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Richter A, Stukenborg-Colsman C, Plaass C. SPECT/CT of Total Ankle Arthroplasty. Clin Podiatr Med Surg 2024; 41:649-663. [PMID: 39237177 DOI: 10.1016/j.cpm.2024.04.002] [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: 09/07/2024]
Abstract
Use of SPECT/CT (Single Photon Emission Computed Tomography/Computed Tomography) is increasing providing additional information in patients with inconclusive clinical examination and unremarkable imaging findings presenting with chronic pain after total ankle arthroplasty. To differentiate the cause of pain after total ankle arthroplasty can be challenging. SPECT/CT combines structural and metabolic imaging as a hybrid tool leading to higher specificity and overall diagnostic accuracy presumably in cases of gutter impingement, prosthetic loosening, and osteoarthritis of adjacent joints. Moreover, SPECT/CT can complement diagnostic work up in periprosthetic joint infections. Basal tracer enhancement has to be considered for the interpretation of imaging findings.
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Affiliation(s)
- Alena Richter
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Strasse 1-7, Hannover 30625, Germany
| | - Christina Stukenborg-Colsman
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Strasse 1-7, Hannover 30625, Germany
| | - Christian Plaass
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Strasse 1-7, Hannover 30625, Germany.
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Wang JEH, Day J, McCann J, Cooper P. Early results of combined total ankle total talus replacement in the revision setting. Foot Ankle Surg 2024; 30:493-498. [PMID: 38584061 DOI: 10.1016/j.fas.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/25/2024] [Accepted: 03/22/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Revision of failed total ankle replacement (TAR) is challenging and associated with increased morbidity. Given the increased popularity of TAR in treating end-stage ankle arthritis (ESAA), viable revision options are needed. The objective of this case series is to present a minimum 2-year clinical and radiographic outcomes of patient-specific custom 3D-printed total ankle total talus (TATR) prostheses in this unique subset of patients. METHODS 19 participants with ESAA and failed primary TAR who underwent TATR by a single surgeon at our institution from 2019 to 2021 were retrospectively identified. All participants were indicated for revision of primary STAR implant (Stryker, Kalamazoo, MI) and underwent replacement with 3D-printed titanium implants based on preoperative CT analysis (Additive Orthopaedics, Little Silver, NJ). Custom components included a mobile-bearing total talus and stemmed tibial system, performed through an anterior approach. Pre- and postoperative patient-reported outcomes were assessed using the Patient Reported Outcomes Measurement Information System (PROMIS). Pre- and postoperative implant alignment was assessed using medial distal tibial angle (MDTA) and tibiotalar angle (TTA) on anteroposterior, and sagittal tibial angle (STA) on lateral weight-bearing plain films. RESULTS The average patient age was 60.6 (range, 39-77) years, with an average follow-up of 37.9 (range, 25.3-57.5) months. There was statistically significant improvement in all PROMIS domains. Short-term survivorship was 100%, with two participants (11.0%) requiring reoperation for postoperative complications: one underwent open reduction internal fixation of the tibia for a periprosthetic fracture, and another underwent medial gutter debridement and tarsal tunnel release for recurrent pain. There were no significant differences in pre- versus postoperative radiographic alignment measured by MDTA (89.9 vs 86.4), TTA (89.7 vs 88.1), or STA (85.2 vs 85.3). CONCLUSION Custom 3D-printed TATR is a promising option for revision TAR. There was significant short-term improvement in pain and physical function, with excellent short-term survivorship and an acceptable postoperative complication rate.
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Affiliation(s)
- Joyce En-Hua Wang
- Department of Orthopedic Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Jonathan Day
- Department of Orthopedic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA.
