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Baker JD, Schroeder P, Kimbler T, Huh J. Reaming for Tibiotalocalcaneal Nailing Removes Only 10% of the Ankle and Subtalar Joints. J Orthop Trauma 2024; 38:210-214. [PMID: 38163916 DOI: 10.1097/bot.0000000000002754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES Tibiotalocalcaneal (TTC) nailing in the setting of acute ankle trauma has become increasingly popular. No consensus exists as to whether formal joint preparation is necessary, although there is some concern that residual motion at unprepared joints may lead to implant loosening and/or breakage. The objective of this study was to quantify the proportion of tibiotalar and subtalar articular surface destruction that occurs during reaming for TTC nail fixation. METHODS Twelve cadaver lower extremities were procured. The specimens were pinned into neutral ankle and hindfoot alignment. A guidewire was inserted under fluoroscopy, followed by a 12-mm opening reamer. The specimens were then dissected, exposing the tibial plafond, talar dome, posterior facet of the talus, and posterior facet of the calcaneus. Images of each joint were obtained, and ImageJ software was used to calculate the total joint surface area and the area of articular destruction. RESULTS The mean proportion of articular cartilage destruction was 9.3%, 10.3%, 8.9%, and 10.3% for the tibial plafond, talar dome, posterior facets of the talus, and posterior facets of the calcaneus, respectively. No joint destruction was observed in the middle facets of the subtalar joint. CONCLUSIONS Reaming for TTC nail placement violates approximately 10% of each articular surface of the tibiotalar and subtalar joints. Retention of 90% of the articular surface may allow for residual motion at the joints and therefore potentially substantial stress on the implant. Formal joint preparation for the purposes of achieving fusion during TTC nail placement may be beneficial to prevent implant loosening or breakage.
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Affiliation(s)
- James D Baker
- Department of Orthopaedic Surgery, Brooke Army Medical Center, San Antonio, TX
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2
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Donaghue P. Radiographical outcomes of a cellular based allograft following foot/ankle arthrodesis in patients with risk for non-union. Orthop Rev (Pavia) 2024; 16:115603. [PMID: 38562146 PMCID: PMC10984644 DOI: 10.52965/001c.115603] [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: 06/06/2023] [Accepted: 02/05/2024] [Indexed: 04/04/2024] Open
Abstract
Morbidity associated with autograft harvest has led to the need for alternative bone grafts during fusion surgical procedures. The purpose of this study is to evaluate the efficacy of a cellular bone allograft (CBA) in patients who underwent foot/ankle fusion surgery. Retrospective data of patients who underwent foot/ankle arthrodesis using a CBA between XXXX and XXXX were collected from a single site. Patients were at least 18 years of age at the time of surgery and had ankle/foot surgery with Trinity ELITE CBA as the primary or only bone graft. Patients' radiographic union was assessed at three (3) months, six (6) months, nine (9) months, and twelve (12) months. Twenty-two (22) patients and 29 joints were evaluated. The mean age and BMI of the cohort were 54±9yrs and 30.5±6kg/m2, respectively. The surgical indications were degenerative joint diseases, trauma, and arthritis. All patients except one had at least one risk factor for non-union. At 12 months, 21 of the 22 patients (95%) attained successful fusion with an average time of 6 months. In addition, there was a 100% fusion among patients with prior failed fusion, nicotine use, diabetes, neuropathy, and osteoporosis. There was no significant difference in time to fusion between patients with non-union risk factor(s) ≤ 1 and ≥ 2 (p=0.71). No complication or adverse event was reported following the surgery. The use of CBA resulted in high fusion among patients with the risk of non-union. CBA is a viable bone graft substitute for autograft in foot/ankle arthrodesis procedures.
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Labmayr V, Huber E, Wenzel-Schwarz F, Holweg P, Ornig M, Jakob G, Palle W, Borchert GH, Pastl K. Non-Union Treatment in the Foot, Ankle, and Lower Leg: A Multicenter Retrospective Study Comparing Conventional Treatment with the Human Allogeneic Cortical Bone Screw (Shark Screw ®). J Pers Med 2024; 14:352. [PMID: 38672979 PMCID: PMC11051244 DOI: 10.3390/jpm14040352] [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: 03/01/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Addressing non-unions involves stabilizing the affected area through osteosynthesis and improving bone biology using bone grafts. However, there is no consensus on the optimal treatment method. This study aims to compare outcomes of non-union surgery using conventional treatment methods (metal hardware ± graft) versus osteosynthesis with the human allogeneic cortical bone screw (Shark Screw®) alone or in combination with a metallic plate. Thirty-four patients underwent conventional treatment, while twenty-eight cases received one or more Shark Screws®. Patient demographics, bone healing, time to bone healing, and complications were assessed. Results revealed a healing rate of 96.4% for the Shark Screw® group, compared to 82.3% for the conventionally treated group. The Shark Screw® group exhibited a tendency for faster bone healing (9.4 ± 3.2 vs. 12.9 ± 8.5 weeks, p = 0.05061). Hardware irritations led to six metal removals in the conventional group versus two in the Shark Screw® group. The Shark Screw® emerges as a promising option for personalized non-union treatment in the foot, ankle, and select lower leg cases, facilitating effective osteosynthesis and grafting within a single construct and promoting high union rates, low complications, and a rapid healing process.
