quality of each included study.

RESULTS

Of 3108 reviewed articles, nine cadaveric studies (113 limbs from 83 cadavers) evaluating the accessibility of the talar dome were included in the final analysis. Most of these (7/9 studies) investigated talar dome access in the context of treating osteochondral lesions of the talus (OLTs) requiring perpendicular visualization of the involved region. Five surgical approaches (anteromedial; AM, anterolateral; AL, posteromedial; PM, posterolateral; PL, and direct posterior via an Achilles tendon splitting; DP), four types of osteotomy (anterolateral tibial, medial malleolar, distal fibular, and plafondplasty), and two methods of distraction (Hintermann retractor and external fixator) were used among the included studies. The most commonly used methods quantified talar access in the sagittal plane (6/9 studies, 66.7%). The greatest exposure of the talar dome can be achieved perpendicularly by performing an additional malleolar osteotomy (90.9% for lateral, and 100% for medial). The methodological quality of all included studies was determined to be satisfactory.

CONCLUSION

Gaining perpendicular access to the central portion of the talar dome, measured in the sagittal plane, has clear limitations via soft tissue approaches either medially or laterally from the anterior or posterior aspects of the ankle. It is possible to access a greater talar dome area in a non-perpendicular fashion, especially from the posterior soft tissue approach. Various types of osteotomies can provide greater accessibility to the talar dome. This systematic review can help surgeons to select the appropriate approach for treatment of OLTs in each individual patient preoperatively.

LEVEL OF EVIDENCE

Level IV.

Sixteen-Year Follow-up of Talar Body Prosthesis and Total Ankle Arthroplasty After Traumatic Talar Extrusion: A Case Report

CASE

We report a case of an extruded talus treated with an agility custom talar body prosthesis with total ankle arthroplasty 2 years after the injury. At the 16-year follow-up, the patient has performed remarkably well. At postoperative year 15, she required 1 additional surgery in which the polyethene was exchanged and the medial and lateral gutters were debrided.

CONCLUSION

Talar body prothesis with total ankle arthroplasty may be a viable option for extrusion of the talus.

Bone health assessment via digital wrist tomosynthesis in the mammography setting

Bone fractures attributable to osteoporosis are a significant problem. Though preventative treatment options are available for individuals who are at risk of a fracture, a substantial number of these individuals are not identified due to lack of adherence to bone screening recommendations. The issue is further complicated as standard diagnosis of osteoporosis is based on bone mineral density (BMD) derived from dual energy x-ray absorptiometry (DXA), which, while helpful in identifying many at risk, is limited in fully predicting risk of fracture. It is reasonable to expect that bone screening would become more prevalent and efficacious if offered in coordination with digital breast tomosynthesis (DBT) exams, provided that osteoporosis can be assessed using a DBT modality. Therefore, the objective of the current study was to explore the feasibility of using digital tomosynthesis imaging in a mammography setting. To this end, we measured density, cortical thickness and microstructural properties of the wrist bone, correlated these to reference measurements from microcomputed tomography and DXA, demonstrated the application in vivo in a small group of participants, and determined the repeatability of the measurements. We found that measurements from digital wrist tomosynthesis (DWT) imaging with a DBT scanner were highly repeatable ex vivo (error = 0.05%-9.62%) and in vivo (error = 0.06%-10.2%). In ex vivo trials, DWT derived BMDs were strongly correlated with reference measurements (R = 0.841-0.980), as were cortical thickness measured at lateral and medial cortices (R = 0.991 and R = 0.959, respectively) and the majority of microstructural measures (R = 0.736-0.991). The measurements were quick and tolerated by human patients with no discomfort, and appeared to be different between young and old participants in a preliminary comparison. In conclusion, DWT is feasible in a mammography setting, and informative on bone mass, cortical thickness, and microstructural qualities that are known to deteriorate in osteoporosis. To our knowledge, this study represents the first application of DBT for imaging bone. Future clinical studies are needed to further establish the efficacy for diagnosing osteoporosis and predicting risk of fragility fracture using DWT.

Upper gastrointestinal safety of oral bisphosphonate in hospitalized patients

Oral bisphosphonates are effective medications for the prevention of fractures in people suffering from osteoporosis. They are associated with gastrointestinal adverse reactions the most severe being an esophageal ulcer. It is unclear if oral bisphosphonates have a similar gastrointestinal safety profile in the hospital setting as in the community setting because hospitalized patients are often bedridden which may hinder proper drug administration.