| | - Julia McCann
- Department of Orthopedic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Paul Cooper
- Department of Orthopedic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
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Abstract
Aims When a total ankle arthroplasty (TAA) fails, it can be converted to a fusion or a revision arthroplasty. Despite the increasing numbers of TAAs being undertaken, there is little information in the literature about the management of patients undergoing fusion following a failed TAA. The primary aim of this study was to analyze the survival of fusions following a failed TAA using a large dataset from the National Joint Registry (NJR). Methods A data linkage study combined NJR and NHS Digital data. Failure of a TAA was defined as a fusion, revision to a further TAA, or amputation. Life tables and Kaplan-Meier graphs were used to record survival. Cox proportional hazards regression models were fitted to compare the rates of failure. Results A total of 131 patients underwent fusion as a salvage procedure following TAA. Their mean age was 65.7 years (SD 10.6) and 73 (55.7%) were male. The mean follow-up was 47.5 months (SD 27.2). The mean time between TAA and fusion was 5.3 years (SD 2.7). Overall, 32 (24.4%) underwent reoperations other than revision and 29 (22.1%) failed. Of these 24 (18.3%) underwent revision of the fusion and five (3.8%) had a below-knee amputation. No patients underwent conversion to a further TAA. Failure usually occurred in the first three postoperative years with one-year survival of fusion being 96.0% (95% confidence interval (CI) 90.7 to 98.3) and three-year survival in 69 patients being 77.5% (95% CI 68.3 to 84.4). Conclusion Salvage fusion after a failed TAA shows moderate rates of failure and reoperations. Nearly 25% of patients required revision within three years. This study is an extension of studies using the same methodology reporting the failure rates and risk factors for failure, which have recently been published, and also one reporting the outcome of revision TAA for a failed primary TAA, using the same methodology, which will shortly be published.
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Affiliation(s)
- Toby Jennison
- Plymouth Hospitals NHS Trust, Plymouth, UK
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | | | - Ian Sharpe
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andrew J Goldberg
- Wellington Hospital, London, UK
- UCL Division of Surgery, Royal Free Hospital, London, UK
- Imperial College London, London, UK
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Richter A, Stukenborg-Colsman C, Plaass C. SPECT/CT of Total Ankle Arthroplasty. Foot Ankle Clin 2023; 28:493-507. [PMID: 37536815 DOI: 10.1016/j.fcl.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Use of SPECT/CT (Single Photon Emission Computed Tomography/Computed Tomography) is increasing providing additional information in patients with inconclusive clinical examination and unremarkable imaging findings presenting with chronic pain after total ankle arthroplasty. To differentiate the cause of pain after total ankle arthroplasty can be challenging. SPECT/CT combines structural and metabolic imaging as a hybrid tool leading to higher specificity and overall diagnostic accuracy presumably in cases of gutter impingement, prosthetic loosening, and osteoarthritis of adjacent joints. Moreover, SPECT/CT can complement diagnostic work up in periprosthetic joint infections. Basal tracer enhancement has to be considered for the interpretation of imaging findings.
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Affiliation(s)
- Alena Richter
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Strasse 1-7, Hannover 30625, Germany
| | - Christina Stukenborg-Colsman
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Strasse 1-7, Hannover 30625, Germany
| | - Christian Plaass
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Strasse 1-7, Hannover 30625, Germany.
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O'Connor K, Klein S, Ebeling P, Flemister AS, Phisitkul P. Republication of "Total Ankle Arthroplasty: Summary of Current Status". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231195063. [PMID: 37655936 PMCID: PMC10467185 DOI: 10.1177/24730114231195063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Affiliation(s)
| | - Sandra Klein
- Washington University in St Louis, Chesterfield, MO, USA
| | - Patrick Ebeling
- Department of Orthopaedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA
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Miner SA, Martucci JA, Brigido SA, DiDomenico L. Time to Revision After Periprosthetic Joint Infection in Total Ankle Arthroplasty: A Systematic Review. J Foot Ankle Surg 2022; 62:186-190. [PMID: 36243626 DOI: 10.1053/j.jfas.2022.09.001] [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: 06/06/2022] [Revised: 07/14/2022] [Accepted: 09/04/2022] [Indexed: 02/03/2023]
Abstract
While not a common complication after total ankle arthroplasty (TAA), periprosthetic joint infection (PJI) presents a significant risk of implant failure. The primary aim of this systematic review was to evaluate time to revision after PJI in patients who had undergone TAA. An extensive search strategy via electronic databases initially captured 11,608 citations that were evaluated for relevance. Ultimately, 12 unique articles studying 3040 implants met inclusion criteria. The time to revision surgery due to PJI was recorded for each study and a weighted average obtained. The prevalence of PJI was 1.12% (n = 34). We found that the average time to revision due to PJI was 30.7 months, or approximately 2.6 years after the index TAA procedure. By literature definitions, the majority of cases (91.2%, n = 31) were beyond the "acute" PJI phase. The population was divided into 2 groups for further analysis of chronic infections. PJIs before the median were classified as "early" and those after as "late" chronic. The majority of cases (61.8%) were late chronic with an average time to revision of 44.3 months. A smaller number were early chronic (29.4%) with revision within 10.8 months. After summarizing the rates of infection and times to revision reported in the literature, we suggest modifying the current PJI classification to include early chronic and late chronic subgroups so that the total ankle surgeon is better prepared to prudently diagnose and treat PJIs.
