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Woo SH. Parallel versus Angulated Screw Configuration in Subtalar Arthrodesis for Posttraumatic Arthritis. Clin Orthop Surg 2024; 16:477-484. [PMID: 38827769 PMCID: PMC11130629 DOI: 10.4055/cios23342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 06/05/2024] Open
Abstract
Background To compare radiographic union and clinical outcomes between parallel and angulated screw configurations (SCs) for patients undergoing subtalar arthrodesis due to posttraumatic subtalar arthritis (PSA) after displaced intra-articular calcaneal fractures. Methods This study retrospectively reviewed 140 consecutive PSA cases from March 2011 to November 2021 (parallel SC: group 1, n = 80; angulated SC: group 2, n = 60). Radiographic union, Foot and Ankle Outcome Score (FAOS), and visual analog scale (VAS) scores were among the outcome assessments. Six months after surgery, nonunion was confirmed based on plain radiographs, clinical evaluation, and computed tomography. Results Groups 1 and 2 included 14 (17.5%) and 3 (5.0%) nonunion cases, respectively (p = 0.035). There was no significant difference in preoperative FAOS and VAS scores between the groups. However, group 2 had significantly better clinical outcomes in 2 of the 5 FAOS domains (sports and quality of life), as well as VAS scores at 3 and 6 months postoperatively and at the final follow-up (p < 0.05). Conclusions Using the angulated SC for PSA had a lower nonunion rate and superior clinical outcomes than the parallel SC. Obtaining better radiological and clinical outcomes when using the angulated SC, rather than the parallel SC, would be advantageous.
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Affiliation(s)
- Seung Hun Woo
- Department of Orthopedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
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2
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Roytman GR, Salameh M, Rizzo SE, Dhodapkar MM, Tommasini SM, Wiznia DH, Yoo BJ. Sustentaculum fracture fixation with lateral plate or medial screw fixation are equivalent. Injury 2024; 55:111532. [PMID: 38614015 DOI: 10.1016/j.injury.2024.111532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/25/2024] [Accepted: 04/01/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Fixation of sustentaculum tali fractures is important to maintain the biomechanical function of the subtalar joint. A common method of fixation is securing the sustentacular fragment by way of a laterally based locking plate (LP). A medial approach with a single screw (MS) has been proposed as an alternative method of fixation. METHODS Five pairs of formalin-preserved cadaveric ankles with the subtalar joint and interosseous ligaments intact ("osseous cadavers") and four pairs of fresh-frozen cadaveric ankles with soft-tissue preserved dissected from mid-tibia down ("soft tissue cadavers") were used in the study. The left ankle was randomly assigned to one of the two fixation methods (LP or MS), while the right ankle was the opposite. These same steps for fixation were repeated for six synthetic ankle models. All models were loaded with a body mass of 80 kg. Statistical differences between LP and MS stiffness were determined using a paired t-test in cadavers and un-paired t-tests in synthetic ankles. RESULTS For osseous cadaveric ankles, LP demonstrated a mean stiffness of 232.95(SD: 59.96) N/mm, while MS was 239.72(SD:131.09) N/mm (p = 0.9293). For soft tissue cadaveric ankles, LP mean stiffness was 133.58(SD:37.84) N/mm, while MS was 134.88(SD:20.75) N/mm (p = 0.9578). For synthetic ankles, LP mean stiffness was 220.40(SD:81.93) N/mm, while MS was 261.50(SD:100.21) N/mm (p = 0.6116). CONCLUSIONS Across all three models, there was no significant difference between LP and MS methods. Retrospective observational studies are recommended to assess patient outcomes from each of the methods.
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Affiliation(s)
- Gregory R Roytman
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA; Biomedical Engineering, Yale University School of Engineering & Applied Science, New Haven, CT, USA.
| | - Motasem Salameh
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Sarah E Rizzo
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Meera M Dhodapkar
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Steven M Tommasini
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA; Biomedical Engineering, Yale University School of Engineering & Applied Science, New Haven, CT, USA
| | - Daniel H Wiznia
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA; Mechanical Engineering & Materials Science, Yale University School of Engineering & Applied Science, New Haven, CT, USA
| | - Brad J Yoo
- Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
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Raykov G, Ivanov S, Gueorguiev B, Pastor T, Berk T, Pastor T, Zderic I. Optimizing Subtalar Arthrodesis: A Human Cadaveric Evaluation of a Novel Partially-Threaded Screw Combination in the Delta Configuration. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:844. [PMID: 38929461 PMCID: PMC11206027 DOI: 10.3390/medicina60060844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/13/2024] [Accepted: 04/18/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: Despite the established role of subtalar joint arthrodesis (SJA) for treatment of subtalar osteoarthritis, achieving bone union remains challenging, with up to 46% non-union rates. Adequate compression and stable fixation are crucial for successful outcomes, with internal screw fixation being the gold standard for SJA. The delta configuration, featuring highly divergent screws, offers stability, however, it can result in hardware irritation in 20-30% of patients. Solutions to solve this complication include cannulated compression screw (CCS) countersinking or cannulated compression headless screw (CCHS) application. The aim of this biomechanical study was to investigate the stability of a delta configuration for SJA utilizing either a combination of a posterior CCHS and an anterior CCS or a standard two-CCS combination. Materials and Methods: Twelve paired human cadaveric lower legs were assigned pairwise to two groups for SJA using either two CCSs (Group 1) or one posterior CCHS and one anterior CCS (Group 2). All specimens were tested under progressively increasing cyclic loading to failure, with monitoring of the talocalcaneal movements via motion tracking. Results: Initial stiffness did not differ significantly between the groups, p = 0.949. Talocalcaneal movements in terms of varus-valgus deformation and internal-external rotation were significantly bigger in Group 1 versus Group 2, p ≤ 0.026. Number of cycles until reaching 5° varus-valgus deformation was significantly higher in Group 2 versus Group 1, p = 0.029. Conclusions: A delta-configuration SJA utilizing a posterior CCHS and an anterior CCS is biomechanically superior versus a standard configuration with two CCSs. Clinically, the use of a posterior CCHS could prevent protrusion of the hardware in the heel, while an anterior CCS could facilitate less surgical time and thus less complication rates.