INTRODUCTION

To evaluate the incidence of upper gastrointestinal symptoms in hospitalized patients taking oral bisphosphonate.

METHODS

This single-center prospective cohort study included hospitalized adult patients actively taking risedronate or alendronate. Upper gastrointestinal symptoms were actively assessed at the baseline and 1 to 5 h following the administration of the oral bisphosphonate.

RESULTS

A total of 298 patients were included in the study. The mean age was 64 ± 15 years. During the follow-up period, gastric and esophageal symptoms affected 32 patients (10.7%). Epigastric burning, dysphagia, and regurgitation were reported in 4.4% (n = 13), 3% (n = 9), 2.7 (n = 8), and 2.3% (n = 7) patients, respectively. Heartburn, retro-sternal pain, and odynophagia were observed in 1.7% (n = 5), 1.7% (n = 5), and 0.3% (n = 1) patients.

CONCLUSION

The incidence of adverse reaction was similar to that reported in community trials. The administration of oral bisphosphonate in hospitalized patients does not represent an additional risk for upper gastrointestinal adverse events. Treatment should be optimized during the hospital stay to improve the pharmacological management of osteoporosis.

Arthroscopically Assisted Internal Fixation of Foot and Ankle Fractures: A Systematic Review

BACKGROUND

Patients undergoing fixation for foot and ankle fractures may experience poor outcomes despite achieving apparent anatomic reduction. Adjunct arthroscopy to identify missed concomitant injuries and subtle displacements has been proposed as a vehicle to enhance functional results for these patients. The purpose of this review is to provide an overview of the literature regarding arthroscopically assisted open reduction and internal fixation (AAORIF) methods for commonly encountered foot and ankle injuries including pilon, ankle, and calcaneus fractures published to date.

METHODS

A systematic review of the literature was performed using the PubMed database to access all studies reporting on arthroscopically assisted internal fixation methods for pilon, ankle, and calcaneus fractures. Relevant publications were analyzed for details on their respective study designs, the operative technique used, clinical outcomes, outcome instruments used, and reported complications.

RESULTS

A total of 32 studies were included in this review. Two studies on pilon fractures, a randomized controlled trial (RCT) and case series with a total of 243 patients, met inclusion criteria. Postoperative articular reductions, bone union, and Mazur scores were found to be significantly better for those using adjunct arthroscopy when compared to those with no arthroscopy use. Patient-reported outcomes were overall reported as excellent for most patients, with no difference in patient-reported outcomes reported in the RCT. For ankle fractures, a total of 17 studies comprising of 2 systematic reviews, 1 meta-analysis, 2 RCTs, 5 retrospective comparative studies, 6 case series, and 1 case-control study met inclusion criteria for this review. Results were mixed, though the overall consensus was that arthroscopy use may help to better visualize concomitant intra-articular injuries and is generally considered safe with at least comparable outcomes to conventional methods. For the calcaneus, 13 studies met the criteria. Two studies were review papers, 8 were case series, and 3 were retrospective comparative studies. A total of 308 patients with 316 fractures formed the basis of analysis. In general, the studies found comparable functional outcomes between with or without arthroscopy use, but found that anatomical reductions were significantly improved with the use of arthroscopy.

CONCLUSIONS

Arthroscopy shows promise as a valuable adjunct tool for internal fixation of foot and ankle fractures, though definitive conclusions as to its clinical significance have yet to be drawn because of limited evidence. Potential advantages related to the direct visualization of the fracture site and minimally invasive nature of arthroscopy were suggested throughout studies examined in this review. The presence of intra-articular pathology may lead to unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with an otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions with arthroscopy, therefore, has the potential to improve patient outcomes. To date, however, available literature has not shown that significant improvements in anatomical reductions and treatment of these intra-articular injuries provide any improvement in outcomes over standard fixation methods. Few prospective randomized controlled studies have been performed comparing these 2 operative techniques, rendering any suggestion that AAORIF improves clinical outcomes over traditional open fixation difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct prior to advocating for its routine use in patients.

Danshen Attenuates Intervertebral Disc Degeneration via Antioxidation in SD Rats

Objective

To investigate the effects of Danshen on the imaging and histological parameters, expression levels of ECM-associated proteins and inflammatory factors, and antioxidative activity in the degenerated intervertebral disc (IVD) of SD rats.