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Affiliation(s)
- Viktor Labmayr
- Department of Orthopaedics and Trauma, Medical University Graz, Auenbruggerplatz 5, A-8036 Graz, Austria; (P.H.); (M.O.)
| | - Elisabeth Huber
- DOKH Friesach, St Veit Str. 12, A-9360 Friesach, Austria; (E.H.); (W.P.)
| | | | - Patrick Holweg
- Department of Orthopaedics and Trauma, Medical University Graz, Auenbruggerplatz 5, A-8036 Graz, Austria; (P.H.); (M.O.)
| | - Martin Ornig
- Department of Orthopaedics and Trauma, Medical University Graz, Auenbruggerplatz 5, A-8036 Graz, Austria; (P.H.); (M.O.)
| | - Gerd Jakob
- Landeskrankenhaus Villach, Nikolaigasse 43, A-9500 Villach, Austria;
| | - Wolfgang Palle
- DOKH Friesach, St Veit Str. 12, A-9360 Friesach, Austria; (E.H.); (W.P.)
| | - Gudrun H. Borchert
- Dr. Borchert Medical Information Management, Egelsbacher Str. 39e, D-63225 Langen, Germany;
| | - Klaus Pastl
- Klinik Diakonissen Linz, Weißenwolffstraße 13, A-4020 Linz, Austria;
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Elattar O, Christophersen CM, Farber D. Pain and Complications Following Bone Marrow Aspirate Concentrate Harvested From the Iliac Crest in Foot and Ankle Surgery. Foot Ankle Spec 2024; 17:23-28. [PMID: 34142581 DOI: 10.1177/19386400211017379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Autologous bone graft is the gold standard in orthopedics, with the iliac crest the most common harvest site. In an attempt to minimize morbidity with open bone graft harvest from the iliac crest and still maintain the benefit of collecting and transplanting live cells and growth factors, bone marrow aspirate concentrate (BMAC) from the iliac crest has become increasingly popular. However, any harvest procedure can potentially cause pain and complications. The purpose of this study was to evaluate the safety and complications of BMAC from the iliac crest for use in foot and ankle fusion procedures. METHODS A retrospective chart review was performed on all patients who underwent BMAC harvest from the iliac crest with their foot or ankle procedure by 1 of 4 fellowship-trained surgeons (2014-2017) with a minimum of 6-month follow-up. Patients were evaluated for complications, pain, and functional limitation secondary to the harvest. The final outcome follow-up was conducted using a specifically designed telephone questionnaire to assess patient satisfaction. A total of 55 patients were included, with a median age of 58 years (range 31-81 years) and 69% were women. RESULTS Out of 55 patients, 52 (94.5%) reported good to excellent results, and satisfaction with the procedure at the time of the questionnaire. Three patients reported persistent complications and some element of dissatisfaction after 6 months. Some patients reported transient complications (hematomas and numbness) that eventually resolved. Fifty percent of patients reported some element of immediate post-operative pain. However, at the time of final follow-up, only 2 reported persistent pain at the harvest site lasting up to 6 months, but it was not activity limiting. CONCLUSION BMAC harvest is a safe procedure with a high rate of patient satisfaction and minimal morbidity. LEVELS OF EVIDENCE Level IV: Case series.
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Affiliation(s)
- Osama Elattar
- Clinical Orthopedic Surgery, University of Toledo, Toledo, Ohio
| | | | - Daniel Farber
- Clinical Orthopedic Surgery, University of Pennsylvania Medicine, Philadelphia, Pennsylvania
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Rao NM, Ligas C. The Ankle Joint: Revision Ankle Fusion Options, Nonunion, Malunion, Protocol for Best Outcome. Clin Podiatr Med Surg 2023; 40:703-710. [PMID: 37716746 DOI: 10.1016/j.cpm.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Ankle arthrodesis has been a time-tested procedure for osteoarthritis, avascular necrosis of the talus, deformity correction, and significant trauma of the ankle. Technique guides have created dissection pearls, ease of fixation, and arthroscopic techniques to mitigate complications of the procedure. Major complications, such as nonunion, malunion, or implant infection are the most worrisome and cumbersome complications to handle. The aim of this article is to provide the practicing surgeon evidence to provide innovative management techniques for nonunion, malunion, and infection following primary ankle arthrodesis.
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Affiliation(s)
- Nilin M Rao
- Foot Specialists of Austin, 1600 West 38th Street, #210, Austin, TX, USA.
| | - Chandler Ligas
- Podiatric Surgery, Silicon Valley Reconstructive Foot and Ankle Fellowship- Palo Alto Medical Foundation, 701 E El Camino Real 1st Floor, Mountain View, CA 94040, USA; Sunnyvale, CA, USA
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Loveland JD. A retrospective review of recombinant human platelet-derived growth factor with beta-tricalcium phosphate bone graft substitute use in hindfoot and/or ankle arthrodesis. J Orthop 2023; 44:93-98. [PMID: 37727282 PMCID: PMC10505666 DOI: 10.1016/j.jor.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023] Open
Abstract
Background Nonunion following foot and ankle arthrodesis can cause chronic pain and disability, poor patient satisfaction, and increased healthcare costs. Nonunion rates are reported in 10%-12% of primary foot and/or ankle arthrodesis procedures, with significantly greater rates among patients with high-risk factors such as smoking, diabetes, obesity, or Charcot neuroarthropathy. Recombinant human platelet-derived growth factor BB-homodimer with beta-tricalcium phosphate (rhPDGF-BB/β-TCP) is a bone graft substitute that has demonstrated efficacy in foot and ankle fusion rates that are comparable to autograft. Methods Charts and radiographs were retrospectively reviewed on consecutive adult patients undergoing talonavicular, calcaneal-cuboid, subtalar, and/or ankle arthrodesis utilizing rhPDGF-BB/β-TCP bone graft substitute. The primary outcome measures were rate of and mean time to fusion, mean time to return to function, and incidence of adverse events. Results This study reviewed133 patients who underwent 209 hindfoot and/or ankle joint arthrodesis procedures with a mean follow-up 20.34 ± 11.05 months. The overall fusion rate was 92.82% (194/209 joints) with a mean time to fusion of 13.14 ± 2.52 weeks and return to function of 16.56 ± 3.26 weeks. Overall, there were 7 (5.26%) patients who experienced an adverse event (AE) with 15 (7.18%) joints experiencing a nonunion. Conclusion Fusion rates with rhPDGF-BB/β-TCP bone grafting material compared favorably to autograft controls when used in hindfoot and/or ankle arthrodesis. No AEwas related to rhPDGF-BB/β-TCP. This study suggests that using rhPDGF-BB/β-TCP is effective in hindfoot and/or ankle arthrodesis, even among patients with comorbidities who are at a higher risk of developing a nonunion. Level of clinical evidence 3.
