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Regal A, Tuifua TS, Scharer BM, DeVries JG. Effect of Preoperative Coronal Plane Alignment on Actual Versus Predicted Alignment Using Patient Specific Instrumentation in Total Ankle Replacement. J Foot Ankle Surg 2024:S1067-2516(24)00171-6. [PMID: 39098649 DOI: 10.1053/j.jfas.2024.07.009] [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: 04/24/2024] [Revised: 06/24/2024] [Accepted: 07/25/2024] [Indexed: 08/06/2024]
Abstract
Alignment in total ankle replacement is important for success and implant survival. Recently there has been the introduction and adoption of patient specific instrumentation for implantation in total ankle replacement. Current literature does not evaluate the effect of preoperative deformity on accuracy of patient specific instrumentation. A retrospective radiographic analysis was performed on 97 consecutive patients receiving total ankle replacement with patient specific instrumentation to assess the accuracy and reproducibility of the instrumentation. Subgroup analysis evaluated the effect of preoperative deformity. All surgeries were performed by fellowship trained foot and ankle surgeons without industry ties to the implants used. Preoperative and postoperative films were compared to plans based on computerized tomography scans to assess how closely the plan would be implemented in patients. Overall postoperative coronal plane alignment was within 2° of predicted in 87.6% (85 patients). Similarly, overall postoperative sagittal plane alignment was within 2° of predicted in 88.7% (86 patients). Tibial implant size was accurately predicted in 81.4% (79 patients), and talus implant size was correct in 75.3% (73 patients). Patients with preoperative varus deformity had a higher difference between predicted and actual postoperative alignment compared to valgus deformity (1.1° compared to 0.3°, p = .02). A higher average procedure time was found in varus patients, and more adjunctive procedures were needed in patients with varus or valgus deformity, but these were not significant, p > .5. Surgeons can expect a high degree of accuracy when using patient specific instrumentation overall, but less accurate in varus deformity.
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Affiliation(s)
- Andrew Regal
- Podiatric Medicine and Surgery Residency, Ascension Wisconsin Hospital, Milwaukee, WI.
| | - Tisileli S Tuifua
- Radiology Department, Aurora St. Luke's Medical Center, Milwaukee, WI
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Mazzotti A, Zielli SO, Arceri A, Artioli E, Langone L, Sgubbi F, Geraci G, Faldini C. Accuracy of patient-specific instrumentation for implant positioning in custom-made total ankle arthroplasty. J Exp Orthop 2024; 11:e12026. [PMID: 39072244 PMCID: PMC11272990 DOI: 10.1002/jeo2.12026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/04/2024] [Accepted: 03/25/2024] [Indexed: 07/30/2024] Open
Abstract
Purpose This retrospective radiological analysis aimed to assess the accuracy of implant positioning in patients with ankle arthritis undergoing custom-made total ankle arthroplasty (TAA) with patient-specific instrumentation (PSI) compared with preoperative planning. Methods Patients who underwent custom-made TAA with PSI from January 2018 to March 2023 were retrospectively evaluated, focusing on the tibial anterior surface (TAS) angle, tibial lateral surface (TLS) angle and tibiotalar ratio (TTR). Additionally, data regarding the time from the preoperative computed tomography (CT) scan to surgery, associated procedures and complications were recorded. Results No associated procedures were performed, and only one intraoperative complication, an iatrogenic lateral malleolar fracture, was recorded. In the coronal plane, custom-made TAA with PSI consistently achieved precise positioning of prosthetic components, even in cases with significant preoperative deformities or bone deficits. However, a statistically significant deviation from the planned values was observed in the sagittal plane (p = 0.007). A notable correlation was identified between the time elapsed from the preoperative CT scan to surgery and the deviation from the planned to the actual postoperative TAS angle (p < 0.001). Conclusion This study underscores the efficacy of PSI systems in achieving precise positioning in the coronal plane, in accordance with preoperative planning. In contrast, sagittal plane positioning did not demonstrate the same level of accuracy, as evidenced by a statistically significant difference between the planned and postoperative TLS values. Nevertheless, all measurements remained within the recommended range according to the existing literature. Level of Evidence Level IV.
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Affiliation(s)
- Antonio Mazzotti
- IRCCS Istituto Ortopedico Rizzoli1st Orthopaedics and Traumatologic ClinicBolognaItaly
- Department of Biomedical and Neuromotor Sciences (DIBINEM)Alma Mater Studiorum University of BolognaBolognaItaly
| | - Simone Ottavio Zielli
- IRCCS Istituto Ortopedico Rizzoli1st Orthopaedics and Traumatologic ClinicBolognaItaly
- Department of Biomedical and Neuromotor Sciences (DIBINEM)Alma Mater Studiorum University of BolognaBolognaItaly
| | - Alberto Arceri
- IRCCS Istituto Ortopedico Rizzoli1st Orthopaedics and Traumatologic ClinicBolognaItaly
- Department of Biomedical and Neuromotor Sciences (DIBINEM)Alma Mater Studiorum University of BolognaBolognaItaly
| | - Elena Artioli
- IRCCS Istituto Ortopedico Rizzoli1st Orthopaedics and Traumatologic ClinicBolognaItaly
- Department of Biomedical and Neuromotor Sciences (DIBINEM)Alma Mater Studiorum University of BolognaBolognaItaly
| | - Laura Langone
- IRCCS Istituto Ortopedico Rizzoli1st Orthopaedics and Traumatologic ClinicBolognaItaly
- Department of Biomedical and Neuromotor Sciences (DIBINEM)Alma Mater Studiorum University of BolognaBolognaItaly
| | - Federico Sgubbi
- IRCCS Istituto Ortopedico Rizzoli1st Orthopaedics and Traumatologic ClinicBolognaItaly
- Department of Biomedical and Neuromotor Sciences (DIBINEM)Alma Mater Studiorum University of BolognaBolognaItaly
| | - Giuseppe Geraci
- IRCCS Istituto Ortopedico Rizzoli1st Orthopaedics and Traumatologic ClinicBolognaItaly
- Department of Biomedical and Neuromotor Sciences (DIBINEM)Alma Mater Studiorum University of BolognaBolognaItaly
| | - Cesare Faldini
- IRCCS Istituto Ortopedico Rizzoli1st Orthopaedics and Traumatologic ClinicBolognaItaly
- Department of Biomedical and Neuromotor Sciences (DIBINEM)Alma Mater Studiorum University of BolognaBolognaItaly
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Mathieu J, Dagneaux L. Midfoot Tarsectomy in Cavovarus: Why PSI Makes a Difference? Foot Ankle Clin 2023; 28:791-803. [PMID: 37863535 DOI: 10.1016/j.fcl.2023.05.003] [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] [Indexed: 10/22/2023]
Abstract
The cavovarus foot is a complex deformity that can be treated using multiple surgical procedures, ranging from soft tissue surgery to triple arthrodesis. Among these options, anterior midfoot tarsectomy is a three-dimensional closed-wedge osteotomy, traditionally performed slowly and progressively in a blind fashion, and remaining a challenge for unexperimented surgeons with variable outcomes. As such, we investigated and discussed the use of patient-specific cutting guides (PSCGs) in computer-assisted anterior midfoot tarsectomy in terms of accuracy, reproducibility, and safety.
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Affiliation(s)
- Julie Mathieu
- Department of Orthopedic Surgery, Lower Limb Surgery Unit, Univ Montpellier, 371 av. Gaston Giraud, Montpellier Cedex 05 34295, France
| | - Louis Dagneaux
- Department of Orthopedic Surgery, Lower Limb Surgery Unit, Univ Montpellier, 371 av. Gaston Giraud, Montpellier Cedex 05 34295, France; Laboratoire de mécanique et génie civil (LMGC), CNRS, Montpellier University of Excellence (MUSE), 860, rue de St-Priest, Montpellier 34090, France.
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Gupta R, Grove K, Wei A, Lee J, Akkouch A. Ankle and Foot Arthroplasty and Prosthesis: A Review on the Current and Upcoming State of Designs and Manufacturing. MICROMACHINES 2023; 14:2081. [PMID: 38004938 PMCID: PMC10673427 DOI: 10.3390/mi14112081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/31/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023]
Abstract
The foot and ankle serve vital roles in weight bearing, balance, and flexibility but are susceptible to many diverse ailments, making treatment difficult. More commonly, Total Ankle Arthroplasty (TAA) and Total Talus Replacement (TTR) are used for patients with ankle degeneration and avascular necrosis of the talus, respectively. Ankle prosthesis and orthosis are also indicated for use with lower limb extremity amputations or locomotor disability, leading to the development of powered exoskeletons. However, patient outcomes remain suboptimal, commonly due to the misfitting of implants to the patient-specific anatomy. Additive manufacturing (AM) is being used to create customized, patient-specific implants and porous implant cages that provide structural support while allowing for increased bony ingrowth and to develop customized, lightweight exoskeletons with multifunctional actuators. AM implants and devices have shown success in preserving stability and mobility of the joint and achieving fast recovery, as well as significant improvements in gait rehabilitation, gait assistance, and strength for patients. This review of the literature highlights various devices and technologies currently used for foot and ankle prosthesis and orthosis with deep insight into improvements from historical technologies, manufacturing methods, and future developments in the biomedical space.
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Affiliation(s)
- Richa Gupta
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI 49008, USA; (R.G.); (K.G.); (A.W.); (J.L.)
| | - Kyra Grove
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI 49008, USA; (R.G.); (K.G.); (A.W.); (J.L.)
| | - Alice Wei
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI 49008, USA; (R.G.); (K.G.); (A.W.); (J.L.)
| | - Jennifer Lee
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI 49008, USA; (R.G.); (K.G.); (A.W.); (J.L.)
| | - Adil Akkouch
- Department of Orthopaedic Surgery and Medical Engineering Program, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI 49008, USA
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April PM, Locke E, Champagne PH, Angers M, Martinez-Gomez AP, Seidel A, Jibri Z, Lalonde KA, Meulenkamp B. Accuracy of a Patient-Specific Total Ankle Arthroplasty Instrumentation. Foot Ankle Int 2023; 44:1150-1157. [PMID: 37727986 DOI: 10.1177/10711007231194049] [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] [Indexed: 09/21/2023]
Abstract
BACKGROUND Total ankle arthroplasty (TAA) is a preferred surgical option for end-stage ankle osteoarthritis; however, it is a demanding procedure with a higher historical rate of revision compared with ankle fusion. Patient-specific instrumentation (PSI) has been introduced to optimize prosthesis alignment and theoretically overall improve TAA outcomes. The goal of this study is to report on the experience and surgical outcomes of one implant with specific evaluation of the accuracy and reproducibility of the system with respect to prosthesis alignment and prediction of implant size. METHODS A retrospective, multicentered study involving 4 foot and ankle fellowship-trained orthopaedic surgeon's patients undergoing TAA between January 1, 2015, and December 31, 2018, using the PROPHECY PSI system. RESULTS 80 TAA procedures were performed. On average the postoperative tibial component alignment was 89.9 (range, 86.1-96.5) degrees in the coronal plane, with a mean sagittal alignment of 88.1 (range, 81.3-96.7) degrees. The mean deviation from neutral sagittal alignment improved from 4.9 ± 3.9 degrees preoperatively to 2.7 ± 1.7 degrees postoperatively, whereas the mean coronal alignment improved from 3.3 ± 2.5 degrees to 1.3 ± 1.1 degrees. The PSI software correctly determined the tibial implant size in 70 patients (89%). Prediction of talar implant sizing was less accurate than the tibial component, with 56 patients (71%) using the predicted sized implant. The overall implant survival at a mean follow-up of 45 months (range, 27-76) was 97.5%. CONCLUSION We found that this PSI system accurately and reliably assisted in implant total ankle prosthesis positioning within a clinically acceptable margin and without significant outliers. Prediction of implant size was not as accurate as component orientation. LEVEL OF EVIDENCE Level III, retrospective study.
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Affiliation(s)
| | - Eric Locke
- Department of Orthopaedics, Civic Hospital, Ottawa, Canada
| | | | | | | | - Angela Seidel
- Department of Orthopaedics, Civic Hospital, Ottawa, Canada
| | - Zaid Jibri
- Department of Orthopaedics, Civic Hospital, Ottawa, Canada
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Yoon YK, Park KH, Shim DW, Han SH, Lee JW, Jung M. Robotic-assisted foot and ankle surgery: a review of the present status and the future. Biomed Eng Lett 2023; 13:571-577. [PMID: 37872981 PMCID: PMC10590355 DOI: 10.1007/s13534-023-00328-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/17/2023] [Accepted: 09/26/2023] [Indexed: 10/25/2023] Open
Abstract
The surgical application of robotics has increased significantly since its first application in 1985 for a brain biopsy acquisition. Robotic-assisted surgery has been one of the viable options in various surgical areas, and also in orthopaedic surgery. Robotic-assisted orthopaedic surgery has gained popularity as a mean of improving accuracy, reducing complications and achieving better patient satisfaction. Numerous clinical research studies have demonstrated advantages of robotic-assisted orthopaedic surgery, however, most of that researches were about the total knee arthroplasty, total hip arthroplasty and spine surgery. The application of robotic technology in foot and ankle surgery is in a very nascent stage. Furthermore, there has been little research on intraoperative use of robotics in foot and ankle surgery in literature. A review of previous preclinical studies in foot and ankle robotics and clinical research studies in various fields of robot-assisted orthopaedic surgery shows that its potential application and benefits over conventional techniques, such as total ankle arthroplasty, minimally invasive surgery for foot and ankle trauma or other corrective procedure, and intraoperative biomechanical testing. More studies on practical application of robotic technology to surgical procedure in the field of foot and ankle surgery are needed to confirm its clinical usefulness and cost effectiveness.