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Affiliation(s)
- Georgi Raykov
- AO Research Institute Davos, 7270 Davos, Switzerland; (S.I.); (B.G.); (T.P.); (T.P.); (I.Z.)
- Department of Surgery, Cantonal Hospital of Uri, 6460 Altdorf, Switzerland
| | - Stoyan Ivanov
- AO Research Institute Davos, 7270 Davos, Switzerland; (S.I.); (B.G.); (T.P.); (T.P.); (I.Z.)
- Department of Orthopedics and Traumatology, Saint Marina Regional Hospital, Medical University Varna, 9002 Varna, Bulgaria
| | - Boyko Gueorguiev
- AO Research Institute Davos, 7270 Davos, Switzerland; (S.I.); (B.G.); (T.P.); (T.P.); (I.Z.)
| | - Tatjana Pastor
- AO Research Institute Davos, 7270 Davos, Switzerland; (S.I.); (B.G.); (T.P.); (T.P.); (I.Z.)
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, 3007 Bern, Switzerland
| | - Till Berk
- AO Research Institute Davos, 7270 Davos, Switzerland; (S.I.); (B.G.); (T.P.); (T.P.); (I.Z.)
- Department of Orthopedics, Traumatology and Reconstructive Surgery, University Hospital Aachen, 52074 Aachen, Germany
| | - Torsten Pastor
- AO Research Institute Davos, 7270 Davos, Switzerland; (S.I.); (B.G.); (T.P.); (T.P.); (I.Z.)
- Department of Orthopedics and Traumatology, Luzern Regional Hospital, 6110 Wolhusen, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, 7270 Davos, Switzerland; (S.I.); (B.G.); (T.P.); (T.P.); (I.Z.)
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Lerch RJ, Gulati A, Highlander PD. Revision of Subtalar Joint Arthrodesis: Considerations for Bone Grafting, Fixation Constructs, and Three-Dimensional Printing. Clin Podiatr Med Surg 2023; 40:633-648. [PMID: 37716742 DOI: 10.1016/j.cpm.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Subtalar joint arthrodesis is a commonly used procedure for numerous pathologic conditions in the foot and ankle. Although rarely performed in isolation, this procedure can provide successful resolution of various lower-extremity complaints. There are traditional approaches to isolated subtalar joint arthrodesis; however, when these fail, the authors recommend alternatives to enhance the success of revisional surgery. These include the use of intramedullary nailing, larger harvest of autograft, and metallic wedge.
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Affiliation(s)
- Ryan J Lerch
- The Reconstruction Institute, The Bellevue Hospital, 1400 West Main Street, Bellevue, OH 44811, USA
| | - Amar Gulati
- Progressive Feet, 611 South Carlin Springs Road, Suite 508, Arlington, VA 22204, USA
| | - Peter D Highlander
- The Reconstruction Institute, The Bellevue Hospital, 1400 West Main Street, Bellevue, OH 44811, USA.
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Kim HN, Choi YR, Kim BS, Kim YM, Lee J, Cho JH, Cha S, Park JY. Factors influencing successful bone union of isolated subtalar arthrodesis for posttraumatic subtalar arthritis: a multicenter case series. J Orthop Surg Res 2023; 18:559. [PMID: 37533050 PMCID: PMC10398992 DOI: 10.1186/s13018-023-04040-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/22/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND The purpose of this study was to find the factors influencing successful bone union for isolated subtalar arthrodesis in posttraumatic subtalar arthritis following calcaneal fracture. MATERIAL AND METHODS We retrospectively analyzed the rate of successful bone union of 119 cases of isolated subtalar arthrodesis for posttraumatic subtalar arthritis performed at five university hospitals between January 2010 and December 2019. Multivariate logistic regression analysis was used to find the factors associated with successful bone union. Successful bone union was defined as resolution of hindfoot pain with the presence of osseous trabecular bridging involving more than 50% of the posterior facet within 6 months postoperatively. RESULTS There were 77 (64.7%) cases of successful bone union, 11 (9.2%) cases of delayed union, 8 (6.7%) cases of questionable union, and 23 (19.3%) cases of nonunion. Use of fully threaded screws was 5.90 times [odds ratio (OR) = 5.90, 95% confidence interval (CI) = 1.42-24.49, p = 0.02] more likely to achieve successful bone union compared to the use of partially threaded screws. Use of two parallel screws or the two divergent screws were 3.71 times (OR = 3.71, 95% CI = 1.05-13.14, p = 0.04) and 4.65 times (OR = 4.65, 95% CI = 1.23-17.53, p = 0.02) more likely to achieve successful bone union compared to the use of a single screw. Use of cancellous autograft or structural autograft was 4.72 times (OR = 4.72, 95% CI = 1.17-19.06, p = 0.03) and 7.12 times (OR = 7.12, 95% CI = 1.46-34.68, p = 0.02) more likely to achieve successful bone union compared to no graft use. CONCLUSION Use of fully threaded screws, autograft, and two screws compared to a single screw were the factors associated with successful bone union within six postoperative months after subtalar arthrodesis for the posttraumatic arthritis.
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Affiliation(s)
- Hyong Nyun Kim
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Young Rak Choi
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bom Soo Kim
- Department of Orthopaedic Surgery, Inha University Hospital, Incheon, Republic of Korea
| | - Yu Mi Kim
- Department of Orthopedic Surgery, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo-si, Gyeonggi-do, Republic of Korea
| | - Jaehyung Lee
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do, Republic of Korea
| | - Jae Ho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Sunho Cha
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jae Yong Park
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do, Republic of Korea.