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Affiliation(s)
- Jeffrey D. Loveland
- Central Tennessee Foot and Ankle Center, 415 Sewell Road, Sparta, TN, 38583, USA
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Roth W, Hoch C, Gross CE, Scott DJ. First metatarsophalangeal arthrodesis outcomes for hallux rigidus versus hallux valgus. Foot Ankle Surg 2023; 29:50-55. [PMID: 36210270 DOI: 10.1016/j.fas.2022.09.003] [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: 05/18/2022] [Revised: 08/04/2022] [Accepted: 09/14/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study compared radiographic and functional patient outcomes of 1st MTP arthrodesis between hallux rigidus (HR) and hallux valgus (HV) cohorts. METHODS A retrospective review was conducted at an academic medical center on patients who underwent 1st MTP arthrodesis during 2009-2021. In total, 136 patients (148 feet: HR=57, HV=47, combined=44) met the inclusion criteria of minimum three-month follow-up (mean=1.25 years, range=0.25-6.14 years). Data collection included patient-reported outcome measures (PROMs), radiographic markers, and complication and reoperation rates. RESULTS PROMs improved overall, with HV patients significantly improving the least. The HR group had a significantly smaller improvement in HV angle (HR=-3.6, HV=-17, Combined=-15 p < .001), intermetatarsal angle (H=-0.16, HV=-2.8, Combined=-2.6 p < .001), and 1st-5th metatarsal width (HR=-0.98, HV=-4.6, Combined=-4.6, p < .001). Complication and reoperation rates did not differ by group. CONCLUSION Outcomes of 1st MTP arthrodesis does not appear to differ between diagnostic indications of hallux rigidus, hallux valgus, or both. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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Affiliation(s)
- Warren Roth
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA
| | - Caroline Hoch
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA
| | - Christopher E Gross
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA
| | - Daniel J Scott
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA.
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Cardoso DV, Veljkovic A. General Considerations About Foot and Ankle Arthrodesis. Any Way to Improve Our Results? Foot Ankle Clin 2022; 27:701-722. [PMID: 36368793 DOI: 10.1016/j.fcl.2022.08.007] [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: 11/09/2022]
Abstract
Nonunion and adjacent joint osteoarthritis (OA) are known complications after a fusion procedure, and foot and ankle surgeons are commonly exposed to such disabling complications. Determining who is at risk of developing nonunion is essential to reducing nonunion rates and improving patient outcomes. Several evidenced-based modifiable risk factors related to adverse outcomes after foot and ankle arthrodesis have been identified. Patient-related risk factors that can be improved before surgery include smoking cessation, good diabetic control (HbAc1 <7%) and vitamin D supplementation. Intraoperatively, using less invasive techniques, avoiding joint preparation with power tools, using bone grafts or orthobiologics in more complex cases, high-risk patients, nonunion revision surgeries, and filling in bone voids at the arthrodesis site should be considered. Postoperatively, pain management with NSAIDs should be limited to a short period (<2 weeks) and avoided in high-risk patients. Furthermore, early postoperative weight-bearing has shown to be beneficial, and it does not seem to increase postoperative complications. The incidence of surrounding joint OA after foot and ankle fusion seems to increase progressively with time. Owing to its progression and high probability of being symptomatic, patients must be informed consequently, as they may require additional joint fusions, resulting in further loss of ankle/foot motion. In patients with symptomatic adjacent joint OA and unsatisfactory results after an ankle arthrodesis, conversion to total ankle arthroplasty (TAA) has become a potential option in managing these complex and challenging situations.
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Affiliation(s)
- Diogo Vieira Cardoso
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva 1205, Switzerland.
| | - Andrea Veljkovic
- Division of Orthopaedics and Trauma Surgery, British Columbia University, Vancouver, Canada
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Lee W, MacDonald J, Prat D, Chao W, Farber DC, Wapner KL. Midfoot Joint Arthrodesis Using Compression Plate With Lag Screw Augmenting With Highly Porous β-Tricalcium Phosphate and Bone Marrow Aspirate Concentrate. Foot Ankle Spec 2022:19386400221123630. [PMID: 36214330 DOI: 10.1177/19386400221123630] [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: 11/17/2022]
Abstract
BACKGROUND There is still a controversy regarding the most optimal fixation instruments and bone graft materials for midfoot joint arthrodesis. We present the results of midfoot joint arthrodesis using compression plate with lag screw augmenting with highly porous β-tricalcium phosphate (β-TCP) and bone marrow aspirate concentrate (BMAC). METHODS We performed a retrospective review of patients undergoing midfoot joint arthrodesis using compression plate with lag screw augmenting with highly porous β-TCP and BMAC from January 2014 to May 2019. The radiographic bony union rate was investigated. Postoperative complications and reoperations were also reviewed. A total of 36 patients (37 feet) including 75 joints were available in this study. RESULTS A high union rate was achieved as of 97.3% in 73 of 75 joints. Nonunion occurred in 2 patients including 2 joints. Other than nonunion, there were no major complications such as deep infection. Minor complications (5 of 75 joints, 6.7%) included hardware irritations. Reoperations were required in 1 patient for revision of arthrodesis and symptomatic hardware removal was performed in all 5 hardware irritation cases. CONCLUSION Based on our results, the fixation construct of compression plate with lag screw augmenting with highly porous β-TCP and BMAC is safe and effective for midfoot joint arthrodesis with an excellent union rate and a low complication rate. LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
- Wonyong Lee
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
- Department of Orthopaedic Surgery, Guthrie Medical Group, Sayre, Pennsylvania
| | - Justin MacDonald
- Department of Orthopaedic Surgery, Guthrie Medical Group, Sayre, Pennsylvania
| | - Dan Prat
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Wen Chao
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Daniel C Farber
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Keith L Wapner
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Does Demineralized Bone Matrix Affect the Nonunion Rate in Arthroscopic Ankle Arthrodesis? J Clin Med 2022; 11:jcm11133893. [PMID: 35807177 PMCID: PMC9267684 DOI: 10.3390/jcm11133893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/13/2022] [Accepted: 07/01/2022] [Indexed: 11/16/2022] Open
Abstract
Demineralized bone matrix (DBM) has been shown to have positive effects on union rates in many orthopedic subspecialties; however, minimal evidence exists about bone graft substitutes in foot and ankle surgery. The purpose of this study is to compare nonunion rates in arthroscopic ankle arthrodesis in patients receiving DBM with those without. We hypothesized DBM to be associated with a decreased risk of nonunion. This retrospective review includes 516 consecutive ankle arthrodesis cases from March 2002 to May 2016. Of these, 58 ankles (56 patients) that underwent primary arthroscopic ankle arthrodesis met the inclusion criteria, and 31 of these ankles received DBM, while 27 did not. Nonunion was assessed by clinical examination and routine postoperative radiographs. If nonunion was suspected, a computed tomography (CT) scan was performed. The primary outcome measure was nonunion rate. Secondary outcome measures included wound complications, return to operating room (OR), and rate of postoperative deep vein thrombosis (DVT) or pulmonary embolism (PE). From the study cases, 58 were available for final follow-up. The average age was 55.9 years (±17.4), and mean follow-up was 43.0 months (range 6.3–119.4). There was no difference in nonunion rate in patients who received DBM (4/31, 12.9%) versus those who did not (4/27, 14.8%) (p = 0.83). Similarly, when comparing the two groups, there were no statistically significant differences in superficial wound complications (6.5% vs. 3.7%, p = 1.0) or rate of return to OR (29% or 0.037/person-years vs. 37% or 0.099/person-years; p = 0.20). No major complications including deep wound infections, DVTs, or PEs occurred. This is the largest study to directly compare nonunion rates and complications for patients receiving DBM versus those who did not in primary arthroscopic ankle arthrodesis. No significant association was found between DBM usage and risk of nonunion, wound complications, return to OR, or postoperative DVT or PE development.