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Affiliation(s)
- Yeo Kwon Yoon
- Department of Orthopaedic Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
| | - Kwang Hwan Park
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Woo Shim
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Hwan Han
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Woo Lee
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Jung
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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7
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Siegler S, Piarulli L, Stolle J. Definitions and Measurements of Hindfoot Alignment and Their Biomechanical and Clinical Implications. Foot Ankle Clin 2023; 28:115-128. [PMID: 36822681 DOI: 10.1016/j.fcl.2022.11.002] [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: 01/03/2023]
Abstract
This article presents a critical review of the past and the current state of the art in defining and measuring hindfoot, ankle, and subtalar alignment. It describes the transition occurring at present from two-dimensional to three-dimensional (3D) alignment measurements, which accompany the emergence of new, functional, high-resolution imaging modalities such as the weight-bearing cone-beam computerized tomography (CT) imaging. To ease and enhance the transition and acceptability of 3D alignment measurements, new acceptable standards for different clinical application are highly desirable.
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Affiliation(s)
- Sorin Siegler
- Department of Mechanical Engineering, Drexel University, 3141 Chestnut Street, Philadelphia, PA, USA.
| | - Luigi Piarulli
- Department of Mechanical Engineering, Drexel University, 3141 Chestnut Street, Philadelphia, PA, USA
| | - Jordan Stolle
- Department of Mechanical Engineering, Drexel University, 3141 Chestnut Street, Philadelphia, PA, USA
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8
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Biela G, Piraino J, Roukis TS. An Analysis of 50 Consecutive Total Ankle Replacements Undergoing Preoperative Computerized Tomography Scan-Based, Engineer-Provided Planning From a Single Noninventor, Nonconsultant Surgeon. J Foot Ankle Surg 2023; 62:228-236. [PMID: 35871115 DOI: 10.1053/j.jfas.2022.06.013] [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: 01/23/2022] [Revised: 06/14/2022] [Accepted: 06/23/2022] [Indexed: 02/03/2023]
Abstract
Preoperative computerized tomography (CT) scan-based, engineer-provided alignment plans and patient-specific pinning blocks for total ankle replacement (TAR) are available for use in the United States. However, nonbiased studies that justify the additional expense associated with this technology through support of the marketed benefits of less procedural complexity, less intraoperative radiation and reduced surgical time, are lacking. Therefore, to verify the manufacturer's proposed benefits, we sought to investigate our experience with this preoperative CT scan-based, engineer-provided plan and patient-specific pinning blocks during primary TAR. In review of our 50 TAR patients, we found that "perfect" radiographic alignment was not consistently achieved and the accuracy of component prediction was modest. Furthermore, the preoperative plans and patient-specific pinning blocks did not simplify the complexity of our operations since the operative time, intraoperative image intensification time and radiation dose per case all exceeded published historical TAR controls. Interestingly, we identified a significant difference in placement accuracy between the arced and flat-top talar component types that were implanted with the arced being more frequently malaligned. We did not find associations between preoperative deformity severity and accuracy of postoperative alignment. These findings suggest that it is imperative to have surgeons continue to rely on their own surgical planning and experience to achieve optimum radiographic alignment rather than depending on engineer-based recommendations or "surface matched" pinning blocks. Ultimately, we were unable to support the purported benefits of this CT scan-based, engineer-provided alignment plan and patient-specific pinning blocks for this manufacturer's primary TAR systems.
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Affiliation(s)
- Garrett Biela
- Post-Graduate Year 2 Resident, Department of Orthopaedic Surgery & Rehabilitation, Foot & Ankle Service Line, University of Florida College of Medicine-Jacksonville, Jacksonville, FL.
| | - Jason Piraino
- Associate Professor, Department of Orthopaedic Surgery & Rehabilitation, Chairman, Foot & Ankle Service Line, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Thomas S Roukis
- Professor, Department of Orthopaedic Surgery & Rehabilitation, Foot & Ankle Service Line, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
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Hinh CM, Chong ACM, Bierman BR, Uglem TP. Computed Tomography Derived Patient-specific Instrumentation Total Ankle Arthroplasty Survivorship Outcomes. J Foot Ankle Surg 2023; 62:338-346. [PMID: 36180364 DOI: 10.1053/j.jfas.2022.08.012] [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: 05/09/2022] [Revised: 08/19/2022] [Accepted: 08/27/2022] [Indexed: 02/03/2023]
Abstract
Computed tomography (CT) derived patient-specific total ankle arthroplasty (TAA) systems have been utilized for improved accuracy and reproducible implant alignment. The purpose of the present study was to report the overall implant survivorship as well as radiographic analysis of patients who underwent primary TAA utilizing CT-derived patient-specific instrumentation. A retrospective review of medical charts and radiographs were performed on patients who had undergone primary TAA at a single institution in the Midwest region from March 2013 to October 2020. Radiographic analysis included preoperative, initial postoperative, and final follow-up coronal and sagittal tibiotalar alignment as well as periprosthetic radiolucency. A total of 96 patients with a mean follow-up of 3 years (range, 0.3-7.3 years) were included. Implant survivorship was found to be 92% at median follow-up of 3 years. A total of 8 cases (8.3%) required revision/reoperation, with 6 (6.3%) of these reoperations directly related for failure of one of the metallic implant components. There was significant improvement in both coronal and sagittal tibiotalar alignment from preoperative to initial postoperative follow-up (p < .001). At latest postoperative follow-up, there were 88% of TAAs that remained in a neutral alignment following surgery. A total of 10 cases were found to have radiolucency at latest follow-up. In conclusion, the use of CT derived patient-specific TAA showed high implant survivorship with significant improvement of sagittal and coronal tibiotalar alignment. With better implant alignment and position, it potentially reduces the risk of early implant failure or implant loosening in long-term follow-up.
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Affiliation(s)
- Christopher M Hinh
- Sanford Health Podiatric Medicine and Surgery Residency, Sanford Orthopedics and Sports Medicine, Fargo, ND
| | - Alexander C M Chong
- Sanford Health Podiatric Medicine and Surgery Residency, Sanford Orthopedics and Sports Medicine, Fargo, ND; Department of Graduate Medical Education - Sanford Health, Fargo, ND.
| | - Bennen R Bierman
- Sanford Health Podiatric Medicine and Surgery Residency, Sanford Orthopedics and Sports Medicine, Fargo, ND
| | - Timothy P Uglem
- Sanford Health Podiatric Medicine and Surgery Residency, Sanford Orthopedics and Sports Medicine, Fargo, ND
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10
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Benignus C, Buschner P, Meier MK, Wilken F, Rieger J, Beckmann J. Patient Specific Instruments and Patient Individual Implants—A Narrative Review. J Pers Med 2023; 13:jpm13030426. [PMID: 36983609 PMCID: PMC10051718 DOI: 10.3390/jpm13030426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/20/2023] [Accepted: 02/25/2023] [Indexed: 03/02/2023] Open
Abstract
Joint arthroplasties are one of the most frequently performed standard operations worldwide. Patient individual instruments and patient individual implants represent an innovation that must prove its usefulness in further studies. However, promising results are emerging. Those implants seem to be a benefit especially in revision situations. Most experience is available in the field of knee and hip arthroplasty. Patient-specific instruments for the shoulder and upper ankle are much less common. Patient individual implants combine individual cutting blocks and implants, while patient individual instruments solely use individual cutting blocks in combination with off-the-shelf implants. This review summarizes the current data regarding the implantation of individual implants and the use of individual instruments.
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Affiliation(s)
- Christian Benignus
- Department of Traumatology and Orthopedic Surgery, Hospital Ludwigsburg, Posilipostr. 4, 71640 Ludwigsburg, Germany
| | - Peter Buschner
- Department of Orthopedic Surgery and Traumatology, Hospital Barmherzige Brüder Munich, Romanstr. 93, 80639 Munich, Germany
| | - Malin Kristin Meier
- Department of Orthopedic Surgery and Traumatology, Inselspital, University Hospital Bern, University of Bern, Freiburgstr. 4, 3010 Bern, Switzerland
| | - Frauke Wilken
- Department of Orthopedic Surgery and Traumatology, Hospital Barmherzige Brüder Munich, Romanstr. 93, 80639 Munich, Germany
| | - Johannes Rieger
- Department of Orthopedic Surgery and Traumatology, Hospital Barmherzige Brüder Munich, Romanstr. 93, 80639 Munich, Germany
| | - Johannes Beckmann
- Department of Orthopedic Surgery and Traumatology, Hospital Barmherzige Brüder Munich, Romanstr. 93, 80639 Munich, Germany
- Correspondence:
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11
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Correction of ankle varus deformity using patient-specific dome-shaped osteotomy guides designed on weight-bearing CT: a pilot study. Arch Orthop Trauma Surg 2023; 143:791-799. [PMID: 34562121 DOI: 10.1007/s00402-021-04164-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 09/01/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Dome-shaped supramalleolar osteotomies are a well-established treatment option for correcting ankle deformity. However, the procedure remains technically demanding and is limited by a two-dimensional (2D) radiographic planning of a three-dimensional (3D) deformity. Therefore, we implemented a weight-bearing CT (WBCT) to plan a 3D deformity correction using patient-specific guides. METHODS A 3D-guided dome-shaped supramalleolar osteotomy was performed to correct ankle varus deformity in a case series of five patients with a mean age of 53.8 years (range 47-58). WBCT images were obtained to generate 3D models, which enabled a deformity correction using patient-specific guides. These technical steps are outlined and associated with a retrospective analysis of the clinical outcome using the EFAS score, Foot and Ankle Outcome Score (FAOS) and visual analog pain scale (VAS). Radiographic assessment was performed using the tibial anterior surface angle (TAS), tibiotalar angle (TTS), talar tilt angle (TTA), hindfoot angle (HA), tibial lateral surface angle (TLS) and tibial rotation angle (TRA). RESULTS The mean follow-up was 40.8 months (range 8-65) and all patients showed improvements in the EFAS score, FAOS and VAS (p < 0.05). A 3-month postoperative WBCT confirmed healing of the osteotomy site and radiographic improvement of the TAS, TTS and HA (p < 0.05), but the TTA and TRA did not change significantly (p > 0.05). CONCLUSION Dome-shaped supramalleolar osteotomies using 3D-printed guides designed on WBCT are a valuable option in correcting ankle varus deformity and have the potential to mitigate the technical drawbacks of free-hand osteotomies. LEVEL OF EVIDENCE Level 5 case series.
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12
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Kim JS, Amendola A, Barg A, Baumhauer J, Brodsky JW, Cushman DM, Gonzalez TA, Janisse D, Jurynec MJ, Lawrence Marsh J, Sofka CM, Clanton TO, Anderson DD. Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 2: Treatment Options. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221127013. [PMID: 36262470 PMCID: PMC9575443 DOI: 10.1177/24730114221127013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
UNLABELLED This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non-joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research. LEVEL OF EVIDENCE Level V, review article/expert opinion.