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Guareschi AS, Hoch C, Reid JJ, Scott DJ, Gross CE. Surgical Construct Type Is Associated With Time to Fusion and Reoperation Rate in Double and Isolated Talonavicular Arthrodeses. Foot Ankle Spec 2023:19386400231162422. [PMID: 37002611 DOI: 10.1177/19386400231162422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
BACKGROUND This study evaluates the effect of surgical construct on postoperative outcomes in patients undergoing isolated talonavicular (TN) or double (TN and subtalar ST) arthrodesis. TN constructs included plate and screw, screw and staple, and isolated staple constructs. Subtalar constructs included 1- and 2-screw constructs. METHODS Retrospective chart review identified 52 patients who underwent double or isolated TN arthrodesis between 2016 and 2021 by a single fellowship-trained foot and ankle surgeon with minimum 6 months of follow-up (mean = 1.62 years, range = 0.50-4.39 years). Data collected included demographics, medical history, surgical indication, surgical constructs used, complications, reoperations, patient-reported outcome measures, and radiographic measures. RESULTS Overall complication and reoperation rates were 26.3% and 12.3%, respectively. Among TN constructs, time to ST (P = .026) and TN (P = .018) fusion was significantly slower among patients receiving a plate and screw construct. Complication rate did not differ, but reoperation rate was significantly higher for plate and screw TN constructs (P = .039). Postoperative Foot and Ankle Outcome Score (FAOS) Quality of Life (P = .028) and Total (P = .016) scores were significantly better among plate and screw TN constructs. CONCLUSION Utilization of screw and staple or isolated staple construct have significantly quicker time to fusion and lower reoperation rates than plate and screw constructs for the TN joint. LEVEL OF EVIDENCE Level III: Retrospective cohort study.
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Affiliation(s)
| | - Caroline Hoch
- Medical University of South Carolina, Charleston, South Carolina
| | - Jared J Reid
- Medical University of South Carolina, Charleston, South Carolina
| | - Daniel J Scott
- Medical University of South Carolina, Charleston, South Carolina
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Beals CJ, Wong GAS, Dupont KM, Safranski DL. Effect of Simulated Bone Resorption on the Biomechanical Performance of Intramedullary Devices for Foot and Ankle Arthrodesis. J Foot Ankle Surg 2022; 62:7-13. [PMID: 35370055 DOI: 10.1053/j.jfas.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/15/2022] [Accepted: 03/02/2022] [Indexed: 02/03/2023]
Abstract
Midfoot and subtalar arthrodesis surgeries are performed to correct foot deformities and relieve arthritic pain. These procedures often employ intramedullary (IM) devices. The aim of the present study was to evaluate the biomechanical performance of a sustained dynamic compression (SDC) IM device compared to mechanically static devices in withstanding the effects of simulated bone resorption. Mechanically static and SDC IM devices were implanted in simulated bone blocks (n = 5/device). Compressive loads were measured with a custom-made mechanism to simulate bone resorption. The construct bending stiffness was determined from a 4-point bend test. Resorption was simulated by cutting a 1 mm or 2 mm gap in the midpoint of each construct and repeating the loading (n = 6/device). Initial compressive loads after device insertion were greater in the SDC IM devices when compared to the static devices (p < .01). The SDC device was able to sustain compression from 2 mm to 5.5 mm of simulated resorption depending upon device length, while the static devices lost compression within 1 mm of simulated resorption regardless of implant length (p < .001). In the 4-point bend test, the SDC device maintained its bending stiffness during simulated resorption whereas the static device displayed a significant loss in bending stiffness after 1 mm of simulated resorption (p < .001). The SDC device exhibited a significantly higher bending stiffness than the static device (p < .001). The SDC IM device demonstrated superior biomechanical performance during simulated resorption compared to static devices (p < .001). In conclusion, the ability of SDC IM devices to maintain construct stability and sustain compression across the fusion site while adapting to bone resorption may lead to greater fusion rates and overall quicker times to fusion than static IM devices. Surgeons who perform midfoot and subtalar arthrodesis procedures should be aware of a device's ability to sustain compression, especially in cases where bone resorption and joint settling are prevalent postoperatively.
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Affiliation(s)
- Caitlyn J Beals
- Engineering Student, Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Gabriella A S Wong
- Engineering Student, Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA
| | | | - David L Safranski
- Research Leader, Clinical Affairs, Foot & Ankle, Atlanta, GA; School of Materials Science and Engineering, Georgia Institute of Technology, Atlanta, GA.
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Kang SW, Jung SW, Woo SH. Factors associated with nonunion of the posttraumatic subtalar arthrodesis after displaced intra-articular calcaneal fractures. Foot Ankle Surg 2022; 29:188-194. [PMID: 36732154 DOI: 10.1016/j.fas.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/22/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study investigated the incidence of and risk factors for nonunion in patients with posttraumatic subtalar arthrodesis (SA). METHODS We retrospectively reviewed 165 posttraumatic SA cases. Nonunion was diagnosed at 6 months after surgery based on the findings of clinical evaluations, plain radiographs, and CT scans. Patient-specific factors and surgeon-specific factors were evaluated as potential risk factors. RESULTS The overall nonunion rate was 13.3 % (22 of 165 cases). In the final multivariate logistic regression analysis, smoking (odds ratio [OR] = 3.64; 95 % confidence interval [CI] = 1.23-10.75), parallel screw configuration (OR = 5.70; 95 % CI = 1.62-20.06), and freeze dried iliac crest (OR = 9.16; 95 % CI = 2.28-36.79) were demonstrated as risk factors for nonunion of posttraumatic SA. CONCLUSION Patients with a history of smoking, parallel screw configuration fixation, and those who received freeze dried iliac crest as an interpositional graft, had a significantly higher rate of nonunion.