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11
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Shlykov MA, Savage-Elliott I, Lonergan TM, Klein SE, Backus JD, Johnson JE, McCormick JJ. Does the Canadian Orthopaedic Foot and Ankle Society Postoperative COFAS End-Stage Ankle Arthritis Classification System Correlate With Pre- and Postoperative PROMIS Scores for Total Ankle Arthroplasty? FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221084635. [PMID: 35321001 PMCID: PMC8935569 DOI: 10.1177/24730114221084635] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Recently, the Canadian Orthopaedic Foot and Ankle Society (COFAS) proposed a classification system addressing adjunct procedures in the treatment for end-stage ankle arthritis. We reviewed Patient-Reported Outcome Measures Information System (PROMIS) data to determine if outcomes of total ankle arthroplasty (TAA) correlated with postoperative COFAS classification. We hypothesize that as COFAS classification increases, patients will demonstrate greater improvement in the change between pre- and postoperative PROMIS scores. Methods: From June 2015 to December 2018, a total of 127 patients underwent 132 TAA. Demographic factors and preoperative and most recent postoperative PROMIS scores were collected. Univariate, multivariate and post hoc analyses with a significance threshold of P <.05 were performed. Results: Eighty-seven patients with a mean follow-up of 13.6±7.3 months and complete PROMIS scores were classified into COFAS types 1-4. Significant differences were identified in the PROMIS Pain Interference domain comparing COFAS types 2 and 4 and COFAS types 3 and 4. These results demonstrate that more complex ankles with a higher COFAS score had worse interval improvement in PROMIS scores. Additionally, multivariate linear regression showed that age and BMI were associated with worse physical function and depression, whereas diabetes and a history of prior surgeries were associated with improved postoperative function. Conclusion: The COFAS postoperative classification system is useful for categorizing end-stage ankle arthritis. Further research into the ideal timing of surgery and higher-level studies to better determine TAA efficacy with different classification systems is warranted. This information can be helpful with preoperative counseling about treatment outcomes. Level of Evidence: Level IV, retrospective analysis of prospectively collected data.
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Affiliation(s)
- Maksim A. Shlykov
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Ian Savage-Elliott
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, MO, USA
| | | | - Sandra E. Klein
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Jonathon D. Backus
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Jeffrey E. Johnson
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Jeremy J. McCormick
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, MO, USA
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Loveland JD, McMillen RL, Cala MA. A Multicenter, Retrospective, Case Series of Patients With Charcot Neuroarthropathy Deformities Undergoing Arthrodesis Utilizing Recombinant Human Platelet-derived Growth Factor With Beta-Tricalcium Phosphate. J Foot Ankle Surg 2021; 60:74-79. [PMID: 33158722 DOI: 10.1053/j.jfas.2020.08.030] [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: 10/01/2019] [Revised: 05/20/2020] [Accepted: 08/31/2020] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy has traditionally been treated using both nonsurgical and surgical strategies. Recently, orthobiologics have been used to promote arthrodesis in Charcot reconstructions, obviating the need for bone graft in some cases. Recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) in combination with beta-tricalcium phosphate scaffold (β-TCP) is a bone graft substitute shown to have comparable efficacy to autograft in incidence of foot and ankle fusion. This multicenter, consecutive case series analyzed patients undergoing Charcot reconstructions utilizing rhPDGF-BB/β-TCP for joint fusion. In this cohort, 98 patients (62.24% male) with a mean age of 62.82 ± 10.28 years (range 40-87) had a fusion incidence of 217 of 223 joints (97.31%) with a mean time to fusion of 13.09 ± 4.87 weeks (range 6-30). There were 6 nonunions in the patient population. Fusion was defined as ≥50% osseous bridging based on computed tomography and/or radiographic consolidation, in addition to clinical findings. With an overall complication rate of 26.53% (26/98), adverse events occurring in more than 1 patient limb included hardware failures (n = 7, 7.14%), infection (n = 4, 4.08%), wound dehiscence (n = 4, 4.08%), amputation (n = 3, 3.06%), and death (n = 2, 2.04%). There were no adverse events related to the grafting material. From this review, we found rhPDGF-BB/β-TCP to be a safe and effective graft material that can be considered a viable alternative to autograft, even in high-risk patients such as those with Charcot neuroarthropathy.