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Affiliation(s)
- Samantha A Miner
- Reconstructive Foot & Ankle Surgery Fellowship, Coordinated Health-Lehigh Valley Health Network, Bethlehem, PA.
| | - John A Martucci
- Reconstructive Rearfoot and Ankle Surgical Fellowship, NOMS Ankle & Foot Care Centers, Youngstown, OH
| | - Stephen A Brigido
- Reconstructive Foot & Ankle Surgery Fellowship, Coordinated Health-Lehigh Valley Health Network, Bethlehem, PA
| | - Lawrence DiDomenico
- Reconstructive Rearfoot and Ankle Surgical Fellowship, NOMS Ankle & Foot Care Centers, Youngstown, OH
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Yoon YK, Park KH, Park JH, Lee W, Han SH, Lee JW. Long-Term Clinical Outcomes and Implant Survivorship of 151 Total Ankle Arthroplasties Using the HINTEGRA Prosthesis: A Minimum 10-Year Follow-up. J Bone Joint Surg Am 2022; 104:1483-1491. [PMID: 35726878 DOI: 10.2106/jbjs.22.00060] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Few studies have investigated long-term clinical outcomes of a mobile-bearing total ankle arthroplasty (TAA) system. This study analyzed long-term outcomes of TAA using the HINTEGRA prosthesis at a single, non-developer center. METHODS Primary TAAs were performed on 213 ankles in 194 patients, and 151 consecutive ankles [71%] in 136 patients with a minimum follow-up of 10 years after the primary TAA were included in this study. Clinical results were assessed using a visual analog scale (VAS) pain score, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale score, the Ankle Osteoarthritis Scale (AOS) pain and disability subscores, and ankle range of motion. Prosthesis survivorship, reoperations, and risk factors were also evaluated. RESULTS The mean follow-up was 135.5 months (range, 120.0 to 204.0 months). All clinical scores and ankle range of motion improved significantly from preoperatively to 2 years, 4 to 6 years, and ≥10 years after TAA (p < 0.001). A total of 43 ankles (28.5%) required revision procedures, with the most common reason being periprosthetic osteolysis (32 ankles [21.2%]). The overall implant survivorship was 93.5% in Kaplan-Meier survival analysis at the mean follow-up of 11.3 years after the TAA. CONCLUSIONS TAA using the HINTEGRA prosthesis with careful follow-up observation and appropriate adjunct procedures for the treatment of end-stage ankle arthritis produced satisfactory clinical results, which were maintained at a follow-up of ≥10 years, and resulted in 93.5% of implant survivorship. LEVEL OF EVIDENCE Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Yeo Kwon Yoon
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kwang Hwan Park
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Han Park
- Department of Orthopaedic Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
| | - Wonwoo Lee
- 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
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Henry JK, Rider C, Cody E, Ellis SJ, Demetracopoulos C. Evaluating and Managing the Painful Total Ankle Replacement. Foot Ankle Int 2021; 42:1347-1361. [PMID: 34315246 DOI: 10.1177/10711007211027273] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The number of total ankle replacements (TARs) performed in the United States has dramatically increased in the past 2 decades due to improvements in implant design and surgical technique. Yet as the prevalence of TAR increases, so does the likelihood of encountering complications and the need for further surgery. Patients with new-onset or persistent pain after TAR should be approached systematically to identify the cause: infection, fracture, loosening/subsidence, cysts/osteolysis, impingement, and nerve injury. The alignment of the foot and ankle must also be reassessed, as malalignment or adjacent joint pathology can contribute to pain and failure of the implant. Novel advanced imaging techniques, including single-photon emission computed tomography and metal-subtraction magnetic resonance imaging, are useful and accurate in identifying pathology. After the foot and ankle have been evaluated, surgeons can also consider contributing factors such as pathology outside the foot/ankle (eg, in the knee or the spine). Treatment of the painful TAR is dependent on etiology and may include debridement, bone grafting, open reduction and internal fixation, realignment of the foot, revision of the implants, arthrodesis, nerve repair/reconstruction/transplantation surgery, or, in rare cases, below-knee amputation.Level of Evidence: Level V, expert opinion or review.