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Affiliation(s)
- Jason S. Kim
- The Arthritis Foundation, Atlanta, GA,
USA,Jason S. Kim, PhD, The Arthritis
Foundation, 1355 Peachtree St NE, Suite 600, Atlanta, GA 30309, USA.
| | | | - Alexej Barg
- Department of Orthopaedics, University
of Utah, Salt Lake City, UT, USA
| | - Judith Baumhauer
- Department of Orthopaedic Surgery,
University of Rochester Medical Center, Rochester, NY, USA
| | | | - Daniel M. Cushman
- Division of Physical Medicine &
Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Tyler A. Gonzalez
- Department of Orthopaedic Surgery,
University of South Carolina, Lexington, SC, USA
| | | | - Michael J. Jurynec
- Department of Orthopaedics and Human
Genetics, University of Utah, Salt Lake City, UT, USA
| | - J. Lawrence Marsh
- Department of Orthopedics and
Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Carolyn M. Sofka
- Department of Radiology and Imaging,
Hospital for Special Surgery, New York, NY, USA
| | | | - Donald D. Anderson
- Department of Orthopedics and
Rehabilitation, University of Iowa, Iowa City, IA, USA
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13
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Stolle J, Lintz F, de Cesar Netto C, Bernasconi A, Rincon MR, Mathew R, Vispute D, Siegler S. Three-dimensional ankle, subtalar, and hindfoot alignment of the normal, weightbearing hindfoot, in bilateral posture. J Orthop Res 2022; 40:2430-2439. [PMID: 35067973 DOI: 10.1002/jor.25267] [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: 08/12/2021] [Revised: 11/17/2021] [Accepted: 01/06/2022] [Indexed: 02/04/2023]
Abstract
The first goal of this study was to develop reliable three-dimensional definitions of alignment for the ankle, subtalar, and hindfoot joints. These alignments are based on three-dimensional morphological features derived from renderings of the bones obtained from weightbearing computer tomography. The second goal was to establish a database quantifying the alignment of the ankle, subtalar, and hindfoot joints in a healthy population during weightbearing bilateral standing. This level 1 study was performed on 95 normal subjects in which random subjects were recruited into a control group. Weightbearing computed tomography scans of the leg were collected in neutral, bilateral, standing posture. In 30 of the subjects, both the left and right leg was scanned. Six alignment parameters for each joint were calculated from morphological measurements conducted on three-dimensional renderings of the bones. Intra- and intertester reliability was assessed from repeated measurements by several testers. Analysis of variance statistics of the alignment parameters showed no statistical differences due to age, gender, or foot side. Intraclass correlation coefficient analysis showed excellent inter- and intratester reliability. It was concluded that the alignment process is comprehensive and reliable. Therefore, without classification by gender or age, it may be used as a foundation for quantifying abnormal alignment associated with various ankle deformities. Clinical significance: The alignment methodology and control database may be used to diagnose ankle, subtalar, and hindfoot misalignment. It can also serve as basis for surgical planning designed to restore normal alignment in various hindfoot pathologies, such as ankle realignment in total ankle replacement.
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Affiliation(s)
- Jordan Stolle
- Department of Mechanical Engineering, Drexel University, Philadelphia, Pennsylvania, USA
| | - Francois Lintz
- Department of Orthopedic Surgery, Ramsay GDS-Clinique de L'Union, Saint Jean, France
| | - Cesar de Cesar Netto
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - Alessio Bernasconi
- Department of Orthopedic Surgery, University of Naples Federico II, Naples, Italy
| | - Maria R Rincon
- Department of Mechanical Engineering, Drexel University, Philadelphia, Pennsylvania, USA
| | - Rena Mathew
- Department of Mechanical Engineering, Drexel University, Philadelphia, Pennsylvania, USA
| | - Dhwanit Vispute
- Department of Mechanical Engineering, Drexel University, Philadelphia, Pennsylvania, USA
| | - Sorin Siegler
- Department of Mechanical Engineering, Drexel University, Philadelphia, Pennsylvania, USA
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14
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Basile P, Miner SA, Crafton JW, McKenna B. Preliminary Report of a Hybrid Total Ankle Arthroplasty Combining a Stemmed Intramedullary Tibial Component With Chamfer-Cut Talar Dome. J Foot Ankle Surg 2022; 61:e25-e33. [PMID: 35379534 DOI: 10.1053/j.jfas.2021.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 02/10/2021] [Accepted: 12/01/2021] [Indexed: 02/03/2023]
Abstract
Total ankle arthroplasty (TAA) is a viable treatment for end-stage ankle arthritis. In our experience, a stemmed intramedullary tibial component combined with a chamfer-cut talar component provides the most stable construct for TAA. We present our technique for placement of this hybrid prosthesis utilizing the INBONE tibial component in combination with the INFINITY talar component. This technique differs from the standard protocol by minimizing use of both patient-specific and standard intraoperative guides. The primary aim of this study is to report our preliminary outcomes with our novel technique. Secondarily, we aim to demonstrate that placement of this hybrid prosthesis is radiographically reproducible and accurate. The first 10 patients undergoing this technique with at least 1 year of follow-up were retrospectively reviewed. Average visual analog pain scale decreased from 7.4 preoperatively to 0.5 at 1 year postoperatively. The average time to weightbearing was 6.4 weeks. Complications were minimal, and no implant-related complications were encountered. First weightbearing ankle radiographs postoperatively were evaluated by 3 reviewers to determine accuracy of the tibial intramedullary stem in relation to the anatomical axis of the tibia. We found that the deviation of the tibial implant from the anatomic axis was on average 0.9°± 0.5° in the coronal plane, and 2.2°± 2.7° in the sagittal plane. Inter-rater reliability was 83%. We conclude that this hybrid technique utilizing a stemmed intramedullary tibial component in combination with a chamfer-cut talar component for TAA is reproducible, accurate, and safe.
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Affiliation(s)
- Philip Basile
- Chief of Foot & Ankle Surgery, Mount Auburn Hospital, Cambridge MA; Assistant Professor of Surgery, Harvard Medical School, Boston, MA
| | - Samantha A Miner
- Fellow, Foot and Ankle Reconstruction Fellowship, Coordinated Health-Lehigh Valley Health Network, Bethlehem, PA.
| | - Jordan W Crafton
- Fellowship-trained Foot & Ankle Surgeon, Arizona Orthopedics, Tucson, AZ; Attending Surgeon, Tucson Medical Center Foot and Ankle Surgery Residency Program, Tucson, AZ
| | - Bryon McKenna
- Fellowship-trained Foot & Ankle Surgeon, Thibodaux Regional Medical Center, Thibodaux, LA
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15
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Togher CJ, Golding SL, Ferrise TD, Butterfield J, Reeves CL, Shane AM. Effects of Patient-Specific Instrumentation and Ancillary Surgery Performed in Conjunction With Total Ankle Implant Arthroplasty: Postoperative Radiographic Findings. J Foot Ankle Surg 2022; 61:739-747. [PMID: 34961682 DOI: 10.1053/j.jfas.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/10/2021] [Accepted: 11/17/2021] [Indexed: 02/03/2023]
Abstract
Accuracy and reproducibility when performing total ankle implant arthroplasty (TAA) are essential for longevity of the implant, maintaining relative stability of the joint, and theoretically reducing the formation of adjacent joint arthritis in the subtalar and knee joints. Studies have helped to illustrate the accuracy of implantation when using patient-specific instrumentation in both knee and ankle implant arthroplasty. Despite the findings of these studies, few have gone on to evaluate the effects of ancillary procedures on TAA; particularly their effects on postoperative implant congruity when performed simultaneously with joint replacement surgery. In this study, preoperative plans on implant alignment based on patient-specific computed tomography images were compared with the alignment observed on immediate postoperative radiographs. Additionally, postoperative joint congruity was measured, and operative reports were assessed to determine if concomitant procedures performed with total ankle replacement had a significant effect on overall alignment. In our population, 46/47 implants were within 1.5° of their anticipated placement in the coronal plane, and 100% were within 2° of anticipated placement in the sagittal plane. Using a spearman's rank-order correlation, our data failed to show any significant relationship between conducting additional procedures in conjunction with TAA (rho = 0.178; p value = .232) and postoperative congruency of the implant. These findings help support the accuracy of ankle implantation using patient-specific instrumentation, while also supporting the appropriate use of indicated procedures in conjunction with total ankle replacement to help obtain a congruent joint postoperatively.
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Affiliation(s)
- Cody J Togher
- Fellow, Orthopedic Foot & Ankle Center, Worthington, OH.
| | - Stephanie L Golding
- Resident, Advent Health East Orlando Podiatric Surgical Residency, Orlando, FL
| | - Thomas D Ferrise
- Resident, Advent Health East Orlando Podiatric Surgical Residency, Orlando, FL
| | | | - Christopher L Reeves
- Department of Podiatric Surgery, AdventHealth System, Faculty, Advent Health East Orlando Podiatric Surgical Residency, Orlando, FL
| | - Amber M Shane
- Chair of Department of Podiatric Surgery, AdventHealth System, Faculty, Advent Health East Orlando Podiatric Surgical Residency, Orlando, FL
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16
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Wu SX, Liu SZ, Ling M, Che YH, Tian X, Duan XL, Yi Z. A Novel Method for Preoperative Positioning of Total Ankle Replacement Using 3D Digital Model. Orthop Surg 2022; 14:1378-1384. [PMID: 35656705 PMCID: PMC9251280 DOI: 10.1111/os.13287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/18/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To establish a digital model of the ankle joint through 3D imaging technology and explore the preoperative placement of ankle replacement prostheses. METHODS Computed tomography images of intact ankle joints from 54 cases in the outpatient and inpatient departments of our hospital were collected; according to the INBONE® total ankle system surgery process, the surgery model and surgical osteotomy were finished using MIMICS based on computer simulation method. The shortest distance was measured between the center point and the anterior, posterior, medial, and lateral, respectively, to ensure the precise position of the ankle replacement prosthesis by digital simulation surgery. The relationship between the two variables was analyzed by bivariate correlation analysis. RESULTS The dataset of this study included 48 cases of the sub-data set (26 males and 22 females) and included 27 cases of left ankle and 21 cases of right ankle. The average medial malleolar angle was 18.67°± 2.87°, the average amount of bone resection was 12.13 ± 1.86 cm3 , the mid-anterior distance was 1.72 ± 0.19 cm, the mid-posterior distance was 2.00 ± 0.19 cm, the ratio of mid-anterior to mid-posterior was 0.87, the mid-medial distance was 1.26 ± 0.17 cm, the mid-lateral distance was 1.19 ± 0.16 cm, and the ratio of mid-medial to mid-lateral was 1.06. After osteotomy, the anteroposterior diameter was 3.73 ± 0.32 cm, the transverse diameter was 2.46 ± 0.27 cm, and the ratio of anteroposterior diameter to transverse diameter was 1.53. In the bottom view, the shape after osteotomy is rectangular. The mid-anterior distance was strongly negatively correlated with age, the mid-anterior distance and the amount of bone resection, the mid-medial distance and the amount of bone resection, the mid-lateral distance and the amount of bone resection, the mid-lateral distance and the anteroposterior diameter, the anteroposterior diameter and the transverse diameter were all strongly positively correlated. CONCLUSION The projection point of the lower tibia centerline on the tibial horizontal osteotomy surface is located at a position slightly anterior to the midpoint of the transverse diameter after ankle arthroplasty. The rational positioning of the total ankle replacement is located at both a position slightly anterior to the midpoint of the transverse diameter and midpoint of the anteroposterior diameter, which can be used as a reference method before total ankle arthroplasty surgery.
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Affiliation(s)
- Shi-Xun Wu
- Department of Orthopedics Surgery, Shaanxi Provincial People's Hospital, Xi'an Jiaotong University, Xi'an, China.,The College of Life Sciences and Medicine, Northwest University, xi'an, China
| | - Shi-Zhang Liu
- Department of Orthopedics Surgery, Shaanxi Provincial People's Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Ming Ling
- Department of Orthopedics Surgery, Shaanxi Provincial People's Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yan-Hui Che
- First Middle School of Xi'an City, Xi'an, China
| | - Xin Tian
- Department of Orthopedics Surgery, Shaanxi Provincial People's Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiang-Long Duan
- The College of Life Sciences and Medicine, Northwest University, xi'an, China.,Second Department of General Surgery, Shaanxi Provincial People's Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Zhi Yi
- Department of Orthopedics Surgery, Shaanxi Provincial People's Hospital, Xi'an Jiaotong University, Xi'an, China
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17
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Heisler L, Vach W, Katz G, Egelhof T, Knupp M. Patient-Specific Instrumentation vs Standard Referencing in Total Ankle Arthroplasty: A Comparison of the Radiologic Outcome. Foot Ankle Int 2022; 43:741-749. [PMID: 35209725 PMCID: PMC9168897 DOI: 10.1177/10711007221077100] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Existing literature on the superiority of patient-specific instrumentation (PSI) in total ankle arthroplasty (TAA) over standard referencing (SR) is limited. Advantages presented include better implant alignment, shorter operating times, and increased accuracy of implant size prediction. The aim of this retrospective study was to analyze PSI in the hands of an experienced foot and ankle surgeon new to both PSI and SR for this specific implant, in regard to determining implant alignment, operative times, and radiologic short-term outcome and predicting implant size for tibial and talar components. METHODS Twenty-four patients undergoing TAA using PSI were compared to 25 patients using SR instrumentation. Outcome measures included alignment of the tibial component (α coronal plane, γ sagittal plane), the tibiotalar tilt (β), and the talar offset x on the sagittal view as well as the presence of radiolucent lines, operation time, and wound healing. Postoperative outcome was assessed at 6 weeks, 4 months, and 1 year postoperatively. RESULTS Implant positioning was similar in both groups, and no advantage in regard to the operative time could be seen when comparing TAA using PSI to SR. Implant size prediction was more reliable for the tibia than for the talus. Three patients (1 from the SR group and 2 from the PSI group) showed radiolucent lines around the tibial component. Two patients (both SR group) suffered delayed wound healing, albeit not requiring any additional measures. CONCLUSION The PSI method did not show an advantage over SR in regard to positioning of the components or the duration of the surgery. The current study suggests that no initial advantage of PSI over SR are to be expected in standard total ankle replacement. LEVEL OF EVIDENCE Level III, retrospective study.