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Affiliation(s)
- Suk-Woong Kang
- Department of Orthopaedic Surgery, Pusan National University School of Medicine, Yangsan, the Republic of Korea
| | - Sung Won Jung
- Department of Orthopaedic Surgery, Pusan National University School of Medicine, Yangsan, the Republic of Korea
| | - Seung Hun Woo
- Department of Orthopaedic Surgery, Pusan National University School of Medicine, Yangsan, the Republic of Korea.
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Jones JM, Vacketta VG, Philp FH, Catanzariti AR. Radiographic Outcomes of Isolated Subtalar Joint Arthrodesis With Varying Fixation Technique. J Foot Ankle Surg 2022; 61:938-943. [PMID: 34996652 DOI: 10.1053/j.jfas.2021.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/07/2021] [Indexed: 02/03/2023]
Abstract
Subtalar joint (STJ) arthrodesis is a well-established and accepted surgical procedure utilized for the treatment of various hindfoot conditions including primary or posttraumatic subtalar osteoarthritis, hindfoot valgus deformity, hindfoot varus deformity, complex acute calcaneal fracture, symptomatic residual congenital deformity, tarsal coalition, and other conditions causing pain and deformity about the hindfoot. Union rates associated with isolated subtalar joint arthrodesis are generally thought to be favorable, though reports have varied significantly, with non-union rates ranging from 0 to 46%. Various fixation constructs have been recommended for STJ arthrodesis. The purpose of this study was to compare radiographic union in a 2-screw fixation technique to a 3-screw fixation technique for patients undergoing primary isolated STJ arthrodesis. To this end, we retrospectively reviewed 54 patients; 26 in the 2-screw group and 28 in the 3-screw group. We found the median time to radiographic union to be 9 weeks for the 2-screw cohort and 7 weeks for the 3-screw cohort. Additionally, we found that the 2-screw fixation cohort had a radiographic non-union rate of 26.9% while the 3-screw cohort had no non-unions. We conclude that the use of a 3-screw construct for isolated STJ arthrodesis has a lower non-union rate and time to union when compared to the traditional 2-screw construct and should be considered as a fixation option for STJ arthrodesis.
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Affiliation(s)
- Jacob M Jones
- Resident, Postgraduate Year 2, Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Vincent G Vacketta
- Resident, Postgraduate Year 2, Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Frances Hite Philp
- Health Outcomes Researcher, AHN Research and Orthopaedic Institutes, Allegheny Health Network, Pittsburgh, PA
| | - Alan R Catanzariti
- Director of Residency Training, Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA.
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10
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Ethical Considerations Surrounding Surgeon Ownership of Ambulatory Surgery Centers. J Am Coll Surg 2022; 235:539-543. [PMID: 35972176 DOI: 10.1097/xcs.0000000000000271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
As surgical care continues to transition to an outpatient setting, ambulatory surgery centers (ASCs) present favorable options for physician investment. As of 2017, more than 90% of ASCs have at least some physician ownership, with 64% solely physician-owned. Yet, physician ownership creates an inherent conflict of interest known as dual agency, where clinicians have a personal financial stake in addition to their obligation towards patient well-being. Here, we assess the ethical considerations surrounding dual agency in the setting of ASCs through the lens of beneficence, nonmaleficence, autonomy, and justice. We further propose strategies for appropriate navigation of such situations, including disclosure of ownership status, instruction on unfamiliar techniques, and adherence to accepted clinical practice guidelines for materials selection and surgical indications.
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Subtalar arthrodesis using a single compression screw: a comparison of results between anterograde and retrograde screwing. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1583-1589. [PMID: 34623469 DOI: 10.1007/s00590-021-03141-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The primary objective of this study was to compare the radiological and clinical results of anterograde and retrograde screwing in subtalar arthrodesis using a single compression screw. The secondary objective was to evaluate the subjective results and consolidation of this procedure. The hypotheses were that isolated screw fixation was sufficient to achieve good consolidation and that there was no difference between the two techniques with a similar rate of bone fusion. METHODS This is a monocentric, retrospective, radio-clinical study based on 99 patients (101 feet), 58 males and 41 females, with an average age of 64 years. The main aetiology was post-traumatic osteoarthritis, which represented 51% of cases. Two groups were formed: group A (52 feet) consisting of fixed arthrodesis with ascending (retrograde) screwing and group D (49 feet) consisting of fixed arthrodesis with descending (anterograde) screwing. The two groups were statistically comparable in terms of demographic data as well as aetiologies and comorbidities. Arthrodeses which were not fused at 6 months were reassessed at one year and in the event of any radio-clinical doubt regarding consolidation, an additional CT scan was prescribed. Average post-operative follow-up was 11 ± 5 years (2-27 years). RESULTS Ninety-two arthrodeses (93%) were fused at one year and 9 were considered to be in non-union, 5 (9.8%) in group A, and 4 (8.3%) in group D. We recorded 30 complications, 22 of which were due to a conflict with the screw head, 18 (34.5%) in group A and 4 (8.3%) in group D (p = 0.03). Conflict between the screw head and the heel led to the removal of the screw after consolidation of the arthrodesis. The clinical results were evaluated using Odom's criteria. Nine per cent of patients described their results as excellent, 29% as good, 51% as satisfactory and 11% found the result to be poor. CONCLUSION The fusion rate for isolated compression screw arthrodesis is good, and there is no difference between anterograde and retrograde screws. However, the discomfort caused by the screw head being insufficiently embedded in the retrograde group led to a non-negligible number of additional surgeries to remove the screw.