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Mertens J, Lootens T, Vercruysse J, Van Den Bossche B, Berwouts D, Lambert B, Van den Wyngaert T. Bone SPECT/CT in the Evaluation of Painful Total Ankle Replacement: Validation of Localization Scheme and Preliminary Evaluation of Diagnostic Patterns. Clin Nucl Med 2021; 46:361-368. [PMID: 33630798 DOI: 10.1097/rlu.0000000000003545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Third-generation total ankle replacement (TAR) is an increasingly popular and effective treatment for end-stage osteoarthritis, yet identifying causes of failure remains challenging. We evaluated integrated bone SPECT/CT in recurrent pain after TAR by validating a standardized reporting scheme, identifying uptake patterns, and assessing diagnostic performance and impact on clinical management. PATIENTS AND METHODS A total of 24 TARs in 16 patients with persistent or recurrent pain received integrated bone SPECT/CT using diagnostic CT settings. Images were retrospectively reviewed, and a novel localization scheme was validated by assessing interrater agreement. Distinct uptake patterns were identified, and diagnostic test characteristics were estimated. Reference standard consisted of clinical follow-up, laboratory findings, and subsequent procedures, including revision surgery. RESULTS Standardized scoring of bone SPECT/CT uptake was highly reproducible (intraclass correlation coefficient, 0.79; 95% confidence interval [CI], 0.75-0.82). The final diagnoses were gutter impingement (n = 12), periprosthetic (stress) fracture (n = 5), loosening (n = 5), tarsal arthritis (n = 1), and erysipelas (n = 1). Overall, the diagnostic test characteristics of bone SPECT/CT were as follows: sensitivity of 100% (95% CI, 82%-100%), specificity of 80% (95% CI, 28%-99%), and accuracy of 96% (95% CI, 79%-100%). Gutter impingement, periprosthetic fracture, and loosening were correctly identified in all cases revealing distinct uptake patterns. Importantly, persistent diffuse uptake was frequently observed, warranting cautious interpretation. Bone SPECT/CT impacted clinical management in 86%, with symptomatic improvement in 83% of patients. CONCLUSIONS Integrated bone SPECT/CT of painful TARs may benefit from standardized localization to reveal distinct uptake patterns representing common complications after TAR. Initial results show highly promising diagnostic value with potentially important impact on clinical management.
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Egglestone A, Kakwani R, Aradhyula M, Kingman A, Townshend D. Outcomes of revision surgery for failed total ankle replacement: revision arthroplasty versus arthrodesis. INTERNATIONAL ORTHOPAEDICS 2020; 44:2727-2734. [DOI: 10.1007/s00264-020-04784-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/25/2020] [Indexed: 12/23/2022]
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Sung KS. Total ankle arthroplasty. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.8.445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
For end-stage ankle arthritis, either arthrodesis or total ankle arthroplasty is a available surgical option. With the failure of earlier generation of arthroplasty, arthrodesis has been the gold standard. However, there are some considerable weaknesses of the arthrodesis. Current total ankle arthroplasty is presently an effective surgical treatment for endstage ankle arthritis with much improvement. The goals of surgery are to decrease pain, preserve range of motion, and eventually improve the patient’s quality of life. Recent literatures on total ankle arthroplasty havs shown successful long-term clinical results due to the innovation of second-generation implants, including more anatomic concepts and designs. For successful outcomes, a thorough evaluation of the entire lower limb alignment, deformities of the foot and ankle, and proper selection of patients are very important. Nevertheless, complications, such as wound problems, osteolysis, gutter pain or impingement, infection, loosening, and others, may occur. In this review, we provide a summary of the current research on total ankle arthroplasty.