Methods

Sixty male rats were randomly divided into three groups (control, IDD, and Danshen IDD). Percutaneous needle puncture in Co8-9 intervertebral disc was conducted in all rats of the IDD and Danshen IDD groups to induce intervertebral disc degeneration (IDD). After operation, animals of the Danshen IDD group were administrated with Danshen granules (3 g/kg body weight ) by gavage once a day. Four weeks later, the coccygeal vertebrae were harvested and used for imaging (disc height and MR signal), histological, immunohistochemical, and biochemical [water content, glycosaminoglycans (GAG), superoxide dismutase (SOD2), glutathione (GSH), and malondialdehyde (MDA)] analyses.

Results

The puncture induced significant decreased IVD space and MR T2 signal at both 2 and 4 weeks, which were attenuated by Danshen treatment. The disc degeneration in the IDD group (HE and Safranin O-Fast Green histological staining was markedly more serious compared with that in the control group. Four weeks of Danshen treatment significantly alleviated this degeneration compared with the IDD group. Needle puncture resulted in the upregulation of IL-1β and TNF-α, MMP-3, and downregulation of COL2 and aggrecan in the IDD group. However, this change was significantly weakened by Danshen treatment. Significantly lower water and GAG content, as well as the SOD2 and GSH levels, in the IDD group were found compared with those in the control group. However, the above parameters of the Danshen IDD group were significantly higher than those of the IDD group. Danshen treatment significantly decreased the content of MDA which was increased by needle puncture in the IDD group.

Conclusion

Danshen can attenuate intervertebral disc degeneration in SD rats by suppressing the oxidation reaction.

Total talar prosthesis with and without ankle ligament reconstruction using the three-dimensional computer-aided design and computer numerical control manufacturing techniques

Severe damage and bone loss of the talus are problematic issues because of its unique shape, function, and characteristics. This present study’s objective is to propose the process of customized total talar prosthesis manufacturing, using three-dimensional (3D) Computer-Aided Design (CAD) with Computer Numerical Control (CNC) production along with evaluation of the results of total talar prosthesis replacement with or without ankle ligament reconstruction in patients with severe conditions of talus. The case series included five patients (mean age: 27.6 years) with severe talar loss or damage. The mean follow-up time was 17.8±8.4 months. Related complications were: i) mild subsidence in 1 patient (20%) and ii) periprosthetic fracture in another patient (20%). The mean clinical scores including VAS-FA and SF-36 were improved following surgeries. Customized total talar prosthesis appears to provide satisfactory outcomes for the treatment of severe talar loss or damage at a short-term follow-up.

Comparison of different bone graft with arthroscopy-assisted arthrodesis for the treatment of traumatic arthritis of the subtalar joint

AIM OF THE STUDY

To compare the clinical outcomes of traumatic arthritis of the subtalar joint treated by arthroscopy-assisted arthrodesis with autologous bone graft, allogenous bone graft, artifical bone graft, and no bone graft .

METHODS

Sixty-two patients (64 ft) with traumatic arthritis of subtalar joint were randomly divided into four groups. The cases treated with arthroscopy-assisted arthrodesis were analyzed retrospectively. The mean follow-up time was about 22 months (18-28 months) in each group. Clinical outcomes were assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) score, Visual Analog Scale (VAS), and radiographic examination. The post-operative complications in each group were recorded respectively.

RESULTS

All operations were successful, without incision complications. The subtalar joint obtained full osseous fusion in each group. The average time of osseous fusion was about 12 weeks. There was no significant difference in the fusion time with each group (P = 0.991). The AOFAS and VAS scores in each group were improved significantly in the pre-operative vs post-operative evaluation (all P < 0.01). The average operation time in autologous bone graft group was 74.56 ± 11.45 min which significantly different from that of other groups(P < 0.01).

CONCLUSION

Similar clinical outcomes were achieved among each type of bone graft. Therefore, which types of bone graft or not may be not the most important for arthroscopy-assisted subtalar arthrodesis.

Finite Element Analysis of the Effect of Talar Osteochondral Defects of Different Depths on Ankle Joint Stability

Background

Talus cartilage injury leads to changes in biomechanics of the ankle joint and ultimately affects ankle joint function, but which talus cartilage defects require surgery is still uncertain. This research used a finite element method to simulate the effect of different depth of talus cartilage defects on the stress and stability of the ankle joint in a certain area.

Material/Methods

A three-dimensional finite element model with different depths of osteochondral defects was created to simulate and calculate joint stress and displacement of the articular surface of the distal tibia and the proximal talus while the ankle joint was in the push-off, midstance, and heel-strike phases.