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Affiliation(s)
- Jeffrey D Loveland
- Foot and Ankle Surgeon, Central Tennessee Foot and Ankle Center, Sparta, TN.
| | - Ryan L McMillen
- Foot and Ankle Surgeon, Allegheny Health Network, Pittsburgh, PA
| | - Mario A Cala
- Foot and Ankle Surgeon, PerfectFeetCare Podiatry Centers, Miami, FL
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13
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Shibuya N, McAlister JE, Prissel MA, Piraino JA, Joseph RM, Theodoulou MH, Jupiter DC. Consensus Statement of the American College of Foot and Ankle Surgeons: Diagnosis and Treatment of Ankle Arthritis. J Foot Ankle Surg 2021; 59:1019-1031. [PMID: 32778440 DOI: 10.1053/j.jfas.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/20/2019] [Indexed: 02/03/2023]
Affiliation(s)
- Naohiro Shibuya
- Professor, College of Medicine, Texas A&M University, Temple, TX.
| | | | - Mark A Prissel
- Faculty, Advanced Foot and Ankle Reconstruction Fellowship Program, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Jason A Piraino
- Associate Professor, Department of Orthopaedic Surgery and Rehabilitation, University of Florida Health, Gainesville, FL
| | - Robert M Joseph
- Chairman, Department of Podiatric Medicine & Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University, North Chicago, IL
| | - Michael H Theodoulou
- Chief, Division of Podiatric Surgery, Cambridge Health Alliance, Instructor of Surgery, Harvard Medical School, Cambridge, MA
| | - Daniel C Jupiter
- Associate Professor, Department of Preventive Medicine and Community, Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX
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Reeves CL, Shane AM, Sahli H, Togher C. Revision of the Malaligned Ankle Arthrodesis. Clin Podiatr Med Surg 2020; 37:475-487. [PMID: 32471613 DOI: 10.1016/j.cpm.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A malaligned ankle arthrodesis is a painful and complicated pathology. Deformities may be present in the frontal, sagittal, or transverse plane or a combination of planes. Thorough preoperative evaluation of the deformity and the patient as a whole is crucial to successful revision. Surgical site for revision should be based on center of rotation of angulation, when possible. Revision commonly is performed through opening wedge osteotomy. Closing wedge and focal dome osteotomies, however, are excellent options. Revision also may be performed through external fixation or total ankle replacement. Although the literature is not rich with data, the options discussed provide favorable results.
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Affiliation(s)
- Christopher L Reeves
- Advent Health East Orlando Podiatric Surgery Residency, Orlando Foot and Ankle Clinic- Upperline Health, 2111 Glenwood Drive Suite 104, Winter Park, FL 32792, USA.
| | - Amber M Shane
- Department of Podiatric Surgery Advent Health System, Advent Health East Orlando Podiatric Surgery Residency, Orlando Foot and Ankle Clinic- Upperline Health, 250 North Alafaya Trail Suite 115, Orlando, FL 32828, USA
| | - Hannah Sahli
- Department of Podiatric Surgery AdventHealth System, Orlando, FL, USA
| | - Cody Togher
- Department of Podiatric Surgery AdventHealth System, Orlando, FL, USA
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15
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Abstract
Union rates vary for arthrodesis sites and bone healing in foot and ankle surgery. The ultimate goal is to achieve complete bone healing within a reasonable time. There are many factors that surgeons cannot control, such as the patient's compliance and ability to heal. However, surgeons can control osseous preparation, stable fixation, preservation of soft tissue, and the osseous fusion initial healing environment. Modification of the healing environment can be achieved with the use of bone graft and orthobiologics. This article discusses the grafts and orthobiologics that can be used in bone healing for the foot and ankle.
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Affiliation(s)
- Sean T Grambart
- Des Moines University, College of Podiatric Medicine and Surgery, 3200 Grand Avenue, Des Moines, IA 50312, USA; Unitypoint Health - Iowa Methodist Medical Center, 1200 Pleasant Street, Des Moines, IA 50309, USA.
| | - Danika S Anderson
- Des Moines University, College of Podiatric Medicine and Surgery, 3200 Grand Avenue, Des Moines, IA 50312, USA
| | - Travis Drew Anderson
- Des Moines University, College of Podiatric Medicine and Surgery, 3200 Grand Avenue, Des Moines, IA 50312, USA
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16
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Koolen M, Amin Yavari S, Lietaert K, Wauthle R, Zadpoor AA, Weinans H. Bone Regeneration in Critical-Sized Bone Defects Treated with Additively Manufactured Porous Metallic Biomaterials: The Effects of Inelastic Mechanical Properties. MATERIALS 2020; 13:ma13081992. [PMID: 32344664 PMCID: PMC7215733 DOI: 10.3390/ma13081992] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/15/2020] [Accepted: 04/21/2020] [Indexed: 02/05/2023]
Abstract
Additively manufactured (AM) porous metallic biomaterials, in general, and AM porous titanium, in particular, have recently emerged as promising candidates for bone substitution. The porous design of such materials allows for mimicking the elastic mechanical properties of native bone tissue and showed to be effective in improving bone regeneration. It is, however, not clear what role the other mechanical properties of the bulk material such as ductility play in the performance of such biomaterials. In this study, we compared the bone tissue regeneration performance of AM porous biomaterials made from the commonly used titanium alloy Ti6Al4V-ELI with that of commercially pure titanium (CP-Ti). CP-Ti was selected because of its high ductility as compared to Ti6Al4V-ELI. Critical-sized (6 mm diameter) femoral defects in rats were treated with implants made from both Ti6Al4V-ELI and CP-Ti. Bone regeneration was assessed up to 11 weeks using micro-CT scanning. The regenerated bone volume was assessed ex vivo followed by histology and biomechanical testing to assess osseointegration of the implants. The bony defects treated with AM CP-Ti implants generally showed higher volumes of regenerated bone as compared to those treated with AM Ti6Al4V-ELI. The torsional strength of the two titanium groups were similar however, and both considerably lower than those measured for intact bony tissue. These findings show the importance of material type and ductility of the bulk material in the ability for bone tissue regeneration of AM porous biomaterials.