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Affiliation(s)
| | - Werner Vach
- Basel Academy for Quality and Research
in Medicine, Basel, Switzerland
| | - Georg Katz
- Merian Iselin Klinik, Institute for
Radiology, Basel, Switzerland
| | - Thomas Egelhof
- Merian Iselin Klinik, Institute for
Radiology, Basel, Switzerland
| | - Markus Knupp
- University of Basel, Basel,
Switzerland,Orthopedic Surgery & Traumatology,
Mein Fusszentrum AG, Basel, Switzerland,Markus Knupp, MD, Specialist in Orthopedic
Surgery & Traumatology, Mein Fusszentrum AG, Eichenstrasse 31, Basel CH
4054, Switzerland.
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18
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Ciufo DJ, Baker EA, Gehrke CK, Vaupel ZM, Fortin PT. Tibial torsion correlates with talar morphology. Foot Ankle Surg 2022; 28:354-361. [PMID: 33888396 DOI: 10.1016/j.fas.2021.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 03/09/2021] [Accepted: 04/15/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is limited literature on axial rotation of the ankle or variations in anatomy of the talus. We aim to evaluate the rotational profile of the distal tibia and its relationship to talus morphology, radiographic foot-type, and tibiotalar tilt in arthritic ankles. METHODS Preoperative imaging was reviewed in 173 consecutive patients with ankle arthritis. CT measurements were used to calculate tibial torsion and the talar neck-body angle (TNBA). Tibiotalar tilt and foot-type were measured on weightbearing plain radiographs. RESULTS Measurements indicated mean external tibial torsion of 29.2±9.1˚ and TNBA of 35.2±7.5˚ medial. Tibiotalar tilt ranged from 48˚ varus to 23.5˚ valgus. A moderate association between increasing external tibial torsion and decreasing TNBA was found (ρ=-0.576, p<.0001). Weak relationships were found between external tibial torsion and varus tibiotalar tilt (ρ=-0.239, p=.014) and plantarflexion of the talo-first metatarsal angle (ρ=-0.218, p<.025). CONCLUSION We observed a statistically significant correlation between tibial torsion and morphology of the talus, tibiotalar tilt, and first ray plantarflexion. This previously unreported association may provide information regarding the development of foot and ankle deformity and pathology. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- David J Ciufo
- Beaumont Health, Departments of Orthopaedic Surgery and Research, Beaumont Research Institute, 3601 West 13 Mile Road, Suite 404, Royal Oak, MI 48073, USA.
| | - Erin A Baker
- Beaumont Health, Departments of Orthopaedic Surgery and Research, Beaumont Research Institute, 3601 West 13 Mile Road, Suite 404, Royal Oak, MI 48073, USA
| | - Corinn K Gehrke
- Beaumont Health, Departments of Orthopaedic Surgery and Research, Beaumont Research Institute, 3601 West 13 Mile Road, Suite 404, Royal Oak, MI 48073, USA
| | - Zachary M Vaupel
- Beaumont Health, Departments of Orthopaedic Surgery and Research, Beaumont Research Institute, 3601 West 13 Mile Road, Suite 404, Royal Oak, MI 48073, USA
| | - Paul T Fortin
- Beaumont Health, Departments of Orthopaedic Surgery and Research, Beaumont Research Institute, 3601 West 13 Mile Road, Suite 404, Royal Oak, MI 48073, USA
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19
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Mazzotti A, Arceri A, Zielli S, Bonelli S, Viglione V, Faldini C. Patient-specific instrumentation in total ankle arthroplasty. World J Orthop 2022; 13:230-237. [PMID: 35317257 PMCID: PMC8935326 DOI: 10.5312/wjo.v13.i3.230] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/09/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
The recent increase in the adoption of total ankle arthroplasty (TAA) reflects the improvements in implant designs and surgical techniques, including the use of preoperative navigation system and patient-specific instrumentation (PSI), such as custom-made cutting guides. Cutting guides are customized with respect to each patient's anatomy based on preoperative ankle computed tomography scans, and they drive the saw intra-operatively to improve the accuracy of bone resection and implant positioning. Despite some promising results, the main queries in the literature are whether PSI improves the reliability of achieving neutral ankle alignment and more accurate implant sizing, whether it is actually superior over standard techniques, and whether it is cost effective. Moreover, the advantages of PSI in clinical outcomes are still theoretical because the current literature does not allow to confirm its superiority. The purpose of this review article is therefore to assess the current literature on PSI in TAA with regard to current implants with PSI, templating and preoperative planning strategies, alignment and sizing, clinical outcomes, cost analysis, and comparison with standard techniques.
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Affiliation(s)
- Antonio Mazzotti
- The First Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico RIzzoli, Bologna 40136, Italy
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna 40136, Italy
| | - Alberto Arceri
- The First Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico RIzzoli, Bologna 40136, Italy
| | - Simone Zielli
- The First Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico RIzzoli, Bologna 40136, Italy
| | - Simone Bonelli
- The First Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico RIzzoli, Bologna 40136, Italy
| | - Valentina Viglione
- The First Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico RIzzoli, Bologna 40136, Italy
| | - Cesare Faldini
- The First Orthopaedics and Traumatologic Clinic, IRCCS Istituto Ortopedico RIzzoli, Bologna 40136, Italy
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna 40136, Italy
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20
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Gauci MO. Patient-specific guides in orthopedic surgery. Orthop Traumatol Surg Res 2022; 108:103154. [PMID: 34838754 DOI: 10.1016/j.otsr.2021.103154] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/10/2021] [Accepted: 04/29/2021] [Indexed: 02/03/2023]
Abstract
The interest of patient-specific guides (PSGs) lies in reliable intraoperative achievement of preoperative planning goals. They are a form of instrumentation optimizing intraoperative precision and thus improving the safety and reproducibility of surgical procedures. Clinical superiority, however, has not been demonstrated. The various steps from design to implementation leave room for error, which needs to be known and controlled by the surgeon who is responsible for final outcome. Instituting large-scale patient-specific surgery requires management systems for guides and innovative implants which cannot be a simple extension of current practices. We shall approach the present state of knowledge regarding PSGs via 5 questions: (1) What is a PSG? Single-use instrumentation produced after preoperative planning, aiming exclusively to optimize procedural exactness. (2) How to use and assess PSGs in orthopedic surgery? Strict rules of use must be adhered to. Any deviation from the predefined objective is, necessarily, an error that must be identified as such. (3) Do PSGs provide greater surgical exactness? The contribution of PSGs varies greatly between procedures. Exactness is enhanced in the spine, in osteotomies around the knee and in bone-tumor surgery. In the shoulder, their contribution is seen only in complex cases. Data are sparse for hip replacement, and controversial for knee replacement. (4) What are the expected benefits of PSGs? As well as improving exactness, PSGs allow a lower radiation dose and shorter operating time. They also enable junior surgeons to train in techniques otherwise reserved to hyperspecialists. (5) How to include PSGs in everyday practice? As well as their potential clinical interest, PSGs involve deep changes in organization, equipment provision and economic model. LEVEL OF EVIDENCE: V; expert opinion.
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Affiliation(s)
- Marc-Olivier Gauci
- Institut Universitaire Locomoteur et du Sport (IULS), CHU de Nice, Unité de Recherche Clinique Côte d'Azur (UCA), Hôpital Pasteur II, 30, voie Romaine, 06000 Nice, France.
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21
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Albagli A, Ge SM, Park P, Cohen D, Epure L, Chaytor RE, Volesky M. Total ankle arthroplasty results using fixed bearing CT-guided patient specific implants in posttraumatic versus nontraumatic arthritis. Foot Ankle Surg 2022; 28:222-228. [PMID: 33814289 DOI: 10.1016/j.fas.2021.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 03/10/2021] [Accepted: 03/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients who undergo total ankle arthroplasty (TAA) for end-stage posttraumatic ankle osteoarthritis have previously reported more complications and lower satisfaction than those with non-traumatic etiologies. The purpose of this study was to evaluate clinical and radiographic outcomes in these two patient groups after TAA using a newer generation implant. METHODS Patients underwent TAA with a third generation implant using CT-based patient-specific cutting guides. Patients were evaluated clinically using the Foot and Ankle Ability Measure (FAAM) and radiographically at a mean follow up of 32, and 24 months respectively. RESULTS Forty-one patients were studied (26 posttraumatic, 15 nontraumatic). There were no significant differences between the two study groups in FAAM scores (p=0.3423) and radiographic measurements. CONCLUSION We were able to show comparable results in terms of patient satisfaction, short term clinical and radiographic results between traumatic and nontraumatic patients using newer patient specific implant systems.
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Affiliation(s)
- Assaf Albagli
- Division of Orthopaedic Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Susan Mengxiao Ge
- Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, QC, Canada.
| | - Patrick Park
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Dan Cohen
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Laura Epure
- Division of Orthopaedic Surgery, Jewish General Hospital, Montreal, QC, Canada
| | | | - Monika Volesky
- Division of Orthopaedic Surgery, Jewish General Hospital, Montreal, QC, Canada
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22
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Umbel BD, Hockman T, Myers D, Sharpe BD, Berlet GC. Accuracy of CT-Derived Patient-Specific Instrumentation for Total Ankle Arthroplasty: The Impact of the Severity of Preoperative Varus Ankle Deformity. Foot Ankle Spec 2022:19386400211068262. [PMID: 34991375 DOI: 10.1177/19386400211068262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Significant preoperative varus tibiotalar deformity was once believed to be a contraindication for total ankle arthroplasty (TAA). Our primary goal was to evaluate the influence of increasing preoperative varus tibiotalar deformity on the accuracy of final implant positioning using computed tomography (CT)-derived patient-specific guides for TAA. METHODS Thirty-two patients with varus ankle arthritis underwent TAA using CT-derived patient-specific guides. Patients were subcategorized into varying degrees of deformity based on preoperative tibiotalar angles (0°-5° neutral, 6°-10° mild, 11°-15° moderate, and >15° severe). Postoperative weightbearing radiographs were used to measure coronal plane alignment of the tibial implant relative to the target axis determined by the preoperative CT template. Average follow-up at the time of data collection was 36.8 months. RESULTS Average preoperative varus deformity was 6.06° (range: 0.66°-16.3°). Postoperatively, 96.9% (30/31) of patients demonstrated neutral implant alignment. Average postoperative tibial implant deviation was 1.54° (range: 0.17°-5.7°). Average coronal deviation relative to the target axis was 1.61° for the neutral group, 1.78° for the mild group, 0.94° for the moderate group, and 1.41° for the severe group (P = .256). Preoperative plans predicted 100% of tibial and talar implant sizes correctly within 1 size of actual implant size. Conclusion. Our study supports the claim that neutral postoperative TAA alignment can be obtained using CT-derived patient-specific instrumentation (PSI). Furthermore, final implant alignment accuracy with PSI does not appear to be impacted by worsening preoperative varus deformity. All but one patient (96.9%) achieved neutral postoperative alignment relative to the predicted target axis. LEVEL OF EVIDENCE Level IV, Clinical Case Series.
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Affiliation(s)
| | | | - Devon Myers
- Orthopedic Surgery Resident, OhioHealth, Columbus, Ohio
| | - B Dale Sharpe
- Orthopedic Surgery Resident, OhioHealth, Columbus, Ohio
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23
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Ferràs-Tarragó J, Grau-Llopis E, Navarrete-Faubel E, Sánchez-González M, Vicent-Carsí V. An Innovative Weightbearing Device for Weightbearing 3-Dimensional Imaging for Foot and Ankle Surgery Preoperative Planning. J Foot Ankle Surg 2021; 60:1124-1130. [PMID: 34024677 DOI: 10.1053/j.jfas.2020.06.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/29/2020] [Accepted: 06/02/2020] [Indexed: 02/03/2023]
Abstract
Three-dimensional preoperative planning has demonstrated multiple surgical advantages. Currently, we cannot carry out preoperative 3-dimensional planning of foot and ankle orthopedics in most hospitals due to the impossibility of performing weightbearing CT imaging. Our objective is to describe and evaluate an innovative accessible, simple, and effective device that simulates standing while in a supine position, to obtain 3-dimensional images supporting bodyweight load with a conventional CT machine. From a group of 30 volunteers, 10 patients were randomly selected and pressure and its distribution were analyzed while in a standing position in both feet. Differences between both feet were considered normal intrapersonal variability. Subsequently, the right footprint of the same 10 subjects was evaluated in the proposed loading device. Then, their pressures and distribution were compared with respect to standing and with respect to intrapersonal variability. The mean total standing pressure was 93 Kpa (standard deviation [SD] 14.32), which was reduced to 81.95 Kpa (SD 19.54) in the loading device. The load device reduced the pressure by a mean of16% (SD 22% (range -25% to -0.03%). At the hindfoot level, the loading device increased pressure by a mean of 20.59 Kpa, which expressed percentage implies an increase of 14% compared to standing. Due to its easy construction and effectiveness, this is the first device that opens the door of foot and ankle orthopedics in any hospital to 3D preoperative planning and the benefits derived from it.