Results

The equivalent stress of the proximal talus did not change significantly at a defect depth of 1 mm, whereas the equivalent stress of the upper talus increased significantly at a defect depth of ≥3 mm or more, reaching a maximum value at a defect depth of 10 mm. The equivalent stress of the tibial cartilage and the equivalent stress and displacement in the corresponding forces in the midstance phase and heel-strike phase were significantly different from those in the normal group, but the difference in stress in each defect group was not obvious.

Conclusions

The effect of cartilage defects of the talus on biomechanics of the ankle is clear, especially in the midstance and push-off phases. When the defect reaches the subchondral bone (at a depth of 3 mm), the most obvious change in ankle joint stability occurs, and it does not increase linearly with the increase in depth of the defect.

Evidence on ankle injections for osteochondral lesions and osteoarthritis: a systematic review and meta-analysis

PURPOSE

To evaluate the evidence supporting safety and effectiveness of intra-articular injective treatments for ankle lesions ranging from osteochondral lesions of the talus (OLT) to osteoarthritis (OA).

METHODS

A systematic review and a meta-analysis were performed on PubMed, Embase, and Cochrane Library in March 2020. Safety was evaluated through the reported side effects and effectiveness through the scores used. The quality of the studies was assessed using the Cochrane Collaboration Risk of Bias 2.0 tool and the Downs and Black checklist. For each outcome, the quality of evidence was graded according to GRADE guidelines.

RESULTS

Twenty-four studies (21 for OA, 3 for OLT) were included on hyaluronic acid (HA), platelet-rich plasma (PRP), saline, methylprednisolone, botulinum toxin type A (BoNT-A), mesenchymal stem cells (MSCs), and prolotherapy. No severe adverse events were reported. For OLT, a comparison was possible between HA and PRP showing no significant difference. For ankle OA, a significant difference favouring HA versus saline was documented at six months (p < 0.001). The GRADE level of evidence was very low.

CONCLUSION

This meta-analysis supports the safety of intra-articular treatment for ankle OA and OLT, while only a very low evidence supports the efficacy of HA in terms of better results versus placebo for the treatment of ankle OA, and other conclusions are hindered by the scarcity of the available literature. This urges further and stronger trials to specifically investigate potential and limitations of these different injective approaches for the treatment of OLT and ankle OA.

Supramalleolar osteotomy with a hexapod type external fixator for the treatment of ankle joint three planar deformity: Case report

The varus ankle deformity can lead to osteoarthritis; therefore, numerous supramalleolar tibia osteotomy techniques are described to correct this deformity. Many of these techniques are more suitable for uniplanar ankle deformity. Particularly, if there are multiplane ankle deformities, the use of the six-axis deformity correction system may be successful in solving the problems which may occur during the correction. In this article, we report two cases of three plane deformities of ankle joint due to trauma sequelae, which were treated with supramalleolar osteotomy using a hexapod fixator which is called the Smart Correction Frame®.

Comparison of 2g vs 1 g of Prophylactic Cefazolin in Surgical Site Infections in Trauma Surgery Below the Knee

BACKGROUND

The rate of surgical site infections (SSIs) after foot or ankle surgery remains high, despite the implementation of antibiotic prophylaxis. Recently, guidelines suggest a single dose of 2 g instead of 1 g of cefazolin for implant surgery; this decision is largely based on pharmacokinetic studies. However, the clinical effect of this higher dose has never been investigated in foot and ankle surgery. This retrospective cohort study investigated the effect of 2 g compared with 1 g of prophylactic cefazolin on the incidence of SSIs in foot and ankle surgery.

METHODS

All patients undergoing trauma-related surgery of the foot, ankle, or lower leg between September 2015 and March 2019 were included. The primary outcome was the incidence of an SSI. SSIs were compared between patients receiving 1 g and 2 g of cefazolin as surgical prophylaxis, using a propensity score to correct for possible confounders.

RESULTS

A total of 293 patients received 1 g and 126 patients received 2 g of cefazolin. The overall number of SSIs was 19 (6.5%) in the 1-g group and 6 (4.8%) in the 2-g group. Corrected for possible confounders, this was not statistically significant (OR, 0.770; P = .608).