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12
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Chraim M, Recheis S, Alrabai H, Wenzel-Schwarz F, Trnka HJ, Bock P. Midterm Outcome of Subtalar Joint Revision Arthrodesis. Foot Ankle Int 2021; 42:824-832. [PMID: 33940969 DOI: 10.1177/1071100721995187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The outcomes of revision subtalar arthrodesis have received relatively little focus in research compared with primary subtalar arthrodesis outcomes. This study aimed to assess the midterm clinical and radiologic results of subtalar joint revision arthrodesis and to analyze the risk factors that might influence the outcome of this procedure. METHODS We performed a retrospective review of 20 patients after subtalar joint revision arthrodesis for malunion, using interposition of iliac crest bone graft. The mean age was 55.75 years and the average follow-up lasted for 48.93 months. Eighty-five percent of the patients had at least 1 risk factor identified prior to revision. Patients' satisfaction and functional outcomes were evaluated with the American Orthopaedic Foot & Ankle Society Scale (AOFAS), the Foot and Ankle Outcome Score (FAOS), the Foot Function Index (FFI), and dynamic pedobarography. RESULTS A fusion rate of 80% was recorded whereas 20% of the cases ended with a painful pseudarthrosis requiring additional surgery. Pedobarographic measurements demonstrated that loading has a propensity toward the lateral column, but no substantial effect on the gait of patients. In this group, the following patient-reported outcomes were observed: 70% of the patients were satisfied, 20% of the patients found the result fair, and 10% were not satisfied with the results. Compared with the preoperative evaluation, postoperative functional scores showed significant improvement on the FOAS, AOFAS, and FFI outcome scales. CONCLUSION Revision arthrodesis of the subtalar joint remains a challenging issue with a relatively high rate of nonunion, especially in a population of patients with multiple risk factors. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | | | - Hamza Alrabai
- Department of Orthopaedics, King Saud University, Riyadh, Saudi Arabia
| | - Florian Wenzel-Schwarz
- Department of Paediatric Orthopaedics and Adult Foot and Ankle Surgery, Orthopaedic Hospital Speising, Vienna, Austria
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Verheyen CCPM. Letter to the editor on "How many screws are necessary for subtalar fusion? A retrospective study". Foot Ankle Surg 2020; 26:948. [PMID: 32978086 DOI: 10.1016/j.fas.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Cees C P M Verheyen
- Department of Orthopedic Surgery and Traumatology, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands.
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Wilhelm MP, Hooper TL, Seeber GH, Browne KL, Sargent E, Gilbert KK, James CR, Brismée JM, Matthijs OC, Matthijs A, Sizer PS. The relationship between measures of foot mobility and subtalar joint stiffness using vibration energy with color Doppler imaging-A clinical proof-of-concept validation study. PLoS One 2020; 15:e0237634. [PMID: 32813729 PMCID: PMC7437893 DOI: 10.1371/journal.pone.0237634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 07/30/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Subtalar joint (STJ) dysfunction can contribute to movement disturbances. Vibration energy with color Doppler imaging (VECDI) may be useful for detecting STJ stiffness changes. OBJECTIVES (1) Support proof-of-concept that VECDI could detect STJ stiffness differences; (2) Establish STJ stiffness range in asymptomatic volunteers; (3) Examine relationships between STJ stiffness and foot mobility; and (4) Assess VECDI precision and reliability for examining STJ stiffness. METHODS After establishing cadaveric testing model proof-of-concept, STJ stiffness (threshold units, ΔTU), ankle complex passive range-of-motion (PROM) and midfoot-width-difference (MFWDiff) data were collected in 28 asymptomatic subjects in vivo. Three reliability measurements were collected per variable; Rater-1 collected on all subjects and rater-2 on the first ten subjects. Subjects were classified into three STJ stiffness groups. RESULTS Cadaveric VECDI measurement intra-rater reliability was 0.80. A significantly lower STJ ΔTU (p = .002) and ankle complex PROM (p < .001) was observed during the screw fixation versus normal condition. A fair correlation (r = 0.660) was observed between cadaveric ΔTU and ankle complex PROM. In vivo VECDI measurements demonstrated good intra-rater (0.76-0.84) versus poor inter-rater (-3.11) reliability. Significant positive correlations were found between STJ stiffness and both dorsum (r = .440) and posterior (r = .390) PROM. MFWDiff exhibited poor relationships with stiffness (r = .103) and either dorsum (r = .256) or posterior (r = .301) PROM. STJ stiffness ranged from 2.33 to 7.50 ΔTUs, categorizing subjects' STJ stiffness as increased (n = 6), normal (n = 15), or decreased (n = 7). Significant ANOVA main effects for classification were found based on ΔTU (p< .001), dorsum PROM (p = .017), and posterior PROM (p = .036). Post-hoc tests revealed significant: (1) ΔTU differences between all stiffness groups (p < .001); (2) dorsum PROM differences between the increased versus normal (p = .044) and decreased (p = .017) stiffness groups; and (3) posterior PROM differences between the increased versus decreased stiffness groups (p = .044). A good relationship was found between STJ stiffness and dorsum PROM in the increased stiffness group (r = .853) versus poor, nonsignificant relationships in the normal (r = -.042) or decreased stiffness (r = -.014) groups. CONCLUSION PROM may not clinically explain all aspects of joint mobility. Joint VECDI stiffness assessment should be considered as a complimentary measurement technique.