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24
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Zeitlin J, Henry J, Ellis S. Preoperative Guidance With Weight-Bearing Computed Tomography and Patient-Specific Instrumentation in Foot and Ankle Surgery. HSS J 2021; 17:326-332. [PMID: 34539274 PMCID: PMC8436345 DOI: 10.1177/15563316211026325] [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] [Received: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/16/2022]
Abstract
The use of preoperative and intraoperative guidance in foot and ankle surgery has grown substantially in recent years. Weight-bearing computed tomography (WBCT) and patient-specific instrumentation (PSI) are used in total ankle arthroplasty (TAA) to achieve precise bone cutting and implant positioning, and intraoperative 3-dimensional (3D) imaging has been used to reduce complications and improve clinical outcomes in other foot and ankle surgical procedures. This narrative review of the literature focuses on the evidence supporting the use of WBCT and PSI in TAA and looks at other promising technologies used to guide foot and ankle surgery.
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Affiliation(s)
| | | | - Scott Ellis
- Hospital for Special Surgery, New York, NY, USA
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Thompson MJ, Consul D, Umbel BD, Berlet GC. Accuracy of Weightbearing CT Scans for Patient-Specific Instrumentation in Total Ankle Arthroplasty. FOOT & ANKLE ORTHOPAEDICS 2021; 6:24730114211061493. [PMID: 35097485 PMCID: PMC8664310 DOI: 10.1177/24730114211061493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Total ankle arthroplasty (TAA) is a popular and viable option for end-stage ankle arthritis. Posttraumatic arthritis is the most common etiology of ankle arthritis, which creates the additional challenge of osseus deformity. Accuracy and reproducibility in placing the implant on the mechanical axis has been shown to be paramount in all joint arthroplasty including total ankle replacement. Patient-specific preoperative navigation is a relatively new technology for TAA, and up until this past year has been based off of nonweightbearing (NWBCT) or simulated weightbearing computed tomography (WBCT). Our institution has created a protocol to use WBCT in the preoperative patient-specific navigation for TAA using the Prophecy system. The purpose of our study was to compare the accuracy and reproducibility of implant alignment and size using WBCT vs prior studies using NWBCT for the Prophecy reports. Methods: All patients from July 2019 through October 2020 who underwent TAA were evaluated. Inclusion criteria consisted of primary TAA using patient-specific preoperative navigation who had postoperative radiographs in the 4-6-week time frame. Prophecy predictions and measurements were then compared to actual implant placement and size. Results: Ten patients met our inclusion criteria of WBCT Prophecy preoperative planning using 2 different implant systems. Preoperative deformities in this cohort were small. The average postoperative coronal alignment was 0.84 degrees, range 0.19 to 2.4 degrees. Average postoperative sagittal plane deformity was 1.9 degrees, range 0.33 to 5.05 degrees. Tibial component size was properly predicted in all patients, talar component in 9 of 10. Conclusion: This initial report supports accuracy and reproducibility in preoperative patient-specific navigation when using WBCT for TAA with these implants. All TAAs were within the intended target of less than 5 degrees varus or valgus. Level of Evidence: Level III, retrospective comparative analysis.
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Affiliation(s)
| | - Devon Consul
- Orthopedic Foot and Ankle Center, Worthington, OH, USA
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Patient-specific instrumentation (PSI) in total ankle arthroplasty: a systematic review. INTERNATIONAL ORTHOPAEDICS 2021; 45:2445-2452. [PMID: 34345975 DOI: 10.1007/s00264-021-05145-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 07/07/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patient-specific instrument (PSI) may theoretically make total ankle arthroplasty (TAA) more accurate. Several studies have reported the outcomes of PSI TAA. The aim of this study is to systematically review the literature of PSI TAA. METHODS PubMed, Embase, Web of Science, and Cochrane Library databases were systematically reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines for PSI TAA. The quality of the included studies was evaluated according to Methodological Index for Non-Randomized Studies (MINORS). RESULT Nine articles were ultimately included in the systematic review. The implant position and function outcome of TAA was similar between PSI and SI. Prediction accuracy of implant size remained great difference. PSI can shorten the operative time and fluoroscopy time. The quality of current studies on PSI TAA is insufficient to produce high-level evidence. CONCLUSION PSI can get similar implant position and clinical outcome in TAA compared to SI, but current evidence is not strong enough to evaluate PSI TAA.
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Claassen L, Luedtke P, Nebel D, Yao D, Ettinger S, Daniilidis K, Stukenborg-Colsman C, Plaass C. Establishing a New Patient-Specific Implantation Technique for Total Ankle Replacement: An In Vitro Study. Foot Ankle Spec 2021:19386400211029741. [PMID: 34253082 DOI: 10.1177/19386400211029741] [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: 11/15/2022]
Abstract
BACKGROUND Revision rates after total ankle replacements (TARs) are higher compared with other total joint replacements. The present study aimed to establish a new patient-specific implantation (PSI) technique for TAR. MATERIAL AND METHODS A total of 10 complete Caucasian cadaver legs had whole leg computed tomography scans. The individual geometrical ankle joint axis was determined, and based on this axis, the position of the prosthesis was planned. We assessed prosthesis placement, guiding block position, and preoperative and postoperative ankle rotational axes. RESULTS The guiding block position interobserver reliability was 0.37 mm 0.45 (mean ± SD) for the tibial guiding block. The value for the first talar guiding block was 1.72 ± 1.3 mm and for the second talar guiding block, 0.61 ± 0.39 mm. The tibial slope as well as the frontal angles of the anatomical tibial axis compared to the tibial and talar articular surfaces showed no statistically relevant differences with numbers available. The deviation of the assessed preoperative joint axis to the postoperative joint axis was 14.6° ± 7.8. CONCLUSION The present study describes the results of an establishing process of a new PSI technique for TAR. The reliability of guiding block positioning and, thereby, prosthesis placement is sufficient. LEVEL OF EVIDENCE Biomechanical study.
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Affiliation(s)
- Leif Claassen
- DIAKOVERE Annastift, Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH)-Hannover Medical School
| | - Philipp Luedtke
- DIAKOVERE Annastift, Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH)-Hannover Medical School
| | - Dennis Nebel
- Laboratory for Biomechanics and Biomaterials of the Hannover Medical School
| | - Daiwei Yao
- DIAKOVERE Annastift, Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH)-Hannover Medical School
| | - Sarah Ettinger
- DIAKOVERE Annastift, Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH)-Hannover Medical School
| | | | | | - Christian Plaass
- DIAKOVERE Annastift, Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH)-Hannover Medical School
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Escudero MI, Le V, Bemenderfer TB, Barahona M, Anderson RB, Davis H, Wing KJ, Penner MJ. Total Ankle Arthroplasty Radiographic Alignment Comparison Between Patient-Specific Instrumentation and Standard Instrumentation. Foot Ankle Int 2021; 42:851-858. [PMID: 33749342 DOI: 10.1177/1071100721996379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several benefits are published supporting patient-specific instrumentation (PSI) in total ankle arthroplasty (TAA). This study seeks to determine if TAA with PSI yields different radiographic outcomes vs standard instrumentation (SI). METHODS Sixty-seven primary TAA patients having surgery using PSI or SI between 2013 and 2015 were retrospectively reviewed using weightbearing radiographs at 6-12 weeks postsurgery. Radiographic parameters analyzed were the medial distal tibia angle (MDTA), talar-tilt angle (TTA), anatomic sagittal distal tibia angle (aSDTA), lateral talar station (LTS), and talar component inclination angle (TCI). A comparison of the 2 groups for each radiologic parameter's distribution was performed using a nonparametric median test and Fisher exact test. Furthermore, TAAs with all radiographic measurements within acceptable limits were classified as "perfectly aligned." The rate of "perfectly aligned" TAAs between groups was compared using a Fisher exact test with a significance of .05. RESULTS Of the 67 TAAs, 51 were done with PSI and 16 with SI. There were no differences between groups in MDTA (P = .174), TTA (P = .145), aSDTA (P = .98), LTS (P = .922), or TCI angle (P = .98). When the rate of "perfectly aligned TAA" between the 2 groups were compared, there was no significant difference (P = .35). CONCLUSION No significant radiographic alignment differences were found between PSI and SI implants. This study showed that both techniques achieve reproducible TAA radiographic coronal and sagittal alignment for the tibial component when performed by experienced surgeons. The talar component's sagittal alignment is similar whether or not PSI was used but is noticeably different from normal anatomic alignment by design. LEVEL OF EVIDENCE Level III, retrospective cohort study using prospectively collected data.
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Affiliation(s)
- Mario I Escudero
- Department of Orthopaedics, University of Chile, Santiago, Chile
| | - Vu Le
- Pacific Orthopaedic Associates, Alhambra, CA, USA
| | | | | | | | - Hodges Davis
- Department of Orthopaedics, OrthoCarolina, Charlotte, NC, USA
| | - Kevin J Wing
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Murray J Penner
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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Bemenderfer TB, Davis WH, Anderson RB, Wing K, Escudero MI, Waly F, Penner M. Heterotopic Ossification in Total Ankle Arthroplasty: Case Series and Systematic Review. J Foot Ankle Surg 2021; 59:716-721. [PMID: 31954598 DOI: 10.1053/j.jfas.2019.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 12/10/2019] [Indexed: 02/03/2023]
Abstract
Heterotopic ossification after total ankle arthroplasty (TAA) is a known sequela and has been reported to contribute to reduced range of motion and poor functional outcomes. However, conflicting results have been reported in the literature. The present study documents the incidence of heterotopic ossification for a novel fourth-generation fixed-bearing 2-component prosthesis and reports a systematic review of the literature. We reviewed the incidence and functional outcome of consecutively enrolled patients who underwent primary Infinity TAA between 2013 and 2015 in a prospective observational study. Preoperative and postoperative radiographic and functional outcome data were collected. A systematic review was also conducted investigating all published studies between 1998 and 2018 reporting the incidence of heterotopic ossification after TAA. The incidence of heterotopic ossification was 70.5% in the 61 patients who underwent primary TAA in the case series. There was no association between heterotopic ossification and American Orthopaedic Foot and Ankle Society (AOFAS) score, foot function index (FFI), visual analogue scale (VAS), and ankle osteoarthritis scale (AOS). Sixteen studies on 1339 TAA implants were included. The overall incidence of heterotopic ossification after TAA was 66.0% at average 3.6 years (range 22.2% to 100%). Four studies (299 ankles) did not address functional outcomes. Eleven studies (960 ankles) reported no association between heterotopic ossification and functional outcomes. One study (80 ankles) reported a statistically significant difference in range of motion (7°) and AOFAS score (7 points). In conclusion, although the incidence of heterotopic ossification after TAA is considerable, there is insufficient literature to suggest that heterotopic ossification after TAA impacts range of motion or functional outcome.
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Affiliation(s)
- Thomas B Bemenderfer
- Surgeon, Carolinas Medical Center, Department of Orthopaedic Surgery, Charlotte, NC.
| | - W Hodges Davis
- Surgeon, OrthoCarolina Research Institute, Charlotte, NC
| | | | - Kevin Wing
- Surgeon, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mario I Escudero
- Surgeon, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Feras Waly
- Surgeon, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada; Surgeon, Department of Orthopaedic Surgery, University of Tabuk, Tabuk, Saudi Arabia
| | - Murray Penner
- Surgeon, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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A new ligament-compatible patient-specific 3D-printed implant and instrumentation for total ankle arthroplasty: from biomechanical studies to clinical cases. J Orthop Traumatol 2020; 21:16. [PMID: 32876778 PMCID: PMC7468019 DOI: 10.1186/s10195-020-00555-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/29/2020] [Indexed: 12/18/2022] Open
Abstract
Background Computer navigation and patient-specific instrumentation for total ankle arthroplasty have still to demonstrate their theoretical ability to improve implant positioning and functional outcomes. The purpose of this paper is to present a new and complete total ankle arthroplasty customization process for severe posttraumatic ankle joint arthritis, consisting of patient-specific 3D-printed implant and instrumentation, starting from a ligament-compatible design. Case presentation The new customization process was proposed in a 57-year-old male patient and involved image analysis, joint modeling, prosthesis design, patient-specific implant and instrumentation development, relevant prototyping, manufacturing, and implantation. Images obtained from a CT scan were processed for a 3D model of the ankle, and the BOX ankle prosthesis (MatOrtho, UK) geometries were customized to best fit the model. Virtual in silico, i.e., at the computer, implantation was performed to optimize positioning of these components. Corresponding patient-specific cutting guides for bone preparation were designed. The obtained models were printed in ABS by additive manufacturing for a final check. Once the planning procedure was approved, the models were sent to final state-of-the-art additive manufacturing (the metal components using cobalt-chromium-molybdenum powders, and the guides using polyamide). The custom-made prosthesis was then implanted using the cutting guides. The design, manufacturing, and implantation procedures were completed successfully and consistently, and final dimensions and location for the implant corresponded with the preoperative plan. Immediate post-op X-rays showed good implant positioning and alignment. After 4 months, clinical scores and functional abilities were excellent. Gait analysis showed satisfactory joint moment at the ankle complex and muscle activation timing within normality. Conclusions The complete customization process for total ankle arthroplasty provided accurate and reliable implant positioning, with satisfactory short-term clinical outcomes. However, further studies are needed to confirm the potential benefits of this complete customization process. Level of evidence 5. Case report.