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Affiliation(s)
- Marianne Koolen
- Department of Orthopaedics, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Saber Amin Yavari
- Department of Orthopaedics, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Karel Lietaert
- 3D Systems Healthcare, 3D Systems Leuven, 3001 Leuven, Belgium
| | - Ruben Wauthle
- 3D Systems Healthcare, 3D Systems Leuven, 3001 Leuven, Belgium
| | - Amir A Zadpoor
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, 2628 CN Delft, The Netherlands
| | - Harrie Weinans
- Department of Orthopaedics, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, 2628 CN Delft, The Netherlands
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17
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Pitts C, Alexander B, Washington J, Barranco H, Patel R, McGwin G, Shah AB. Factors affecting the outcomes of tibiotalocalcaneal fusion. Bone Joint J 2020; 102-B:345-351. [DOI: 10.1302/0301-620x.102b3.bjj-2019-1325.r1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Tibiotalocalcaneal (TTC) fusion is used to treat a variety of conditions affecting the ankle and subtalar joint, including osteoarthritis (OA), Charcot arthropathy, avascular necrosis (AVN) of the talus, failed total ankle arthroplasty, and severe deformity. The prevalence of postoperative complications remains high due to the complexity of hindfoot disease seen in these patients. The aim of this study was to analyze the relationship between preoperative conditions and postoperative complications in order to predict the outcome following primary TTC fusion. Methods We retrospectively reviewed the medical records of 101 patients who underwent TTC fusion at the same institution between 2011 and 2019. Risk ratios (RRs) associated with age, sex, diabetes, cardiovascular disease, smoking, preoperative ankle deformity, and the use of bone graft during surgery were related to the postoperative complications. We determined from these data which pre- and perioperative factors significantly affected the outcome. Results Out of the 101 patients included in the study, 29 (28.7%) had nonunion, five (4.9%) required below-knee amputation (BKA), 40 (39.6%) returned to the operating theatre, 16 (15.8%) had hardware failure, and 22 (21.8%) had a postoperative infection. Patients with a preoperative diagnosis of Charcot arthropathy and non-traumatic OA had significantly higher nonunion rates of 44.4% (12 patients) and 39.1% (18 patients) (p = 0.016) and infection rates of 29.6% (eight patients) and 37% (17 patients) compared to patients with traumatic arthritis, respectively (p = 0.002). There was a significantly increased rate of nonunion in diabetic patients (RR 2.22; p = 0.010). Patients with chronic kidney disease were 2.37-times more likely to have a nonunion (p = 0.006). Patients aged over 60 years had more than a three-fold increase in the rate of postoperative infection (RR 3.60; p = 0.006). The use of bone graft appeared to be significantly protective against postoperative infection (p = 0.019). Conclusion We were able to confirm, in the largest series of TTC ankle fusions currently in the literature, that there remains a high rate of complications following this procedure. We found that patients with a Charcot or non-traumatic arthropathy had an increased risk of nonunion and postoperative infection compared to individuals with traumatic arthritis. Those with diabetes, chronic kidney disease, or aged over 60 years had an increased risk of nonunion. These findings help to confirm those of previous studies. Additionally, our study adds to the literature by showing that autologous bone graft may help in decreasing infection rates. These data can be useful to surgeons and patients when considering, discussing and planning TTC fusion. It helps surgeons further understand which patients are at a higher risk for postoperative complications when undergoing TTC fusion. Cite this article: Bone Joint J. 2020;102-B(3):345–351.
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Affiliation(s)
- Charles Pitts
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Bradley Alexander
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joshua Washington
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hannah Barranco
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Romil Patel
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gerald McGwin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ashish B. Shah
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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18
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Peterson JR, Chen F, Nwankwo E, Dekker TJ, Adams SB. The Use of Bone Grafts, Bone Graft Substitutes, and Orthobiologics for Osseous Healing in Foot and Ankle Surgery. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419849019. [PMID: 35097327 PMCID: PMC8500392 DOI: 10.1177/2473011419849019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Achieving fusion in osseous procedures about the foot and ankle presents unique challenges to the surgeon. Many patients have comorbidities that reduce osseous healing rates, and the limited space and high weightbearing demand placed on fusion sites makes the choice of bone graft, bone graft substitute, or orthobiologic agent of utmost importance. In this review, we discuss the essential characteristics of grafts, including their osteoconductive, osteoinductive, osteogenic, and angiogenic properties. Autologous bone graft remains the gold standard and contains all these properties. However, the convenience and lack of donor site morbidity of synthetic bone grafts, allografts, and orthobiologics, including growth factors and allogenic stem cells, has led to these being used commonly as augments.