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Affiliation(s)
- Mark P Wilhelm
- Tufts University School of Medicine, Medford, Massachusetts, United States of America
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, Texas, United States of America
| | - Troy L Hooper
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, Texas, United States of America
| | - Gesine H Seeber
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, Texas, United States of America
- University Hospital for Orthopaedics and Trauma Surgery Pius-Hospital, Medical Campus University of Oldenburg, Oldenburg, Germany
| | - Kevin L Browne
- College of Health Sciences, University of Texas at El Paso, El Paso, Texas, United States of America
| | - Elizabeth Sargent
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont, United States of America
| | - Kerry K Gilbert
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, Texas, United States of America
| | - C Roger James
- Texas Tech University Health Sciences Center, Lubbock, Texas, United States of America
| | - Jean-Michel Brismée
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, Texas, United States of America
| | - Omer C Matthijs
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, Texas, United States of America
- Boma, Physical Therapy Outpatient Clinic, Kapfenberg, Styria, Austria
| | - Anja Matthijs
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, Texas, United States of America
- Boma, Physical Therapy Outpatient Clinic, Kapfenberg, Styria, Austria
| | - Phillip S Sizer
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, Texas, United States of America
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Characteristics of anterior inferior calcaneal cortex. Foot Ankle Surg 2019; 25:323-326. [PMID: 29409173 DOI: 10.1016/j.fas.2017.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 12/13/2017] [Accepted: 12/13/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Minimal invasive surgery of calcaneal fracture provided satisfactory outcomes. In tongue type calcaneal fracture, percutaneous screw usually purchases in anterior inferior calcaneal cortex. However, there was no detail about the cortex of anterior inferior calcaneus so the surface anatomy and cortical thickness of this area were studied. METHODS 88 calcaneus from embalmed cadavers were enrolled. Anterior part of the inferior cortex was identified. Surface anatomy was examined. Length, anterior and posterior widths were measured. Anterior inferior calcaneal cortex was divided into anterior, middle and posterior segments. The cortical thickness at middle, medial most and lateral most of 3 segments were measured. RESULTS Anterior inferior calcaneal cortex was a long trapezoidal shape with well-defined borders as a dense and thick cortical bone, convex relief from medial and lateral walls. Mean(SD) length was 33.40(3.46) millimeters (mm). Median(min,max) of anterior and posterior width were 10.50(8.21,19.26) mm and 14.00(10.05,20.42) mm, respectively. Mean(SD) of middle cortical thickness of anterior and middle segment were 3.12(0.76) and 3.72(0.74). Median(min,max) middle cortical thickness of posterior segment was 3.13(1.62,6.51) mm. Whereas, of the medial most were 1.31(0.78,3.11), 1.31(0.90,2.57) and 1.26(0.85,2.61) mm and of the lateral most were 1.17(0.67,2.64), 1.38(0.80,2.55) and 1.31(0.84,2.61) mm, respectively. Inter-intraobserver reliabilities of the measurements were >0.79. The statistical analysis showed the middle cortex is significantly the thickest (P<0.001) and posterior width is significant wider than the anterior (P<0.001). CONCLUSIONS Anterior inferior calcaneal cortex has special characteristics in term of surface anatomy, width and thickness. For the percutaneous screw insertion from posterosuperior to anterior inferior calcaneus in tongue type calcaneal fracture, we recommend that screw should purchase in middle cortex due to maximal cortical thickness as well as its cortical width could accept 6.5 or 7.0mm screw without screw extrusion.
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Vilá-Rico J, Bravo-Giménez B, Jimenez-Díaz V, Mellado-Romero MA, Ojeda-Thies C. Arthroscopic Subtalar Arthrodesis: Does the Type of Fixation Modify Outcomes? J Foot Ankle Surg 2018; 57:726-731. [PMID: 29709422 DOI: 10.1053/j.jfas.2017.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Indexed: 02/03/2023]
Abstract
The goal of the present study was to analyze a modified American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score, time to union, and the incidence of fusion after isolated arthroscopic posterior subtalar arthrodesis using either 1 or 2 screws of different diameters. We reviewed a consecutive series of 65 patients, mean age 50.0 ± 15.6 years, including 38 males (58.5%) and 27 females (41.5%), who had undergone arthrodesis from May 2004 to February 2011. The mean follow-up duration was 57.5 (range 24 to 105) months. The patients were divided into 3 groups according to the fixation method used: group 1 (n = 12; 18.5%) underwent fixation with one 6.5-mm screw; group 2 (n = 40; 61.5%) with one 7.3-mm screw; and group 3 (n = 13; 20%) with two 7.3-mm screws. An overall statistically significant (p <.0001) improvement was seen in the modified AOFAS scale score for all 3 fixation groups; however, the difference was not statistically significant (p = .79) among the fixation groups. Fusion was achieved in 62 patients (95.4%) after a mean of 12.1 (range 9 to 16) weeks. The difference in the time to union was not statistically significant (p = .781) among the fixation groups. Nine patients (13.8%) experienced complications, and nonunion was significantly (p = .005) more prevalent in the single 6.5-mm screw group. In conclusion, all 3 screw configurations led to improved modified AOFAS scale scores, although nonunion was more common among patients fixed with a single 6.5-mm screw.
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Affiliation(s)
- Jesús Vilá-Rico
- Orthopedic Surgeon, Hospital Universitario Doce de Octubre, Madrid, Spain; Assistant Professor, Departamento de Cirugía, Universidad Complutense, Madrid, Spain.
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17
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Eichinger M, Brunner A, Stofferin H, Bölderl A, Blauth M, Schmölz W. Screw tip augmentation leads to improved primary stability in the minimally invasive treatment of displaced intra-articular fractures of the calcaneus: a biomechanical study. INTERNATIONAL ORTHOPAEDICS 2018; 43:2175-2181. [PMID: 30306219 DOI: 10.1007/s00264-018-4171-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 09/18/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To investigate if the stability of minimally invasive screw osteosynthesis of displaced intra-articular calcaneal fractures (DIACF) can be effectively increased by an innovative approach to screw tip augmentation. METHODS In eight-paired human cadaver hindfoot specimens, DIACF of Sanders type IIB were treated with either standard screw osteosynthesis or with bone cement augmentation of the screw tips in the main fragments. The instrumented specimens were subjected to a cyclic loading protocol (9000 cycles, with stepwise increasing loads, 100-1000 N). The interfragment motions were quantified as tuber fragment tilt (TFT) and posterior facet inclination angle (PFIA) using a 3-D motion analysis system. Böhler's angle (BA) was evaluated from X-rays. A load-to-failure test was performed after the cyclic loading protocol. RESULTS All but one specimen of the augmented group withstood more cycles than the respective specimens of the non-augmented group. Mean cycles to failure for the failure criterion of 5° TFT were 7299 ± 1876 vs. 3864 ± 1810, corresponding to loads of 811 N ± 195 vs. 481 N ± 180, (P = 0.043). There were no significant differences observed in the PFIAs. The failure criterion of 5° BA was reached after a mean of 7929 cycles ± 2004 in the augmented group and 4129 cycles ± 2178 in the non-augmented group, corresponding to loads of 893 N ± 200 vs. 513 N ± 218, (P = 0,090). The mean load-to-failure of the four specimens in the augmented group that completed the cyclic loading was 1969 N over a 1742-2483 N range. CONCLUSION Screw tip augmentation significantly improved the mechanical stability of the calcanei after osteosynthesis in terms of decreased tuber fragment tilts and less changes in Böhler's angle.