CONCLUSION

Even though the decrease in SSI rate from 6.5% to 4.8% was found not to be statistically significant, it might be clinically relevant considering the reduction in morbidity, mortality, and healthcare costs. Research linking pharmacokinetic and clinical results of prophylactic cefazolin is needed to establish whether or not the current recommendations and guidelines are sufficient for preventing SSIs in foot and ankle surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Secondary prevention of fragility fractures in Asia Pacific: an educational initiative

The Asia -Pacific Bone Academy (APBA) Fracture Liaison Service (FLS) Focus Group educational initiative has stimulated activity across the Asia -Pacific region with the intention of supporting widespread implementation of new FLS. In 2017, the APBA FLS Focus Group developed a suite of tools to support implementation of FLS across the Asia-Pacific region as a component of a multi-faceted educational initiative. This article puts this initiative into context with a narrative review describing the burden of fragility fractures in the region, the current secondary fracture prevention care gap and a summary of emerging best practice. The results of a survey to evaluate the impact of the APBA educational initiative is presented, in addition to commentary on recent activities intended to improve the care of individuals who sustain fragility fractures across the Asia -Pacific. A FLS Toolbox for Asia-Pacific was developed which included the following sections:1. The burden of fragility fractures in the Asia-Pacific region.2. A summary of evidence for FLS in the Asia-Pacific.3. A generic, fully referenced FLS business plan template.4. Potential cost savings accrued by each country, based on a country-specific FLS Benefits Calculator.5. How to start and expand FLS programmes in the Asia-Pacific context.6. A step-by-step guide to setting up FLS in countries in the Asia-Pacific region.7. Other practical tools to support FLS establishment.8. FLS online resources and publications.The FLS Toolbox was provided as a resource to support FLS workshops immediately following the 5th Scientific Meeting of the Asian Federation of Osteoporosis Societies (AFOS) held in Kuala Lumpur in October 2017. The FLS workshops addressed three key themes:• The FLS business case.• Planning the FLS patient pathway.• The role of the FLS coordinator in fragility fracture care management.A follow-up survey of 142 FLS workshop participants was conducted in August-September 2018. The survey included questions regarding how FLS were developed, funded, the scope of service provision and the support provided by the educational initiative. Almost one-third (30.3%) of FLS workshop participants completed the survey. Survey responses were reported for those who had established a FLS at the time the survey was conducted and, separately, for those who had not established a FLS. Findings for those who had established a FLS included:• 78.3% of respondents established a multidisciplinary team to develop the business case for their FLS.• 87.0% of respondents stated that a multidisciplinary team was established to design the patient pathway for their FLS.• 26.1% of respondents stated that their FLS has sustainable funding.• The primary source of funding for FLS was from public hospitals (83.3%) as compared with private hospitals (16.7%).Most hospitals that had not established a FLS at the time the survey was conducted were either in the process of setting-up a FLS (47%) or had plans in place to establish a FLS for which approval is being sought (29%). The primary barrier to establishing a new FLS was lack of sustainable funding. The APBA FLS Focus Group educational initiative has stimulated activity across the Asia-Pacific region with the intention of supporting widespread implementation of new FLS. A second edition of the FLS Toolbox is in development which is intended to complement ongoing efforts throughout the region to expedite widespread implementation of FLS.

Morphometric geometric differences between right and left human tali: A cadaveric study of fluctuating asymmetry via systematic measurement and three-dimensional scanning

Background

Little is known about differences in the size and morphology of the right and left human tali. The present study demonstrates differences between right and left talar morphometric geometric profiles as fluctuating asymmetry in matched pairs of cadaveric specimens.

Methods

In total, 24 tali were collected in this study. All eligible tali were systematically measured with a Vernier caliper and three-dimensional laser scanner, which provided data for further analysis regarding the talar morphometric geometric profiles. Data were calculated to demonstrate differences between the right and left talar profiles using a matched-pair method, including the general size of the talus.

Results

The average talar length was 53.5 mm, the average talar dome height was 31.2 mm, and the average talar body width was 41.3 mm. The average anterior trochlear width, middle trochlear width, posterior trochlear width, and trochlear length were 31.8, 31.2, 28.3, and 30.7 mm, respectively. Eleven matched pairs of intact tali were eligible for the matched-pair study. Paired t-tests showed significant differences in the talar dome height (P = 0.019), middle trochlear width (P = 0.027), and posterior trochlear width (P = 0.016) between the right and left tali. However, there were no significant differences in the surface area or volume between the right and left tali.

Conclusion

Significant differences in the morphometric profile were found between the right and left matched pairs of tali. This basic information indicates that the profile of the contralateral talus may not be used as a single reference to reconstruct or duplicate the talus of interest in certain conditions such as talar prosthesis implantation or customized total ankle replacement.