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Affiliation(s)
- Jonathan R. Peterson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Fangyu Chen
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Eugene Nwankwo
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Travis J. Dekker
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samuel B. Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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19
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Gaul F, Barr CR, McCauley JC, Copp SN, Bugbee WD. Outcomes of Salvage Arthrodesis and Arthroplasty for Failed Osteochondral Allograft Transplantation of the Ankle. Foot Ankle Int 2019; 40:537-544. [PMID: 30698469 DOI: 10.1177/1071100718824082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Osteochondral allograft (OCA) transplantation is a useful treatment for posttraumatic ankle arthritis in young patients, but failure rates are high and reoperations are not uncommon. The aim of this study was to evaluate the outcomes of failed ankle OCA transplantation converted to ankle arthrodesis (AA) or total ankle arthroplasty (TAA). METHODS We evaluated 24 patients who underwent salvage procedures (13 AA and 11 TAA) after primary failed ankle OCA transplantation. Reoperations were assessed. Failure of the salvage procedure was defined as an additional surgery that required a revision AA/TAA or amputation. Evaluation among nonfailing ankles included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM), pain, and satisfaction. RESULTS In the salvage AA cohort, 3 patients were classified as failures (2 revision AA and 1 amputation). The 10 nonfailing patients had a mean follow-up of 7.4 years. Eighty-eight percent were satisfied with the procedure, but 63% reported continued problems with their ankle (eg, pain, swelling, stiffness). Mean pain level was 1.9 and AAOS-FAM core score was 83±13. In the salvage TAA cohort, 2 patients were classified as failures (both revision TAA). The 9 nonfailing patients had a mean follow-up of 3.8 years. Fifty percent were satisfied with the procedure, but 40% reported continued problems with their ankle. The mean pain level was 1.3, and the median AAOS-FAM core score was 82±26. CONCLUSION Revision and reoperation rates for salvage procedures following failed OCA transplantation of the ankle are higher compared to published data for primary AA and TAA procedures. However, we believe OCA transplantation can serve as an interim procedure for younger patients with advanced ankle joint disease who may not be ideal candidates for primary AA or TAA at the time of initial presentation. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Florian Gaul
- 1 Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA
- 2 Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
- 4 Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Germany
| | - Cameron R Barr
- 3 Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Julie C McCauley
- 1 Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA
| | - Steven N Copp
- 3 Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - William D Bugbee
- 1 Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA
- 3 Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
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20
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Karthas TA, Cook JJ, Matthews MR, Sganga ML, Hansen DD, Collier B, Basile P, Cook EA. Development and Validation of the Foot Union Scoring Evaluation Tool for Arthrodesis of Foot Structures. J Foot Ankle Surg 2018; 57:675-680. [PMID: 29661672 DOI: 10.1053/j.jfas.2017.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Indexed: 02/03/2023]
Abstract
Reliable evaluation of osseous consolidation after pedal arthrodesis can be difficult, and the presence or absence of radiographic healing often dictates care. Plain radiographs remain the mainstay imaging tool owing to their cost, efficiency, and low radiation exposure. Applying radiographic parameters that can reliably determine osseous healing is essential. However, currently, no reliable or validated measures are available to determine osseous union of any joint in the foot or ankle. The purpose of the present study was to develop a radiographic healing scoring system that would enhance the diagnostic healing assessment after joint arthrodesis of the foot or ankle. We adapted several existing scales previously validated for fracture healing in the leg, because no study has attempted to apply this to a joint fusion model. A total of 150 cases were evaluated by 6 blinded assessors to test the interrater reliability of the subjective healing assessment compared with the proposed scoring system. The radiographs were classified by the postoperative period: ≤4 weeks, 5 to 12 weeks, and >12 weeks. The initial proposed scale was found to have high interrater reliability but was burdensome. Using a priori item reduction protocols, a limited 5-item scale further improved the internal consistency and reduced the burden. The result was excellent interrater reliability (α = 0.978, standard deviation 0.02, 95% confidence interval 0.96 to 0.99) among all assessors compared with the reduced reliability (α = 0.752) for subjective arthrodesis healing. Intrarater reliability was also found to be superior using a test-retest method. The reliability of this system appeared superior to the subjective assessment of arthrodesis healing, even in the absence of clinical correlates, after foot arthrodesis.
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Affiliation(s)
- Timothy A Karthas
- Chief Resident, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA; Clinical Fellow, Department of Surgery, Harvard Medical School, Boston, MA.
| | - Jeremy J Cook
- Instructor, Department of Surgery, Harvard Medical School, Boston, MA; Director of Research and Quality Assurance, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA
| | - Michael R Matthews
- Chief Resident, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA; Clinical Fellow, Department of Surgery, Harvard Medical School, Boston, MA
| | - Michael L Sganga
- Clinical Fellow, Department of Surgery, Harvard Medical School, Boston, MA
| | - Daniel D Hansen
- Clinical Fellow, Department of Surgery, Harvard Medical School, Boston, MA
| | - Byron Collier
- Clinical Fellow, Department of Surgery, Harvard Medical School, Boston, MA
| | - Philip Basile
- Instructor, Department of Surgery, Harvard Medical School, Boston, MA; Chief, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA
| | - Emily A Cook
- Instructor, Department of Surgery, Harvard Medical School, Boston, MA; Director of Resident Training, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA
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21
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Cottom JM, Plemmons BS. Bone Marrow Aspirate Concentrate and Its Uses in the Foot and Ankle. Clin Podiatr Med Surg 2018; 35:19-26. [PMID: 29156164 DOI: 10.1016/j.cpm.2017.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Bone marrow aspirate has been used for the adjunctive treatment of numerous pathologic conditions in orthopedics. Viable cells are found in aspiration from many different anatomic regions of the body. Concentration of these cells has been shown to improve healing due to the increased number of certain important cells. This article discusses the mechanisms involved and reviews the literature.
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Affiliation(s)
- James M Cottom
- Florida Orthopedic Foot & Ankle Center, 2030 Bee Ridge Road, Suite B, Sarasota, FL 34239, USA.
| | - Britton S Plemmons
- Florida Orthopedic Foot & Ankle Center, 2030 Bee Ridge Road, Suite B, Sarasota, FL 34239, USA
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22
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Salvage of failed ankle arthrodesis after posttraumatic septic arthritis by Ilizarov external fixator: mid-term results. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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23
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Ramanujam CL, Stapleton JJ, Zgonis T. Operative Fixation Options for Elective and Diabetic Ankle Arthrodesis. Clin Podiatr Med Surg 2017; 34:347-355. [PMID: 28576194 DOI: 10.1016/j.cpm.2017.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Ankle arthrodesis remains one of the most definitive treatment options for end-stage arthritis, paralysis, posttraumatic and postinfectious conditions, failed total ankle arthroplasty, and severe deformities. The general aims of ankle arthrodesis are to decrease pain and instability, correct the accompanying deformity, and create a stable plantigrade foot. Several surgical approaches have been reported for ankle arthrodesis with internal fixation options. External fixation has also evolved for ankle arthrodesis in certain clinical scenarios. This article provides a comprehensive analysis of midterm to long-term outcomes for ankle arthrodesis using internal and/or external fixation each for elective and diabetic conditions.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, MSC 7776, San Antonio, TX 78229, USA
| | - John J Stapleton
- Foot and Ankle Surgery, Lehigh Valley Hospital, 1250 South Cedar Crest Boulevard, Suite 110, Allentown, PA 18103, USA; Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA.
| | - Thomas Zgonis
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, MSC 7776, San Antonio, TX 78229, USA
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24
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Yeoh JC, Taylor BA. Osseous Healing in Foot and Ankle Surgery with Autograft, Allograft, and Other Orthobiologics. Orthop Clin North Am 2017; 48:359-369. [PMID: 28577785 DOI: 10.1016/j.ocl.2017.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the surgical treatment of foot and ankle abnormality, many problems require bone grafting for successful osseous union. Nonunion, reconstruction, and arthrodesis procedures pose specific challenges due to bony defects secondary to trauma, malunions, or previous surgery. Nonunion in foot and ankle arthrodesis is a significant risk and is well documented in recent literature. This article is a review of the recent literature regarding the use of bone graft and orthobiologics in foot and ankle surgery.