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Kim SJ, Sung IH, Song SY, Jo YH. The Epidemiology and Trends of Primary Total Ankle Arthroplasty and Revision Procedure in Korea between 2007 and 2017. J Korean Med Sci 2020; 35:e169. [PMID: 32508066 PMCID: PMC7279944 DOI: 10.3346/jkms.2020.35.e169] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/31/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the surgical trends of primary total ankle arthroplasty (TAA) and revision procedure in Korea from 2007 to 2017 using national population-based data. METHODS We reviewed the National Health Insurance data of Korea from 2007 to 2017. The data included diagnosis codes, procedure codes, prescriptions, medical costs, and other demographic data. Trends of primary diagnosis for primary TAA were evaluated. Annual trends and incidences per 100,000 person-years of primary TAA and revision procedures as well as compound annual growth rate (CAGR) during the study period were analysed. Surgical trends according to patients' age, hospital grades, and insurance systems were also evaluated. RESULTS Primary diagnosis for primary TAA was mostly degenerative arthritis (6,501 cases; 90.5%). From 2007 to 2017, the total number of cases of primary TAA and revision procedures was 7,183 and 585, respectively. The number of cases in 2007 of primary TAA was 313; there were no cases of revision. The number of cases in 2017 of primary TAA were 986 and of revision were 108. The CAGR during this period was 28.6% for primary TAA and 44.6% for revision procedures. Incidences per 100,000 person-years in 2017 were 1.91 for primary TAA and 0.21 for revision procedures. The average cost paid by patients themselves was USD 813 (19%) and by the National Health Insurance Service was USD 3,480 (81%). CONCLUSION The incidence of primary TAA and revision procedures steadily increases in Korea during the 11-year study period.
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Affiliation(s)
- Sung Jae Kim
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Il Hoon Sung
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, Korea
| | - Si Young Song
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Young Hoon Jo
- Department of Orthopaedic Surgery, Hanyang University Guri Hospital, Guri, Korea.
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Gurbani A, Demetracopoulos C, O'Malley M, Deland J, Cody E, Sofka C, Scharf S, Ellis S. Correlation of Single-Photon Emission Computed Tomography Results With Clinical and Intraoperative Findings in Painful Total Ankle Replacement. Foot Ankle Int 2020; 41:639-646. [PMID: 32156161 DOI: 10.1177/1071100720909357] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Evaluating pain after total ankle replacement (TAR) is often difficult, and traditional imaging modalities do not always adequately assess potential etiologies of failure. Our study adds to the current understanding of single-photon emission computed tomography combined with conventional computed tomography (SPECT-CT) as a diagnostic tool for painful TAR. We hypothesized that SPECT-CT would be predictive of clinical and intraoperative findings and would be more useful than magnetic resonance imaging (MRI) in our cohort. METHODS A retrospective review of SPECT-CT imaging performed at our institution in patients with painful TAR from January 2014 to November 2018 was conducted. A total of 37 patients were identified, and 28 of them underwent revision surgery. Additionally, 19 patients had an MRI during the same time frame. Imaging results were compared to the documented clinical findings and intraoperative findings during revision surgery. RESULTS Of the 37 patients included, 89.2% (33/37) had SPECT-CT results that were consistent with the ultimate diagnosis documented in the medical record. Aseptic loosening (12/33) and impingement (11/33) were the most common diagnoses. Among patients who underwent revision surgery, SPECT-CT results were consistent with intraoperative findings in 26 of the 28 (92.9%) cases. In the 19 patients who also underwent MRI, the findings were consistent with clinical findings 36.8% (7/19) of the time. CONCLUSION In our cohort, there was high consistency between SPECT-CT results and documented clinical diagnoses. SPECT-CT also demonstrated high consistency with intraoperative findings during revision surgery. Compared with MRI, SPECT-CT proved more useful in establishing a diagnosis of pain after TAR. LEVEL OF EVIDENCE Level III, comparative series.