Limb lengthening history, evolution, complications and current concepts

Limb lengthening continues to be a real challenge to both the patient and the orthopaedic surgeon. Although it is not a difficult operative problem, there is a long and exhausting postoperative commitment which can jeopardize early good results. I aim to review the history, evolution, biology, complications and current concepts of limb lengthening. Ilizarov's innovative procedure using distraction histeogenesis is the mainstay of all newly developing methods of treatment. The method of fixation is evolving rapidly from unilateral external fixator to ring fixator, computer assisted and finally lengthening intramedullary nails. The newly manufactured nails avoid many of the drawbacks of external fixation but they have their own complications. In general, the indications for limb lengthening are controversial. The indications have been extended from lower limb length inequality to upper extremity lengthening, including humeral, forearm and phalangeal lengthening. A wide range in frequency of complications is recorded in the English literature, which may reach up to 100% of cases treated. With developing experience, cosmetic lengthening has become possible using external or internal lengthening devices with an acceptable rate of problems.Level of evidence: V.

Finite element analysis of bone-prosthesis interface micromotion for cementless talar component fixation through critical loading conditions

The total ankle replacement (TAR) survivability rate is still suboptimal, and this leads to many orthopaedic surgeons opting arthrodesis as a better option for the ankle arthritis patients. One of the fundamental reasons is due to the lack of primary stability of the prosthesis fixation at the bone-prosthesis interface hence leading to long-term aseptic loosening of the talar component. The commercially available Scandinavian Total Ankle Replacement (STAR) Ankle design and several additional design features (including trabecular metal, side fin, double fin, and polka-dot designs) were studied using finite element analysis, and the bone-prosthesis interface relative micromotion (BPIRM) and talar bone minimum principal stresses were examined and analysed. Three loading conditions at a gait cycle of heel strike, midstance, and toe off with different meniscal bearing displacement were also included as part of the study parameters. The results were correlated to in vitro cadaveric measurements and reported clinical studies. Simulated results showed that the de-bonding relative distance between the bone and prosthesis upon loading (COPEN defined by the simulation software) was the main reason constituting to the high interface micromotion between the talar component and talus bone (which could lead to long-term aseptic loosening). The polka-dot design was shown to induce the lowest BPIRM among all the designs studied.

Injection Techniques for Common Chronic Pain Conditions of the Foot: A Comprehensive Review

Purpose of Review

This is a comprehensive literature review of the available evidence and techniques of foot injections for chronic pain conditions. It briefly describes common foot chronic pain syndromes and then reviews available injection techniques for each of these syndromes, weighing the available evidence and comparing the available approaches.

Recent Findings

Foot and ankle pain affects 20% of the population over 50 and significantly impairs mobility and ability to participate in activities of daily living (ADLs), as well as increases fall risk. It is commonly treated with costly surgery, at times with questionable efficacy. Injection therapy is challenging when the etiology is anatomical or compressive. Morton’s neuroma is a budging of the interdigital nerve. Steroid, alcohol, and capsaicin injections provide some benefit, but it is short lived. Hyaluronic acid (HA) injection provided long-term relief and could prove to be a viable treatment option. Achilles tendinopathy (AT) is most likely secondary to repeat tendon stress—platelet-rich-plasma (PRP) and prolotherapy have been trialed for this condition, but more evidence is required to show efficacy. Similar injections were trials for plantar fasciitis and achieved only short-term relief; however, some evidence suggests that PRP injections reduce the frequency of required therapy. Tarsal tunnel syndrome, a compressive neuropathy carries a risk of permanent neural injury if left untreated. Injection therapy can provide a bridge to surgery; however, surgical decompression remains the definitive therapy. When the etiology is inflammatory, steroid injection is more likely to provide benefit. This has been shown in several studies for gout, as well as osteoarthritis of the foot and ankle and treatment-refractory rheumatoid arthritis. HA showed similar benefit, possibly due to anti-inflammatory effects. Stem cell injections may provide the additional benefit of structure restoration.

Summary

Chronic foot pain is common in the general population and has significant associated morbidity and disability. Traditionally treated with surgery, these are costly and only somewhat effective. Injections provide an effective alternative financially and some evidence exists that they are effective in pain alleviation. However, current evidence is limited and the benefit described from injection therapy has been short-lived in most cases. Further studies in larger populations are required to evaluate the long-term effects of these treatments.