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Affiliation(s)
- Martin Eichinger
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Alexander Brunner
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Hannes Stofferin
- Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Müllerstrasse 59, 6020, Innsbruck, Austria
| | - Andreas Bölderl
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Michael Blauth
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Werner Schmölz
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
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Abstract
The subtalar joint plays an important role for the hindfoot when accommodating during gait. Joint degeneration may be caused by posttraumatic, inflammatory, and pathologic biomechanical changes. Once conservative treatment has failed, subtalar fusion should be considered. The indication for surgery is based on thorough clinical and radiographic evaluation. Several techniques for subtalar fusion are published in literature. This article aims to describe a technique for in situ arthrodesis of the subtalar joint, paying special attention to biomechanical aspects as well as preoperative clinical and radiological work-up.
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Affiliation(s)
- Stephan H Wirth
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, Zürich 8008, Switzerland.
| | - Stefan M Zimmermann
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, Zürich 8008, Switzerland
| | - Arnd F Viehöfer
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, Zürich 8008, Switzerland
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Subtalar Joint Arthrodesis for Elective and Posttraumatic Foot and Ankle Deformities. Clin Podiatr Med Surg 2017; 34:327-338. [PMID: 28576192 DOI: 10.1016/j.cpm.2017.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Subtalar joint arthrodesis is a procedure used in posttraumatic arthritis, osteoarthritis, tarsal coalition management, posterior tibial tendon dysfunction, and inflammatory arthropathies, and can be used in deformity correction. The goals of the procedure are to eliminate pain, improve function, restore stability, and realign the hind foot. The procedure has high patient satisfaction with low complications while preserving motion in adjacent tarsal joints. Joint preparation is important and time should be spent preparing the joint for successful arthrodesis and the fixation construct needs to be done well and effectively to provide a solid Arbeitsgemeinschaft für Osteosynthesefragen (AO) construct for good results.
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20
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Torsional stiffness after subtalar arthrodesis using second generation headless compression screws: Biomechanical comparison of 2-screw and 3-screw fixation. Clin Biomech (Bristol, Avon) 2017; 45:32-37. [PMID: 28458187 DOI: 10.1016/j.clinbiomech.2017.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Subtalar joint arthrodesis is a common operative treatment for symptomatic subtalar arthrosis. Because excessive relative motion between the talus and calcaneus can delay or prohibit fusion, fixation should be optimized, particularly in patients at risk for subtalar arthrodesis nonunion. Tapered, fully-threaded, variable pitch screws are gaining popularity for this application, but the mechanical properties of joints fixed with these screws have not been characterized completely. We quantified the torsion resistance of 2-screw and 3-screw subtalar joint fixation using this type of screw. METHODS Ten pairs of cadaveric subtalar joints were prepared for arthrodesis and fixed using Acutrak 2-7.5 screws. One specimen from each pair was fixed with two diverging posterior screws, and the contralateral joint was fixed using two posterior screws and a third screw directed through the anterior calcaneus into the talar neck. Internal and external torsional loads were applied and joint rotation and torsional stiffness were measured at two torque levels. FINDINGS Internal rotation was significantly less in specimens fixed with three screws. No difference was detectable between 2-screw and 3-screw fixation in external rotation or torsional stiffness in either rotation direction. Both 2-screw and 3-screw fixation exhibited torsion resistance surpassing that reported previously for subtalar joints fixed with two diverging conventional lag screws. INTERPRETATION Performance of the tapered, fully threaded, variable pitch screws exceeded that of conventional lag screws regardless of whether two or three screws were used. Additional resistance to internal rotation afforded by a third screw placed anteriorly may offer some advantage in patients at risk for nonunion.
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21
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Ziegler P, Friederichs J, Hungerer S. Fusion of the subtalar joint for post-traumatic arthrosis: a study of functional outcomes and non-unions. INTERNATIONAL ORTHOPAEDICS 2017; 41:1387-1393. [DOI: 10.1007/s00264-017-3493-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 04/03/2017] [Indexed: 01/13/2023]
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Matsumoto T, Glisson RR, Reidl M, Easley ME. Compressive Force With 2-Screw and 3-Screw Subtalar Joint Arthrodesis With Headless Compression Screws. Foot Ankle Int 2016; 37:1357-1363. [PMID: 27587373 DOI: 10.1177/1071100716666275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Joint compression is an essential element of successful arthrodesis. Although subtalar joint compression generated by conventional screws has been quantified in the laboratory, compression obtainable with headless screws that rely on variable thread pitch to achieve bony contact has not been assessed. This study measured subtalar joint compression achieved by 2 posteriorly placed contemporary headless, variable-pitch screws, and quantified additional compression gained by placing a third screw anteriorly. METHODS Ten, unpaired fresh-frozen cadaveric subtalar joints were fixed sequentially using 2 diverging posterior screws (one directed into the talar dome, the other into the talar neck), 2 parallel posterior screws (both ending in the talar dome), and 2 parallel screws with an additional anterior screw inserted from the plantar calcaneus into the talar neck. Joint compression was quantified directly during screw insertion using a novel custom-built measuring device. RESULTS The mean compression generated by 2 diverging posterior screws was 246 N. Two parallel posterior screws produced 294 N of compression, and augmentation of that construct with a third, anterior screw increased compression to 345 N (P < .05). Compression subsequent to 2-screw fixation was slightly less than that reported previously for subtalar joint fixation with 2 conventional lag screws, but was comparable when a third screw was added. CONCLUSIONS Under controlled testing conditions, 2 tapered, variable-pitch screws generated somewhat less compression than previously reported for 2-screw fixation with conventional headed screws. A third screw placed anteriorly increased compression significantly. CLINICAL RELEVANCE Because headless screws are advantageous where prominent screw heads are problematic, such as the load-bearing surface of the foot, their effectiveness compared to other screws should be established to provide an objective basis for screw selection. Augmenting fixation with an anterior screw may be desirable when conditions for fusion are suboptimal.