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Affiliation(s)
- Ajay Gurbani
- University of California Los Angeles, Los Angeles, CA, USA
| | | | | | | | | | | | | | - Scott Ellis
- Hospital for Special Surgery, New York, NY, USA
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Halverson AL, Goss DA, Berlet GC. Ankle Arthrodesis With Structural Grafts Can Work for the Salvage of Failed Total Ankle Arthroplasty. Foot Ankle Spec 2020; 13:132-137. [PMID: 31006273 DOI: 10.1177/1938640019843317] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background. Treatment options after failed total ankle arthroplasty (TAA) are limited. This study reports midterm outcomes and radiographic results in a single-surgeon group of patients who have undergone ankle arthrodesis with intramedullary nail fixation and structural allograft augmentation following failed TAA. Methods. A retrospective review on patients who underwent failed TAA revision with structural femoral head allograft and intramedullary tibiotalocalcaneal (TTC) nail fixation was completed. Foot Function Index (FFI), American Orthopaedic Foot & Ankle Society (AOFAS) outcome scores, and radiographs were obtained at each visit with 5-year follow-up. Results. Five patients were followed to an average of 5.2 years (range 4.7-5.6). Enrollment FFI was 34.82 (range 8.82-75.88); at midterm follow-up it was 20.42 (range 0-35.38). Enrollment AOFAS scores averaged 66.6 (range 61-77); at midterm follow-up it was 70.33 (range 54-88). Radiographs showed union in 4 of 5 patients at enrollment and 2 of 3 patients at midterm. Conclusions. Utilization of TTC fusion with femoral head allograft is a salvage technique that can produce a functional limb salvage. Our results show continued improvement in patient-reported outcomes, with preservation of limb length and reasonable union rate. Levels of Evidence: Therapeutic, Level II: Prospective, comparative trial.
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Affiliation(s)
| | - David A Goss
- Orthopaedic Foot and Ankle Center, Westerville, Ohio
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15
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Goodman SB, Gallo J, Gibon E, Takagi M. Diagnosis and management of implant debris-associated inflammation. Expert Rev Med Devices 2020; 17:41-56. [PMID: 31810395 PMCID: PMC7254884 DOI: 10.1080/17434440.2020.1702024] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/04/2019] [Indexed: 02/07/2023]
Abstract
Introduction: Total joint replacement is one of the most common, safe, and efficacious operations in all of surgery. However, one major long-standing and unresolved issue is the adverse biological reaction to byproducts of wear from the bearing surfaces and modular articulations. These inflammatory reactions are mediated by the innate and adaptive immune systems.Areas covered: We review the etiology and pathophysiology of implant debris-associated inflammation, the clinical presentation and detailed work-up of these cases, and the principles and outcomes of non-operative and operative management. Furthermore, we suggest future strategies for prevention and novel treatments of implant-related adverse biological reactions.Expert opinion: The generation of byproducts from joint replacements is inevitable, due to repetitive loading of the implants. A clear understanding of the relevant biological principles, clinical presentations, investigative measures and treatments for implant-associated inflammatory reactions and periprosthetic osteolysis will help identify and treat patients with this issue earlier and more effectively. Although progressive implant-associated osteolysis is currently a condition that is treated surgically, with further research, it is hoped that non-operative biological interventions could prolong the lifetime of joint replacements that are otherwise functional and still salvageable.
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Affiliation(s)
- Stuart B. Goodman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Jiri Gallo
- Department of Orthopaedics, Palacký University Olomouc, Olomouc, Czech Republic
| | - Emmanuel Gibon
- Department of Orthopaedic Surgery, University of Florida, Gainesville, FL, USA
| | - Michiaki Takagi
- Department of Orthopaedic Surgery, Yamagata University, Yamagata, Japan
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16
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Total ankle arthroplasty and ankle arthrodesis affect the biomechanics of the inner foot differently. Sci Rep 2019; 9:13334. [PMID: 31527781 PMCID: PMC6746773 DOI: 10.1038/s41598-019-50091-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 09/05/2019] [Indexed: 02/08/2023] Open
Abstract
Ankle arthrodesis and total ankle arthroplasty are the two primary surgeries for treatment of end-stage degenerative ankle arthritis. The biomechanical effects of them on the inner foot are insufficient to identify which is superior. This study compared biomechanical parameters among a foot treated by ankle arthrodesis, a foot treated by total ankle arthroplasty, and an intact foot using computational analysis. Validated finite element models of the three feet were developed and used to simulate the stance phase of gait. The results showed total ankle arthroplasty provides a more stable plantar pressure distribution than ankle arthrodesis. The highest contact pressure, 3.17 MPa, occurred in the medial cuneonavicular joint in the total ankle arthroplasty foot. Neither of the surgeries resulted in contact pressure increase in the subtalar joint. The peak stress in the metatarsal bones was increased in both surgical models, especially the second and third metatarsals. This study enables us to get visual to the biomechanics inside of an intact foot, and feet treated by total ankle arthroplasty and ankle arthrodesis during walking.