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Najefi AA, Malhotra K, Goldberg A. Mechanical and anatomical axis of the lower limb in total ankle arthroplasty. Foot (Edinb) 2020; 44:101666. [PMID: 32172139 DOI: 10.1016/j.foot.2020.101666] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/25/2020] [Accepted: 01/31/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Inadequate correction of mechanical alignment may lead to failure of Total Ankle Replacements (TAR). The mechanical axis of the lower limb (MAL), the mechanical axis of the tibia (MAT) and the anatomical axis of the tibia (AAT) are three well described coronal plane measurements using plain radiography. The assumption is that the MAL, MAT and AAT are equivalent. The relationship between these axes can vary in the presence of proximal deformity. The purpose of this study was to assess the relationship between MAL, MAT and AAT in a cohort of patients considered for TAR. METHODS 75 consecutive standardised preoperative long leg radiographs of patients with end stage ankle osteoarthritis, between 2016 and 2017 at a specialist tertiary center for elective orthopedic surgery were analysed. Patients were split into 2 groups. The first group had a clinically and radiologically detectable deformity proximal to the ankle (such as previous tibial or femoral fracture, severe arthritis, or previous reconstructive surgery), whereas the second (normal) group did not. The MAL, MAT and AAT were measured and the difference between these values were calculated. RESULTS There were 54 patients in the normal group, and 21 patients in the deformity group. The mean difference between the MAL and AAT was 1.7 ± 1.3° (range, 0.1-5.4°). In the normal group, 15 patients (27%) had a difference of >2° between the MAL and AAT, compared with 52% in the deformity group. The mean difference between the MAL and MAT was 0.9 ± 1.7° (range, -4 to -3.5°). In the deformity group, 42% of patients had a difference between MAT and MAL of >2°, compared with 20% in the normal group. CONCLUSION MAT, MAL and AAT should not be assumed to be the same in all patients. The authors recommend considering the use of full-length weightbearing lower limb radiographs to plan TAR.
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Affiliation(s)
- Ali-Asgar Najefi
- Institute of Orthopaedics and Musculoskeletal Science, Royal National Orthopaedic Hospital NHS Trust, Stanmore, Middlesex, HA7 4LP, United Kingdom.
| | - Karan Malhotra
- Foot & Ankle Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, United Kingdom
| | - Andy Goldberg
- Institute of Orthopaedics and Musculoskeletal Science, Royal National Orthopaedic Hospital NHS Trust, Stanmore, Middlesex, HA7 4LP, United Kingdom; The London Ankle Arthritis Centre, Wellington Hospital, London, United Kingdom
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Beredjiklian PK, Wang M, Lutsky K, Vaccaro A, Rivlin M. Three-Dimensional Printing in Orthopaedic Surgery: Technology and Clinical Applications. J Bone Joint Surg Am 2020; 102:909-919. [PMID: 32079880 DOI: 10.2106/jbjs.19.00877] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Pedro K Beredjiklian
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute Orthopaedics, Philadelphia, Pennsylvania
| | - Mark Wang
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute Orthopaedics, Philadelphia, Pennsylvania
| | - Kevin Lutsky
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute Orthopaedics, Philadelphia, Pennsylvania
| | - Alexander Vaccaro
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute Orthopaedics, Philadelphia, Pennsylvania
| | - Michael Rivlin
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Institute Orthopaedics, Philadelphia, Pennsylvania
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Abstract
Hallux valgus (HV) represents a progressive 3-dimensional deformity that includes bone malalignment, hypermobility of the first ray, and imbalanced soft-tissue structures of the midfoot and forefoot. Conventional radiographs provide sectorized and limited information of the deformity in different planes. The literature evidence supporting the use of cone beam weightbearing computed tomography in the assessment of HV has been growing. It demonstrates important advances that include the ability to reliably perform traditional measurements such as HV angle and intermetatarsal angle in the 3-dimensional setting.
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Escudero MI, Symes M, Bemenderfer TB, Barahona M, Anderson R, Davis H, Wing KJ, Penner MJ. Does Patient-Specific Instrumentation Have a Higher Rate of Early Osteolysis Than Standard Referencing Techniques in Total Ankle Arthroplasty? A Radiographic Analysis. Foot Ankle Spec 2020; 13:32-42. [PMID: 30757922 DOI: 10.1177/1938640019828069] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Patient-specific instrumentation (PSI) has been developed for total ankle arthroplasty (TAA), with proven benefits. One concern regarding PSI is the need for more soft tissue dissection in order to accurately position the PSI guides, which has the theoretical disadvantage of increased osteolysis. The purpose of our study is to compare the incidence and magnitude of osteolysis for the INFINITY Total Ankle System between PSI and standard referencing (SR) techniques. Methods: Sixty-seven patients who underwent primary TAA using Prophecy (PSI) or SR technique between 2013 and 2015 were reviewed in a retrospective observational study. Osteolysis was assessed on radiographs at 2 years. The incidence was calculated by binomial distribution. The number of zones compromised and the magnitude of osteolysis was calculated using the median as a summary statistic and interquartile range as dispersion statistic. Fisher exact test was used to compare both groups, then a regression model was estimated to calculate the odds ratio for osteolysis. Results: Of the 67 TAAs, 51 were in the PSI group and 16 in the SR group. In the PSI group the incidence, number of compromised zones (CZ), and magnitude was 41% (25%-59%), 1 [1-2], and 2 [2-3], respectively. In the SR group these were 36% (13%-65%), 3 [2-3], and 3 [2-4], respectively. No significant differences were found (P = .46, P = .12, P = .33). A slightly higher risk of osteolysis was found in the PSI group (odds ratio = 1.33 [0.36-4.83]) (P = .46). The majority of lesions were in 1 zone with size of 2 to 5 mm (63% for all cohort, 64% PSI, 60% SR). Two cases underwent revision for aseptic loosening, 1 in the SR group and 1 in the PSI group. Conclusion: According to our data, there is no significant difference between PSI and SR in terms of risk, incidence, size and magnitude of osteolysis in the INFINITY Total Ankle System at 2 years. Levels of Evidence: Therapeutic, Level III, Retrospective cohort study.
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Affiliation(s)
- Mario I Escudero
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada (MIE, MS, KJW, MJP).,Orthocarolina Foot and Ankle Institute, Charlotte, North Carolina (TBB, RA, HD).,Department of Orthopaedics, University of Chile, Santiago, Chile (MIE, MB)
| | - Michael Symes
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada (MIE, MS, KJW, MJP).,Orthocarolina Foot and Ankle Institute, Charlotte, North Carolina (TBB, RA, HD).,Department of Orthopaedics, University of Chile, Santiago, Chile (MIE, MB)
| | - Thomas Bradford Bemenderfer
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada (MIE, MS, KJW, MJP).,Orthocarolina Foot and Ankle Institute, Charlotte, North Carolina (TBB, RA, HD).,Department of Orthopaedics, University of Chile, Santiago, Chile (MIE, MB)
| | - Maximiliano Barahona
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada (MIE, MS, KJW, MJP).,Orthocarolina Foot and Ankle Institute, Charlotte, North Carolina (TBB, RA, HD).,Department of Orthopaedics, University of Chile, Santiago, Chile (MIE, MB)
| | - Robert Anderson
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada (MIE, MS, KJW, MJP).,Orthocarolina Foot and Ankle Institute, Charlotte, North Carolina (TBB, RA, HD).,Department of Orthopaedics, University of Chile, Santiago, Chile (MIE, MB)
| | - Hodges Davis
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada (MIE, MS, KJW, MJP).,Orthocarolina Foot and Ankle Institute, Charlotte, North Carolina (TBB, RA, HD).,Department of Orthopaedics, University of Chile, Santiago, Chile (MIE, MB)
| | - Kevin J Wing
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada (MIE, MS, KJW, MJP).,Orthocarolina Foot and Ankle Institute, Charlotte, North Carolina (TBB, RA, HD).,Department of Orthopaedics, University of Chile, Santiago, Chile (MIE, MB)
| | - Murray J Penner
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada (MIE, MS, KJW, MJP).,Orthocarolina Foot and Ankle Institute, Charlotte, North Carolina (TBB, RA, HD).,Department of Orthopaedics, University of Chile, Santiago, Chile (MIE, MB)
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Gagne OJ, Veljkovic A, Townshend D, Younger A, Wing KJ, Penner MJ. Intraoperative Assessment of the Axial Rotational Positioning of a Modern Ankle Arthroplasty Tibial Component Using Preoperative Patient-Specific Instrumentation Guidance. Foot Ankle Int 2019; 40:1160-1165. [PMID: 31327252 DOI: 10.1177/1071100719856548] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of patient-specific instrumentation (PSI) in modern total ankle replacement (TAR) has augmented positioning of the tibial component, eliminating the need for complex jigs. Coronal and sagittal alignment are intuitive with this design and have been studied, but axial rotation has not. The purpose of this study was to assess the relationship between the planned preoperative axial rotation as set by the PSI guide and the rotation determined intraoperatively with non-PSI instrumentation. METHODS This was a prospective cohort study of 22 consecutive cases. The axial rotation angle between the medial gutter and the tibial implant position on the preoperative CT-scan based plan was extracted. At the time of surgery, the medial gutter alignment instrument from the non-PSI instrumentation was inserted and an intraoperative axial photograph obtained to record the angle between the medial gutter and the axial rotation guide pins set by the PSI instrumentation. The 2 measurements were compared and further statistical analysis included Pearson correlation and paired Student t test. RESULTS The average axial rotation angle between the medial gutter and the implant on the PSI preoperative plan was 5.4 ± 2.9 degrees, whereas the intraoperative photograph from the medial gutter alignment instrument to the pin was 5.9 ±3.8 degrees. This demonstrated a Pearson correlation of R = 0.54 and a P value of .53. The average difference between the two was -0.46 (95% CI: -2.04, 1.10), meaning that components were either slightly externally rotated or that the fork was aimed internally. Based on this group, 50% (11/22) were within 2 degrees of the target and 77% (17/22) were within 4 degrees of the target. CONCLUSION Patient-specific guides allowed for reproducible rotational tibial component implantation in modern TAR. Further work is needed to better understand the biomechanical effects of the rotational profile and consequences on survivorship. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Oliver J Gagne
- University of British Columbia Department of Orthopedics, Vancouver, British Columbia, Canada
| | - Andrea Veljkovic
- Department of Orthopedics, University of British Columbia, St. Paul's Hospital, Partner, Footbridge Centre for Integrated Foot and Ankle Care, Vancouver, British Columbia, Canada
| | - Dave Townshend
- Northumbria NHS Healthcare Trust, North Shields, United Kingdom
| | - Alastair Younger
- University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Kevin J Wing
- Department of Orthopedics, University of British Columbia, St. Paul's Hospital, Partner, Footbridge Centre for Integrated Foot and Ankle Care, Vancouver, British Columbia, Canada
| | - Murray J Penner
- Department of Orthopedics, University of British Columbia, St. Paul's Hospital, Partner, Footbridge Centre for Integrated Foot and Ankle Care, Vancouver, British Columbia, Canada
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Savage-Elliott I, Wu VJ, Wu I, Heffernan JT, Rodriguez R. Comparison of Time and Cost Savings Using Different Cost Methodologies for Patient-Specific Instrumentation vs Standard Referencing in Total Ankle Arthroplasty. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419884278. [PMID: 35097347 PMCID: PMC8697097 DOI: 10.1177/2473011419884278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Patient-specific 3-D printing cutting blocks (PSI) have been used instead of traditional intramedullary cutting guides. We hypothesized that PSI would lead to significantly decreased operating room (OR) time and significant cost savings to our institution with noninferior radiographic outcomes and no difference in expected vs actual implant size when compared with standard referencing (SR). Methods: Patients who had undergone total ankle replacements at our institution from 2013 through 2016 were included in the study. Associations between demographic variables and postoperative alignment in the SR vs PSI group were calculated using the Wilcoxon rank-sum test and the intraclass correlation coefficient. The cost of the operation was calculated using both an institutionally based fixed cost of OR time and using Time Driven Activity Based Cost (TDABC) accounting. A total of 43 patients were included in the study, 13 in the SR group and 30 in the PSI group. Results: Operative time (168 vs 137 minutes) and tourniquet time (123 vs 113 minutes) were significantly lower in the PSI vs the SR group. PSI predictions were accurate 100% of the time for tibial components and 83% of the time for talar components. Average costs of TAA using PSI were significantly reduced by $7597.00 when using traditional OR accounting, whereas PSI was $836.00 more expensive on average using TDABC accounting. Conclusion: Further research is needed to determine the cost-effectiveness of PSI vs SR in TAA; however, it does appear to save time intraoperatively. The long-term effect on clinical outcomes requires further study. Level of Evidence: Level III, case-control study.