Five-Year Follow-Up of Distal Tibia Bone and Foot and Ankle Trauma Treated with a 3D-Printed Titanium Cage

Large bone defects from trauma or cancer are difficult to treat. Current treatment options include the use of external fixation with bone transport, bone grafting, or amputation. These modes of therapy continue to pose challenges as they are associated with high cost, failure, and complication rates. In this study, we report a successful case of bone defect treatment using personalized 3D-printed implant. This is the longest known follow-up using a 3D-printed custom implant for this specific application. Ultimately, this report adds to existing literature as it demonstrates successful and maintained incorporation of bone into the titanium implant. The use of patient-specific 3D-printed implants adds to the available arsenal to treat complex pathologies of the foot and ankle. Moreover, the technology's flexibility and ease of customization makes it conducive to tailor to specific patient needs.

Natural Value of Böhler's Angle in Normal Chinese Population

Objective

To determine the value of Böhler's angle (BA) in a group of Chinese people, analyze possible factors that influence it, and compare BA with that in previous literature.

Methods

A total of 143 cases, aged from 4 to 79 years, were enrolled in the study, including 64 males and 79 females (79 left feet and 64 right feet). Radiographs were independently measured by six observers. Age, sex, body side, subtalar joint congruity (STJC), and X‐beam obliquity (TT) were recorded. The database was assessed based on intraobserver agreement, data distribution, the randomness of case selection, and the ratio equality of binomial variables. Then, the normal value of BA was established, as well as the correlation between BA and other parameters.

Results

In the present study, the interobserver reliability of BA, STJC, and TT was excellent. The BA data revealed a normal distribution, and the randomness of case selection was verified for age, sex, and body side. The ratio of sex and body side was equal. Homogeneity of variance was observed when comparing the value of BA between different groups. The value of BA was 31.6° ± 5.19° (range, 20.08°–47.19°), which was not related to age, sex, body side, and minor X‐ray beam obliquity. BA application was not suitable for individuals younger than 10 years. The mean value of BA in this study was not identical with those in previous reports. This demonstrated that BA varies for different races.

Conclusion

For Chinese people, 30° to 33° is recommended as the target value of BA for calcaneal fracture reduction, except in children under 10 years of age.

Prevalence of Osteoporosis in Patients with Distal Radius Fracture from Low-Energy Trauma

Introduction: Osteoporosis is a devastating problem leading to significant morbidity and mortality. Patients with osteoporosis usually present with fractures from low-energy trauma and falls, commonly of the distal radius, which may precede more severe fractures like fracture of the neck of femur, but data from Thailand are limited. The objective of our study was to determine the prevalence of osteoporosis in patients with distal radius fracture from low-energy trauma. Materials and Methods: This was a descriptive retrospective study, performed at Thammasat University Hospital in Thailand, from January 2011 to June 2017. Patients aged more than 50 years with distal radial fractures from low-energy trauma with available bone mineral density (BMD) result were included. Patients with known secondary causes of osteoporosis were excluded. Patients were grouped by age, sex, and BMD status (normal, osteopenic and osteoporotic). Results: One hundred out of 351 patients with distal radial fractures had bone mineral density data but only 79 (73 females) met the inclusion criteria. Most patients were aged 60-69 years old (n=31, 42.5%). 47 (59.5%) patients were osteoporotic, 23 (29.1%) osteopenic, and 9 (11.4%) were normal. Seven (6 osteoporotic) patients suffered a more severe fracture subsequently. No deaths were recorded. Conclusion: Our study found a high rate of osteoporosis mostly in females, consistent with published literature. Assessing BMD is crucial in middle age and elderly patients with fractures to better manage osteoporosis and prevent more severe fractures in the future.

Platelet-Rich plasma Injection Management for Ankle osteoarthritis study (PRIMA): protocol of a Dutch multicentre, stratified, block-randomised, double-blind, placebo-controlled trial

INTRODUCTION

Platelet-rich plasma (PRP) is a potentially efficacious treatment for ankle osteoarthritis (OA), but its use has not been examined in high-quality studies. Systematic reviews show that PRP injections significantly decrease pain and improve function in patients with knee OA. Ankle OA is more common than hip or knee OA in the young active population; with a prevalence of 3.4%.PRP injections in ankle OA are shown to be safe and improve quality of life over time, but no randomised controlled trial has been conducted. Our randomised controlled trial will evaluate the efficacy of PRP injections for symptom reduction and functional improvement, compared with placebo, in the treatment of ankle (talocrural) OA.