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Uçkay I, Pedowitz D, Assal M, Stull JD. What Tests Are Useful to Investigate a Possible Infection of Total Ankle Arthroplasty (TAA)? What Are Their Thresholds? Foot Ankle Int 2019; 40:22S-23S. [PMID: 31322967 DOI: 10.1177/1071100719859537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION Overall, the approach to a potentially infected total ankle arthroplasty (TAA) does not change compared to other periprosthetic joint infections (PJIs). There are no novel or unique diagnostic procedures for TAA infection, specifically. Joint aspiration or intraoperative tissue/synovial biopsies with microbiological cultures are the most important diagnostic tests for suspected TAA infections. In the absence of specific data related to TAA, the threshold for these tests should be derived from the hip and knee PJI literature. LEVEL OF EVIDENCE Strong. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Affiliation(s)
- Ilker Uçkay
- 1 Infectiology, Balgrist University Hospital, Zurich, Switzerland
| | - David Pedowitz
- 2 Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA. USA
| | - Mathieu Assal
- 3 Hirslanden Clinique La Colline, Geneva, Switzerland
| | - Justin D Stull
- 4 Thomas Jefferson University Hospital, The Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Raikin S, Parekh S, McDonald E. What Is the Treatment "Algorithm" for an Infected Total Ankle Arthroplasty (TAA)? Foot Ankle Int 2019; 40:43S-46S. [PMID: 31322968 DOI: 10.1177/1071100719861090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION The treatment of an infected total ankle arthroplasty (TAA) is largely dictated by the acuity of the infection. The following treatment algorithm modified for TAA is recommended.19. LEVEL OF EVIDENCE Limited. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Affiliation(s)
- Steven Raikin
- 1 Rothman Institute at Thomas Jefferson University Hospital Sydney Kimmel Medical College, Philadelphia, PA, USA
| | - Selene Parekh
- 2 North Carolina Orthopaedic Clinic, Duke University, Durham, NC, USA
| | - Elizabeth McDonald
- 1 Rothman Institute at Thomas Jefferson University Hospital Sydney Kimmel Medical College, Philadelphia, PA, USA.,3 Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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19
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Plöeger MM, Aiyer A. What Are the Indications for Aspiration of a Possibly Infected Total Ankle Arthroplasty (TAA)? Foot Ankle Int 2019; 40:24S-25S. [PMID: 31322945 DOI: 10.1177/1071100719859545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION Whenever a periprosthetic joint infection (PJI) of a total ankle arthroplasty (TAA) is clinically possible or suspected, especially when elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) levels exist, and in correspondence to the literature on PJI in total hip and knee arthroplasties, joint aspiration is indicated. LEVEL OF EVIDENCE Consensus. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Affiliation(s)
- Milena M Plöeger
- 1 Department for Orthopedics and Trauma Surgery, University of Bonn, Bonn, Germany
| | - Amiethab Aiyer
- 2 University of Miami/Miller School of Medicine, Miami, FL, USA
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Emara K, Embil JM. Is There a Role for Measuring Synovial Biomarkers for Diagnosis of Infected Total Ankle Arthroplasty (TAA)? Foot Ankle Int 2019; 40:27S-29S. [PMID: 31322931 DOI: 10.1177/1071100719859570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION Based on the hip and knee arthroplasty literature, measuring synovial biomarkers may play a role in the diagnosis of infected total ankle arthroplasty (TAA). The diagnosis of periprosthetic joint infection (PJI) in the setting of a TAA can be confirmed with cultures, provided that a plausible pathogen is recovered in the context of a compatible clinical picture. In the absence of a positive culture, synovial biomarker analysis may help in establishing the diagnosis. LEVEL OF EVIDENCE Moderate. DELEGATE VOTE Agree: 92%, Disagree: 8%, Abstain: 0% (Super Majority, Strong Consensus).