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Affiliation(s)
- Ian Savage-Elliott
- Department of Orthopedic Surgery, Tulane University, New Orleans, LA, USA
| | - Victor J Wu
- Department of Orthopedic Surgery, Tulane University, New Orleans, LA, USA
| | - Isabella Wu
- Department of Orthopedic Surgery, Tulane University, New Orleans, LA, USA
| | | | - Ramon Rodriguez
- Department of Orthopedic Surgery, Tulane University, New Orleans, LA, USA
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Ankle morphometry based on computerized tomography. Foot Ankle Surg 2019; 25:674-678. [PMID: 30306892 DOI: 10.1016/j.fas.2018.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/02/2018] [Accepted: 08/01/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Thorough understanding of the morphometry of the ankle joint is crucial to optimize conservative and operative therapy of ankle joint disorders. Despite recent improvements, basic anatomic and biomechanical correlations of the ankle joint including the orientation of the ankle joint axis and joint morphology as its key biomechanical features are not sufficiently recorded to date. The aim of this study was the evaluation of the ankle morphometry to gain information about the ankle joint axis. MATERIAL AND METHODS In this study 98 high-resolution CT-scans of complete Caucasian cadaver legs were analysed. Using the software Mimics and 3-Matic (Materialize) 22 anatomic parameters of the talocrural joint were assessed, including the length, width and surface area of the tibial and talar articular areas. Additionally, the radii of the articular areas, the medial distal tibial angle and the height of the talar dome were determined. RESULTS The radius of the central trochlea tali was 44.6±4.1mm (mean±SD). The central trochlea tali arc length was 40.8±3.0mm and its width was 27.4±2.5mm. Additionally we determined 47.0±4.4mm for the tibial sagittal radius, 27.6±3.0mm for the tibial arc length and 27.4±2.5mm for the central tibial width. CONCLUSION The present study describes the three-dimensional morphometry of Caucasian ankle joints in detail. This dimensional analysis of the ankle joint will inform the development and placements of implants and prostheses.
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AAFD: Conventional Radiographs are not Enough! I Need the Third Dimension. TECHNIQUES IN FOOT AND ANKLE SURGERY 2019. [DOI: 10.1097/btf.0000000000000234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kunz M, Rudan JF. Patient-Specific Surgical Guidance System for Intelligent Orthopaedics. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1093:225-243. [PMID: 30306485 DOI: 10.1007/978-981-13-1396-7_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Clinical benefits for image-guided orthopaedic surgical systems are often measured in improved accuracy and precision of tool trajectories, prosthesis component positions and/or reduction of revision rate. However, with an ever-increasing demand for orthopaedic procedures, especially joint replacements, the ability to increase the number of surgeries, as well as lowering the costs per surgery, is generating a similar interest in the evaluation of image-guided orthopaedic systems. Patient-specific instrument guidance has recently gained popularity in various orthopaedic applications. Studies have shown that these guides are comparable to traditional image-guided systems with respect to accuracy and precision of the navigation of tool trajectories and/or prosthesis component positioning. Additionally, reports have shown that these single-use instruments also improve operating room management and reduce surgical time and costs. In this chapter, we discuss how patient-specific instrument guidance provides benefits to patients as well as to the health-care community for various orthopaedic applications.
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Affiliation(s)
- Manuela Kunz
- Department of Surgery, Queen's University, Kingston, ON, Canada.
| | - John F Rudan
- Department of Surgery, Queen's University, Kingston, ON, Canada
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Saito GH, Sanders AE, O'Malley MJ, Deland JT, Ellis SJ, Demetracopoulos CA. Accuracy of patient-specific instrumentation in total ankle arthroplasty: A comparative study. Foot Ankle Surg 2019; 25:383-389. [PMID: 30321969 DOI: 10.1016/j.fas.2018.02.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/22/2018] [Accepted: 02/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patient-specific instrumentation (PSI) for TAA is a novel technology with several potential benefits. The primary goal of this study was to compare the use of PSI with the standard referencing guide (SRG) in regards to accuracy of tibial implant positioning. Operative time, fluoroscopy time and accuracy of PSI preoperative reports were also evaluated. METHODS A retrospective analysis of 99 patients who underwent a primary TAA with the INFINITY prosthesis (Wright Medical, Memphis, TN) was performed. Patients were divided in two groups based on the type of instrumentation used during the TAA (75 in the PSI group vs 24 in the SRG group). There was no significant difference between groups in regards to age at the time of surgery (P=0.122), sex (P=0.138), number of concomitant procedures performed during surgery (P=0.567) and etiology (P=0.841). However, preoperative deformity was significantly smaller in the PSI group (P=0.002). RESULTS Tibial implant positioning was similar between groups. In the coronal plane, the absolute deviation of the tibial implant from the intended alignment was 1.7±1.4° for the SRG and 1.6±1.2° for PSI (P=0.710). In the sagittal plane, the absolute alignment deviation of the tibial implant was 1.8±1.4° for the SRG and 1.9±1.5° for PSI (P=0.675). Operative time (167 vs 190min, P=0.040) and fluoroscopy time (85 vs 158s, P<0.001) were significantly decreased in the PSI group. The PSI preoperative plan report correctly predicted the implant size in 73% of cases for the tibial component and in 51% of cases for the talar component. CONCLUSIONS PSI provided similar tibial component alignment as standard instrumentation. Additionally, PSI preoperative plan reports were poor predictors of implant sizing. Therefore, the final decision should always be based on surgeon's experience in order to prevent errors in implant sizing and positioning. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Guilherme H Saito
- Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY 10021, United States.
| | - Austin E Sanders
- Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY 10021, United States
| | - Martin J O'Malley
- Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY 10021, United States
| | - Jonathan T Deland
- Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY 10021, United States
| | - Scott J Ellis
- Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY 10021, United States
| | - Constantine A Demetracopoulos
- Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY 10021, United States
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Burssens A, Vermue H, Barg A, Krähenbühl N, Victor J, Buedts K. Templating of Syndesmotic Ankle Lesions by Use of 3D Analysis in Weightbearing and Nonweightbearing CT. Foot Ankle Int 2018; 39:1487-1496. [PMID: 30122077 DOI: 10.1177/1071100718791834] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Diagnosis and operative treatment of syndesmotic ankle injuries remain challenging due to the limitations of 2-dimensional imaging. The aim of this study was therefore to develop a reproducible method to quantify the displacement of a syndesmotic lesion based on 3-dimensional computed imaging techniques. METHODS: Eighteen patients with a unilateral syndesmotic lesion were included. Bilateral imaging was performed with weightbearing cone-beam computed tomography (CT) in case of a high ankle sprain (n = 12) and by nonweightbearing CT in case of a fracture-associated syndesmotic lesion (n = 6). The healthy ankle was used as a template after being mirrored and superimposed on the contralateral ankle. The following anatomical landmarks of the distal fibula were computed: the most lateral aspect of the lateral malleolus and the anterior and posterior tubercle. The change in position of these landmarks relative to the stationary, healthy fibula was used to quantify the syndesmotic lesion. A control group of 7 studies was used. RESULTS: The main clinical relevant findings demonstrated a statistically significant difference between the mean mediolateral diastasis of both the sprained (mean [SD], 1.6 [1.0] mm) and the fracture group (mean [SD], 1.7 [0.6] mm) compared to the control group ( P < .001). The mean external rotation was statistically different when comparing the sprained (mean [SD], 4.7 [2.7] degrees) and the fracture group (mean [SD], 7.0 [7.1] degrees) to the control group ( P < .05). CONCLUSION: This study evaluated an effective method for quantifying a unilateral syndesmotic lesion of the ankle. Applications in clinical practice could improve diagnostic accuracy and potentially aid in preoperative planning by determining which correction needs to be achieved to have the fibula correctly reduced in the syndesmosis. LEVEL OF EVIDENCE: Level III, retrospective comparative study.
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Affiliation(s)
- Arne Burssens
- 1 Department of Orthopaedic Surgery, Ghent University Hospital, Gent, Belgium
| | - Hannes Vermue
- 1 Department of Orthopaedic Surgery, Ghent University Hospital, Gent, Belgium
| | - Alexej Barg
- 2 Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Nicola Krähenbühl
- 2 Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Jan Victor
- 1 Department of Orthopaedic Surgery, Ghent University Hospital, Gent, Belgium
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Sun Z, Li N, Zhang T, Xin J, Ma X. [Progress of total ankle arthroplasty for end-stage ankle osteoarthritis]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:1313-1316. [PMID: 30215493 DOI: 10.7507/1002-1892.201803028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the progress of total ankle arthroplasty (TAA) in treatment of end-stage ankle osteoarthritis (AOA). Methods The domestic and foreign literatures about TAA in recent years were reviewed. The current status and progress of TAA were summarized from the results of traditional and computer-assisted TAA clinical outcomes. Results End-stage AOA often leads to severe pain and dysfunction, and arthrodesis is still the main selective treatment option. In recent years, with the advancement of surgical techniques and prosthesis design, TAA which can remain joint mobility has increased gradually, and the surgical results also have significant progress. Accurate prosthesis implant and mechanical alignment restoration are critical factors for TAA, and surgery-related malalignment is correlative to the prosthesis failure. Computer assisted patient-specific guide can simplify the TAA procedures and obtain the accuracy of tibia and talus osteotomy. Conclusion The clinical efficiency of preoperative CT based patient-specific guide technology for TAA needs further clinical follow-up. Meanwhile, it is necessary to further develop intraoperative navigation and robotic surgery system suitable for TAA.
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Affiliation(s)
- Zhenhui Sun
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, 300211, P.R.China[]
| | - Nan Li
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, 300211, P.R.China[]
| | - Tao Zhang
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, 300211, P.R.China[]
| | - Jingyi Xin
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, 300211, P.R.China[]
| | - Xinlong Ma
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, 300211, P.R.China[]
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Abstract
Surgeons and engineers constantly search for methods to improve the surgical positioning of implants used for joint arthroplasty. Rapid prototyping is being used to develop patient-specific instrumentation (PSI) and has already been successfully translated into large-scale clinical use for knee arthroplasty. PSI has been used in shoulder arthroplasty; however, it is not yet known whether PSI provides improved accuracy and outcomes compared with conventional methods in either shoulder arthroplasty or knee arthroplasty. In the hip, PSI has been limited to the positioning of custom-manufactured implants and a small number of surgeons testing the emerging solutions from different manufacturers. Early results indicate consistent accurate positioning of implants with the use of PSI in hip arthroplasty but with added costs and uncertain effect on clinical outcomes.
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DeVries JG, Derksen TA, Scharer BM, Limoni R. Perioperative Complications and Initial Alignment of Lateral Approach Total Ankle Arthroplasty. J Foot Ankle Surg 2018. [PMID: 28645548 DOI: 10.1053/j.jfas.2017.04.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Total ankle replacement continues to become a more common treatment of end-stage ankle arthritis. A lateral approach total ankle implant system is an innovative approach for this treatment. We performed a retrospective review of 16 patients treated with lateral approach total ankle replacement. The implant was successful and retained in all cases during a follow-up period of 769 ± 221.3 days (25.3 ± 7.3 months). Initial satisfactory alignment was achieved in all cases. For patients in whom a frontal plane incongruent deformity was present preoperatively, a statistically significant correction was obtained (p = .0122). Three cases of delayed or nonunion of the fibula (18.8%) occurred, and one case of infection that led to removal of the fibular plate developed, for a total of 4 complications (25.0%) related to the fibular osteotomy. Our findings indicate that lateral approach total ankle replacement is effective with unique advantages and disadvantages for treating end-stage ankle arthritis.
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Affiliation(s)
- J George DeVries
- Foot and Ankle Surgeon, Orthopedic & Sports Medicine, BayCare Clinic, Green Bay, WI.
| | - Todd A Derksen
- Foot and Ankle Surgeon, Orthopedics and Sports Institute of the Fox Valley, Appleton, WI
| | - Brandon M Scharer
- Foot and Ankle Surgeon, Orthopedic & Sports Medicine, BayCare Clinic, Green Bay, WI
| | - Robert Limoni
- Orthopedic Surgeon, Orthopedic & Sports Medicine, BayCare Clinic, Green Bay, WI
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Waly FJ, Yeo NE, Penner MJ. Computed Navigation Guidance for Ankle Replacement in the Setting of Ankle Deformity. Clin Podiatr Med Surg 2018; 35:85-94. [PMID: 29156170 DOI: 10.1016/j.cpm.2017.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Total ankle replacement (TAR) has evolved over the past decade as a treatment for end-stage ankle arthritis with improved survivorship. Despite the improving outcomes, ankle deformity represents a challenge to the foot and ankle surgeon with increased risk of implant failure. The use of preoperative computer-assisted guidance has led to better understanding the 3-dimensional ankle anatomy and associated deformities and allows for reproducible, anatomic placement of the TAR components.