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Affiliation(s)
- Jane C Yeoh
- Campbell Clinic Foot & Ankle Department, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Brandon A Taylor
- Campbell Clinic Foot & Ankle Department, 1400 South Germantown Road, Germantown, TN 38138, USA.
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25
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Abstract
Reoperation rates are higher in total ankle arthroplasties (TAAs) compared with ankle arthrodesis. Infection rates for primary TAAs are 1.4% to 2.4%. The survival rate of TAA is approximately 75% to 90% at 10 years. Arc of motion is maintained with TAAs compared with ankle arthrodesis. Ankle arthrodesis increases arc of motion through the talonavicular joint. Several factors are strong reasons to favor ankle fusion rather than TAA. TAA and ankle arthrodesis are effective treatments of end-stage ankle arthritis but the choice must be tailored to individual patients.
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Affiliation(s)
- Joel Morash
- QE2 Health Science Center, Halifax Infirmary (Room 4867), 1796 Summer Street, Halifax, Nova Scotia B3H 3A7, Canada.
| | - David M Walton
- Beaumont Orthopedics, Michigan Orthopedic Institute, Royal Oak, MI 21601, USA
| | - Mark Glazebrook
- QE2 Health Science Center, Halifax Infirmary (Room 4867), 1796 Summer Street, Halifax, Nova Scotia B3H 3A7, Canada
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Dekker TJ, White P, Adams SB. Efficacy of a Cellular Bone Allograft for Foot and Ankle Arthrodesis and Revision Nonunion Procedures. Foot Ankle Int 2017; 38:277-282. [PMID: 27923216 DOI: 10.1177/1071100716674977] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Bone graft substitutes are often required in patients at risk for nonunion, and therefore, an allograft that most closely mimics an autograft is highly sought after. This study explored the utility and efficacy of a cellular bone allograft used for foot and ankle arthrodesis and revision nonunion procedures in a patient population at risk for nonunion. METHODS An institutional review board-approved retrospective review of consecutive patients who underwent arthrodesis and revision nonunion procedures with a cellular bone allograft was performed at a single academic institution. No external sources of funding were provided for this study. Inclusion criteria included patients who were more than 1 year after surgery or less than 1 year after surgery if they had undergone a second operative procedure for nonunion or if they had computed tomography-documented union. Forty operative procedures in 36 patients with a mean follow-up of 13 months (range, 6-25 months) were included for data analysis. All patients had at least one of the following risk factors associated with nonunion: current smoker, diabetes, avascular necrosis (AVN) of the involved bone, active same-site operative infection, history of nonunion, previous same-site surgery, or gap of 5 mm or greater after joint preparation. The primary outcome was radiographic union. RESULTS The union rate in this high-risk population was 83% (33/40). Univariate analysis demonstrated that the use of a cellular bone allograft helped mitigate the presence of risk factors known to cause nonunion. There was no significant difference in fusion rates among groups with current smoking, AVN of the involved bone, active same-site operative infections, history of nonunion, rheumatoid arthritis on medication, previous same-site operative procedures or infections, or a gap of 5 mm or greater after joint preparation. However, in this population, diabetic and female patients remained at a high risk of recurrent nonunion ( P = .0015), despite the use of a cellular bone allograft. Chi-square analysis of patients with increasing numbers of risk factors directly correlated with an increased risk of nonunion ( P = .025). Four wound complications were reported in this cohort that required irrigation and debridement (10%). CONCLUSION These data demonstrated a union rate of 83% in patients with risk factors known to cause nonunion. The benefits of the use of a cellular bone allograft allowed for the avoidance of morbidity associated with autograft harvesting while still improving the local biology to facilitate fusion in a difficult patient population to attain a successful fusion mass. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Travis J Dekker
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Peter White
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samuel B Adams
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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27
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Dekker TJ, White P, Adams SB. Efficacy of a Cellular Allogeneic Bone Graft in Foot and Ankle Arthrodesis Procedures. Foot Ankle Clin 2016; 21:855-861. [PMID: 27871418 DOI: 10.1016/j.fcl.2016.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A cellular allogeneic bone graft can be used in patients at high risk for nonunion after arthrodesis surgery. This study explores the utility and efficacy of MAP3 in foot and ankle arthrodesis procedures. Map3 is a cellular allogeneic bone graft that contains osteogenic, osteoconductive, osteoinductive, and angiogenic properties. A total of 23 mostly high-risk patients were included in this study. The overall fusion rate was 83%. Univariate analysis demonstrated diabetic patients remain at risk of recurrent nonunion (P<.001) despite supplementation with MAP3. These data demonstrate successful fusion in high-risk patients when MAP3 is used.
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Affiliation(s)
- Travis J Dekker
- Department of Orthopaedic Surgery, Duke University Medical Center, Erwin Road, Durham, NC 27710, USA
| | - Peter White
- Department of Orthopaedic Surgery, Duke University Medical Center, Erwin Road, Durham, NC 27710, USA
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Erwin Road, Durham, NC 27710, USA.
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28
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Harford JS, Dekker TJ, Adams SB. Bone Marrow Aspirate Concentrate for Bone Healing in Foot and Ankle Surgery. Foot Ankle Clin 2016; 21:839-845. [PMID: 27871416 DOI: 10.1016/j.fcl.2016.07.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Autologous bone marrow aspirate concentrate (BMAC) has become a popular orthobiologic to augment bone healing. The potential benefit comes from osteoprogenitor cells and growth factors that can lead to new bone formation in the setting of foot and ankle arthrodesis procedures. BMAC has an excellent safety record and has demonstrated efficacy in animal models of bone healing. Although scant, the literature on the use of BMAC in foot and ankle surgery does demonstrate promise for this orthobiologic adjuvant.
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Affiliation(s)
- Joshua S Harford
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Travis J Dekker
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA.
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