METHODS AND ANALYSIS

We will conduct the Platelet-Rich plasma Injection Management for Ankle OA study: a multicentre, randomised, placebo-controlled trial. One hundred patients suffering from ankle OA will be randomised into two treatment groups: PRP injection or placebo (saline) injection. Both groups will receive two injections of PRP or placebo at an interval of 6 weeks. Primary outcome is the American Orthopaedic Foot and Ankle Society score at 26 weeks. Secondary outcomes determined at several follow-up moments up to 5 years, include Ankle Osteoarthritis Score, Foot and Ankle Outcome Score, pain subscale of (0-40), Visual Analogue Scale score (0-100), Ankle Activity Score (0-10), subjective patient satisfaction Short Form Health Survey-36, Global Attainment Scaling and the EuroQol-5 dimensions-3 levels utility score. A cost-effectiveness analysis will be performed at 1 year.

ETHICS AND DISSEMINATION

The study is approved by the Medical Ethics Review Committee Amsterdam Medical Center, the Netherlands (ABR 2018-042, approved 23 July 2018) and registered in the Netherlands trial register (NTR7261). Results and new knowledge will be disseminated through the Dutch Arthritis Association (ReumaNederland), Dutch patient federation, conferences and published in a scientific peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NTR7261.

Influence of bone densitometry on the anti-osteoporosis treatment after fragility hip fracture

BACKGROUND

Fragility fracture significantly increases risk of future fracture. The fragility fracture cycle should be disrupted. The secondary fracture prevention is important for the patients with fragility hip fracture. The pharmacotherapy for osteoporosis is important for prevention of new fracture. However, many patients with hip fracture do not receive osteoporosis treatment. This retrospective study investigates the influence of bone mineral density (BMD) assessment on the initiation of anti-osteoporosis medications in the hospitalized patients with fragility hip fracture.

METHODS

This retrospective research enrolled 1211 patients with fragility hip fracture 50 years of age and older. Among 1211 patients aged from 50 to 103 years with the average age of 77.83 ± 9.95 years, there were 807 females and 404 males. There were 634 fractures of femoral neck and 577 intertrochanteric fractures of femur. We examined whether patients had received bone mineral density assessment and received anti-osteoporosis therapy during the period of hospitalization. The patients were divided into BMD assessment group and no BMD assessment group. Measurement data were expressed as mean ± standard deviation and compared with t test. All parameters of groups were compared with Chi-square test.

RESULTS

Of 1211 patients, 331 (27.33%) had received BMD assessment and 925 (76.38%) had received anti-osteoporosis drugs during the period of hospitalization. The rate of bisphosphonate use was lower and only 11.31% in the total patients. The anti-osteoporosis treatment rate was 93.66% in the patients receiving BMD assessment and 69.89% in the patients without BMD assessment (p < 0.01). The zoledronate use significantly increased from 6.7% in the patients without BMD assessment to 23.56% in the patients receiving BMD assessment (p < 0.01).

CONCLUSIONS

BMD assessment is a good basis for communication between patients and orthopedic surgeons. BMD assessment significantly increases the initiation of osteoporosis treatment and bisphosphonate use in the patients with hip fracture during the period of hospitalization.

The Combined Lambrinudi and Ankle Arthrodesis with Ring External Fixation in the Long-term Severe Neuromuscular Equinocavovarus Deformity with Ankle and Hindfoot Osteoarthritis: The Cases Presentation and Modified Guideline of Treatment

Background:

Severe equinocavovarus deformity develops from various causes and generally results in major disability that affects patient’s mobility and quality of life. It can be divided into neuromuscular and non-neuromuscular deformities, including two major subtypes: i.e., paralytic and spastic. In addition, ankle osteoarthritis could be caused by prolonged or progressive foot deformity.

Objective:

The present report proposes a modification of the accepted treatment algorithm and Lambrinudi’s surgical technique with ankle and hindfoot arthrodesis to correct theses challenging deformities with the long-term condition.

Results:

Two equinocavovarus cases were included, one in a 54-year old male and the second in a 63-year old female with paralaytic and spastic etiologies respectively. Patient’s deformity correction was acceptable. Each patient demonstrated improved outcomes due to a postoperative plantigrade foot and ankle position. No significant complications were encountered during the course of care and last follow-up. The mean follow-up time was 26 months.

Conclusion:

Severe long term neuromuscular equinocavovarus deformities are a challenging disability in the foot and ankle surgery. The present article proposes a modified guideline of treatment illustrated in two representative case studies of long-term paralytic and spastic equinocavovarus deformities. These conditions can be treated surgically using the stepwise approach as demonstrated in this article with acceptable outcomes.