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Affiliation(s)
- Feras J Waly
- Department of Orthopaedic Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada; Department of Orthopedic Surgery, University of Tabuk, Tabuk 71491, Saudi Arabia.
| | - Nicholas E Yeo
- Department of Orthopaedic Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada; Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Murray J Penner
- Department of Orthopedic Surgery, University of British Columbia, 3114 - 910 West 10th Avenue, Vancouver, British Columbia V5Z 1M9, Canada
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Use of CT Scan-derived Patient-specific Instrumentation in Total Ankle Arthroplasty. TECHNIQUES IN FOOT & ANKLE SURGERY 2017. [DOI: 10.1097/btf.0000000000000175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Optimal placement of correctly sized total ankle replacement (TAR) implants is elemental to prolonging the working life. The negative mechanical effects of implant malalignment are well characterized. There is one FDA-approved navigated TAR system with limited but encouraging outcomes data. Therefore, its value can be estimated only based on benefits other than a proven clinical outcomes improvement over conventional systems. These include unique preoperative planning through 3-dimensional templating and virtual surgery and the patient-specific cut guides, which also reduce overall instrumentation needed for the case. To better inform this conversation, well-observed longitudinal outcomes studies are warranted.
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Affiliation(s)
- Christopher W Reb
- Division of Foot and Ankle Surgery, Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, 3450 Hull Road, Gainesville, FL 32607, USA
| | - Gregory C Berlet
- Orthopedic Foot and Ankle Center, 300 Polaris Parkway, Suite 2000, Westerville, OH 43082, USA.
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Daigre J, Berlet G, Van Dyke B, Peterson KS, Santrock R. Accuracy and Reproducibility Using Patient-Specific Instrumentation in Total Ankle Arthroplasty. Foot Ankle Int 2017; 38:412-418. [PMID: 27920333 DOI: 10.1177/1071100716682086] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Implant survivorship is dependent on accuracy of implantation and successful soft tissue balancing. System instrumentation for total ankle arthroplasty implantation has a key influence on surgeon accuracy and reproducibility. The purpose of this study was to determine the accuracy and reproducibility of implant position with patient-specific guides for total ankle arthroplasty across multiple surgeons at multiple facilities. METHODS This retrospective, multicenter study included 44 patients who received a total ankle implant (INBONE II Total Ankle System; Wright Medical Technology, Memphis, TN) using PROPHECY patient-specific guides from January 2012 to December 2014. Forty-four patients with an average age of 63.0 years underwent total ankle arthroplasty using this preoperative patient-specific system. Preoperative computed tomography (CT) scans were obtained to assess coronal plane deformity, assess mechanical and anatomic alignment, and build patient-specific guides that referenced bony anatomy. The mean preoperative coronal deformity was 4.6 ± 4.6 degrees (range, 14 degrees varus to 17 degrees valgus). The first postoperative weightbearing radiographs were used to measure coronal and sagittal alignment of the implant vs the anatomic axis of the tibia. RESULTS In 79.5% of patients, the postoperative implant position of the tibia corresponded to the preoperative plan of the tibia within 3 degrees of the intended target, within 4 degrees in 88.6% of patients, and within 5 degrees in 100% of patients. The tibial component coronal size was correctly predicted in 98% of cases, whereas the talar component was correctly predicted in 80% of cases. CONCLUSION The use of patient-specific instrumentation for total ankle arthroplasty provided reliable alignment and reproducibility in the clinical situation similar to that shown in cadaveric testing. This study has shown that the preoperative patient-specific instrumentation provided for accuracy and reproducibility of ankle arthroplasty implantation in a cohort across multiple surgeons and facilities. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
| | - Gregory Berlet
- 2 Orthopedic Foot and Ankle Center, Westerville, OH, USA
| | | | | | - Robert Santrock
- 5 West Virginia University Orthopaedics, Morgantown, WV, USA
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49
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Hamid KS, Matson AP, Nwachukwu BU, Scott DJ, Mather RC, DeOrio JK. Determining the Cost-Savings Threshold and Alignment Accuracy of Patient-Specific Instrumentation in Total Ankle Replacements. Foot Ankle Int 2017; 38:49-57. [PMID: 27649973 DOI: 10.1177/1071100716667505] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Traditional intraoperative referencing for total ankle replacements (TARs) involves multiple steps and fluoroscopic guidance to determine mechanical alignment. Recent adoption of patient-specific instrumentation (PSI) allows for referencing to be determined preoperatively, resulting in less steps and potentially decreased operative time. We hypothesized that usage of PSI would result in decreased operating room time that would offset the additional cost of PSI compared with standard referencing (SR). In addition, we aimed to compare postoperative radiographic alignment between PSI and SR. METHODS Between August 2014 and September 2015, 87 patients undergoing TAR were enrolled in a prospectively collected TAR database. Patients were divided into cohorts based on PSI vs SR, and operative times were reviewed. Radiographic alignment parameters were retrospectively measured at 6 weeks postoperatively. Time-driven activity-based costing (TDABC) was used to derive direct costs. Cost vs operative time-savings were examined via 2-way sensitivity analysis to determine cost-saving thresholds for PSI applicable to a range of institution types. Cost-saving thresholds defined the price of PSI below which PSI would be cost-saving. A total of 35 PSI and 52 SR cases were evaluated with no significant differences identified in patient characteristics. RESULTS Operative time from incision to completion of casting in cases without adjunct procedures was 127 minutes with PSI and 161 minutes with SR ( P < .05). PSI demonstrated similar postoperative accuracy to SR in coronal tibial-plafond alignment (1.1 vs 0.3 degrees varus, P = .06), tibial-plafond alignment (0.3 ± 2.1 vs 1.1 ± 2.1 degrees varus, P = .06), and tibial component sagittal alignment (0.7 vs 0.9 degrees plantarflexion, P = .14). The TDABC method estimated a PSI cost-savings threshold range at our institution of $863 below which PSI pricing would provide net cost-savings. Two-way sensitivity analysis generated a globally applicable cost-savings threshold model based on institution-specific costs and surgeon-specific time-savings. CONCLUSIONS This study demonstrated equivalent postoperative TAR alignment with PSI and SR referencing systems but with a significant decrease in operative time with PSI. Based on TDABC and associated sensitivity analysis, a cost-savings threshold of $863 was identified for PSI pricing at our institution below which PSI was less costly than SR. Similar internal cost accounting may benefit health care systems for identifying cost drivers and obtaining leverage during price negotiations. LEVEL OF EVIDENCE Level III, therapeutic study.
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50
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Prissel MA, Berlet GC, Scott RT, Daigre JL, Bull PE, Peterson KS, Collins CL, Hyer CF. Radiographic Assessment of a Medullary Total Ankle Prosthesis: A Test of Agreement and Reliability. Foot Ankle Spec 2016; 9:486-493. [PMID: 27412962 DOI: 10.1177/1938640016656785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
UNLABELLED Total ankle replacement (TAR) is a viable alternative to ankle fusion in certain patients with end-stage ankle arthritis. Despite the importance of understanding alignment and movement of the prosthesis, there is no standardized radiographic method for evaluating the position and movement of the INBONE 2 prosthesis. The aims of this study were to describe a radiographic measurement protocol for INBONE 2 for clinical practice and research while determining the interobserver and intraobserver reliability using standard weightbearing radiographs. Fifteen patients were randomly selected with operative dates from January 2011 to January 2014 who underwent primary TAR using the INBONE 2 prosthesis. Most recent preoperative and first postoperative weightbearing anteroposterior and lateral radiographs were pulled and deidentified. Three foot and ankle surgeons blinded from the patient selection and deidentification, measured the described measurements on separate occasions. Intraobserver reliability: surgeon 1 had acceptable reliability for 9 of 13 continuous radiographic measurements (69.2%), surgeon 2 had acceptable reliability for 8 of 13 measurements (61.5%), and surgeon 3 had acceptable reliability for 12 of 13 measurements (92.3%). Interobserver reliability: among the first measurements, 6 of 13 continuous radiographic measurements (46.2%) had acceptable reliability. Among the second measurements, 7 of 13 measurements (53.8%) had acceptable reliability. Among the first and second measurements combined, 7 of 13 measurements (53.8%) had acceptable reliability. This study promotes the need for meticulous evaluation of annual radiographic findings following TAR in an effort to avoid catastrophic failure and represents moderate agreement can be obtained by employing the proposed measurements for surveillance of INBONE 2 TAR at annual postoperative visits. Measurements on the anteroposterior radiograph appear to demonstrate more consistent results for surveillance than lateral measurements. The intraobserver reliability results were somewhat superior to the interobserver reliability, implying more relevance for a single surgeon applying these measurements annually for postoperative surveillance. LEVELS OF EVIDENCE Diagnostic, Level III.
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Affiliation(s)
- Mark A Prissel
- Atlantic Foot & Ankle Center, Chesapeake, Virginia (MAP).,Orthopedic Foot & Ankle Center, Westerville, Ohio (PEB, GCB, CFH).,The CORE Institute, Phoenix, AZ (RTS).,Decatur Orthopaedic Clinic, Decatur, Alabama (JLD).,Suburban Orthopaedics, Bartlett, IL (KSP).,OhioHealth Research and Innovation Institute, Columbus, Ohio (CLC)
| | - Gregory C Berlet
- Atlantic Foot & Ankle Center, Chesapeake, Virginia (MAP).,Orthopedic Foot & Ankle Center, Westerville, Ohio (PEB, GCB, CFH).,The CORE Institute, Phoenix, AZ (RTS).,Decatur Orthopaedic Clinic, Decatur, Alabama (JLD).,Suburban Orthopaedics, Bartlett, IL (KSP).,OhioHealth Research and Innovation Institute, Columbus, Ohio (CLC)
| | - Ryan T Scott
- Atlantic Foot & Ankle Center, Chesapeake, Virginia (MAP).,Orthopedic Foot & Ankle Center, Westerville, Ohio (PEB, GCB, CFH).,The CORE Institute, Phoenix, AZ (RTS).,Decatur Orthopaedic Clinic, Decatur, Alabama (JLD).,Suburban Orthopaedics, Bartlett, IL (KSP).,OhioHealth Research and Innovation Institute, Columbus, Ohio (CLC)
| | - Justin L Daigre
- Atlantic Foot & Ankle Center, Chesapeake, Virginia (MAP).,Orthopedic Foot & Ankle Center, Westerville, Ohio (PEB, GCB, CFH).,The CORE Institute, Phoenix, AZ (RTS).,Decatur Orthopaedic Clinic, Decatur, Alabama (JLD).,Suburban Orthopaedics, Bartlett, IL (KSP).,OhioHealth Research and Innovation Institute, Columbus, Ohio (CLC)
| | - Patrick E Bull
- Atlantic Foot & Ankle Center, Chesapeake, Virginia (MAP).,Orthopedic Foot & Ankle Center, Westerville, Ohio (PEB, GCB, CFH).,The CORE Institute, Phoenix, AZ (RTS).,Decatur Orthopaedic Clinic, Decatur, Alabama (JLD).,Suburban Orthopaedics, Bartlett, IL (KSP).,OhioHealth Research and Innovation Institute, Columbus, Ohio (CLC)
| | - Kyle S Peterson
- Atlantic Foot & Ankle Center, Chesapeake, Virginia (MAP).,Orthopedic Foot & Ankle Center, Westerville, Ohio (PEB, GCB, CFH).,The CORE Institute, Phoenix, AZ (RTS).,Decatur Orthopaedic Clinic, Decatur, Alabama (JLD).,Suburban Orthopaedics, Bartlett, IL (KSP).,OhioHealth Research and Innovation Institute, Columbus, Ohio (CLC)
| | - Christy L Collins
- Atlantic Foot & Ankle Center, Chesapeake, Virginia (MAP).,Orthopedic Foot & Ankle Center, Westerville, Ohio (PEB, GCB, CFH).,The CORE Institute, Phoenix, AZ (RTS).,Decatur Orthopaedic Clinic, Decatur, Alabama (JLD).,Suburban Orthopaedics, Bartlett, IL (KSP).,OhioHealth Research and Innovation Institute, Columbus, Ohio (CLC)
| | - Christopher F Hyer
- Atlantic Foot & Ankle Center, Chesapeake, Virginia (MAP).,Orthopedic Foot & Ankle Center, Westerville, Ohio (PEB, GCB, CFH).,The CORE Institute, Phoenix, AZ (RTS).,Decatur Orthopaedic Clinic, Decatur, Alabama (JLD).,Suburban Orthopaedics, Bartlett, IL (KSP).,OhioHealth Research and Innovation Institute, Columbus, Ohio (CLC)
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