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Affiliation(s)
- Takumi Matsumoto
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Richard R Glisson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Markus Reidl
- Department of Trauma Surgery, Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Effects of five hindfoot arthrodeses on foot and ankle motion: Measurements in cadaver specimens. Sci Rep 2016; 6:35493. [PMID: 27752084 PMCID: PMC5067490 DOI: 10.1038/srep35493] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/30/2016] [Indexed: 11/12/2022] Open
Abstract
Single, double, and triple hindfoot arthrodeses are used to correct hindfoot deformities and relieve chronic pain. However, joint fusion may lead to dysfunction in adjacent articular surfaces. We compared range of motion in adjacent joints before and after arthrodesis to determine the effects of each procedure on joint motion. The theory of moment of couple, bending moment and balanced loading was applied to each of 16 fresh cadaver feet to induce dorsiflexion, plantarflexion, internal rotation, external rotation, inversion, and eversion. Range of motion was measured with a 3-axis coordinate measuring machine in a control foot and in feet after subtalar, talonavicular, calcaneocuboid, double, or triple arthrodesis. All arthrodeses restricted mainly internal-external rotation and inversion-eversion. The restriction in a double arthrodesis was more than that in a single arthrodesis, but that in a calcaneocuboid arthrodesis was relatively low. After triple arthrodeses, the restriction on dorsiflexion and plantarflexion movements was substantial, and internal-external rotation and inversion-eversion were almost lost. Considering that different arthrodesis procedures cause complex, three-dimensional hindfoot motion reductions, we recommend talonavicular or calcaneocuboid arthrodesis for patients with well-preserved functions of plantarflexion/dorsiflexion before operation, subtalar or calcaneocuboid arthrodesis for patients with well-preserved abduction/adduction, and talonavicular arthrodesis for patients with well-preserved eversion/inversion.
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Abstract
This manuscript will provide an overview of how the age and osteoporosis related changes in mechanical properties of bone affect the stability of osteosynthesis constructs, both from a mechanical as well as from a clinical perspective. The manuscript will also address some of the principles of fracture fixation for osteoporotic fractures and discuss applications of osteoporotic fracture fixation at sites typically affected by fragility fractures, namely the distal radius, the proximal humerus, the femur and the spine. The primary aim of operative treatment in elderly individuals is the avoidance of immobilization of the patient. In selected cases conservative treatment might be required. Generally, choice of treatment should be individualized and based on the evaluation of patient-specific, fracture-specific and surgeon-specific aspects. The orthopaedic surgeon plays an essential role in enabling functional recovery by providing good surgery but a multidisciplinary approach is essential in order to support the patient to regain his/her quality of life after fragility fracture. Overall, the therapy of fractures in osteoporotic bone in the elderly requires a multidisciplinary therapeutic acute care concept including treatment of co-morbidities and correct choice of timing, and technique of the operative intervention.
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Affiliation(s)
- Christian von Rüden
- Institute of Biomechanics, Berufsgenossenschaftliche Unfallklinik Murnau, Germany; Institute of Biomechanics, Paracelsus Medical UniversitySalzburg, Austria
| | - Peter Augat
- Institute of Biomechanics, Berufsgenossenschaftliche Unfallklinik Murnau, Germany; Institute of Biomechanics, Paracelsus Medical UniversitySalzburg, Austria.
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25
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Subtalar arthrodesis stabilisation with screws in an angulated configuration is superior to the parallel disposition: a biomechanical study. INTERNATIONAL ORTHOPAEDICS 2015; 39:2275-80. [PMID: 26253359 DOI: 10.1007/s00264-015-2944-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/16/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to compare the stability of two established screw configurations (SC) for subtalar arthrodesis using a cyclic loading model. METHODS Eight paired human cadaver hindfoot specimens underwent subtalar arthrodesis with either parallel or angulated SC. The instrumented specimens were subjected to a cyclic loading protocol (1000 cycles: ±5 Nm rotation moment, 50 N axial force). The joint range of motion (ROM) was quantified before and after cyclic loading, in the three principal motion planes of the subtalar joint using pure bending moments of ±3 Nm. RESULTS After instrumentation, the angulated SC showed significantly less mean ROM compared to the parallel SC in internal/external rotation (1.4° ± 2.2° vs. 3.3° ± 2.8°, P = 0.006) and in inversion/eversion (0.9° ± 1.4° vs. 1.5° ± 1.1°, P = 0.049). After cyclic loading, the angulated SC resulted in significantly less mean ROM compared to the parallel SC in internal/external rotation (3.3° ± 4.6° vs. 8.8° ± 8.0°, P = 0.006) and in inversion/eversion (1.9° ± 2.3° vs. 3.9° ± 3.9°, P = 0.017). No significant differences in the mean ROM were found between the angulated and parallel SC in dorsal extension/plantar flexion. CONCLUSION The angulated SC resulted in decreased ROM in the subtalar arthrodesis construct after instrumentation and after cyclic loading compared to the parallel SC. The data from our study suggest that the clinical use of the angulated SC for subtalar arthrodesis might be superior to the parallel SC.
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