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Abstract
Chronic postsurgical pain affects between 5 and 75% of patients, often with an adverse impact on quality of life. While the transition of acute to chronic pain is a complex process-involving multiple mechanisms at different levels-the current strategies for prevention have primarily been restricted to perioperative pharmacological interventions. In the present paper, we first present an up-to-date narrative literature review of these interventions. In the second section, we develop several ways by which we could overcome the limitations of the current approaches and enhance the outcome of our surgical patients, including the better identification of individual risk factors, tailoring treatment to individual patients, and improved acute and subacute pain evaluation and management. The third and final section covers the treatment of established CPSP. Given that evidence for the current therapeutic options is limited, we need high-quality trials studying multimodal interventions matched to pain characteristics.
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Affiliation(s)
- Arnaud Steyaert
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Patricia Lavand'homme
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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Walley KC, Arena CB, Juliano PJ, Aynardi MC. Diagnostic Criteria and Treatment of Acute and Chronic Periprosthetic Joint Infection of Total Ankle Arthroplasty. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419841000. [PMID: 35097323 PMCID: PMC8696803 DOI: 10.1177/2473011419841000] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Prosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a serious complication that results in significant consequences to the patient and threatens the survival of the ankle replacement. PJI in TAA may require debridement, placement of antibiotic spacer, revision arthroplasty, conversion to arthrodesis, or potentially below the knee amputation. While the practice of TAA has gained popularity in recent years, there is some minimal data regarding wound complications in acute or chronic PJI of TAA. However, of the limited studies that describe complications of PJI of TAA, even fewer studies describe the criteria used in diagnosing PJI. This review will cover the current available literature regarding total ankle arthroplasty infection and will propose a model for treatment options for acute and chronic PJI in TAA. Methods: A review of the current literature was conducted to identify clinical investigations in which prosthetic joint infections occurred in total ankle arthroplasty with associated clinical findings, radiographic imaging, and functional outcomes. The electronic databases for all peer-reviewed published works available through January 31, 2018, of the Cochrane Library, PubMed MEDLINE, and Google Scholar were explored using the following search terms and Boolean operators: “total ankle replacement” OR “total ankle arthroplasty” AND “periprosthetic joint infection” AND “diagnosis” OR “diagnostic criteria.” An article was considered eligible for inclusion if it concerned diagnostic criteria of acute or chronic periprosthetic joint infection of total ankle arthroplasty regardless of the number of patients treated, type of TAA utilized, conclusion, or level of evidence of study. Results: No studies were found in the review of the literature describing criteria for diagnosing PJI specific to TAA. Conclusions: Literature describing the diagnosis and treatment of PJI in TAA is entirely reliant on the literature surrounding knee and hip arthroplasty. Because of the limited volume of total ankle arthroplasty in comparison to knee and hip arthroplasty, no studies to our knowledge exist describing diagnostic criteria specific to total ankle arthroplasty with associated reliability. Large multicenter trials may be required to obtain the volume necessary to accurately describe diagnostic criteria of PJI specific to TAA. Level of Evidence: Level III, systematic review.
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Affiliation(s)
- Kempland C. Walley
- Department of Orthopaedic Surgery, Penn State Hershey Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Christopher B. Arena
- Department of Orthopaedic Surgery, Penn State Hershey Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Paul J. Juliano
- Department of Orthopaedic Surgery, Penn State Hershey Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Michael C. Aynardi
- Department of Orthopaedic Surgery, Penn State Hershey Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Movassaghi K, Wakefield C, Bohl DD, Lee S, Lin J, Holmes GB, Hamid KS. Septic Arthritis of the Native Ankle. JBJS Rev 2019; 7:e6. [DOI: 10.2106/jbjs.rvw.18.00080] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Clough T, Bodo K, Majeed H, Davenport J, Karski M. Survivorship and long-term outcome of a consecutive series of 200 Scandinavian Total Ankle Replacement (STAR) implants. Bone Joint J 2019; 101-B:47-54. [PMID: 30601052 DOI: 10.1302/0301-620x.101b1.bjj-2018-0801.r1] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants. PATIENTS AND METHODS Between November 1993 and February 2000, 200 consecutive STAR prostheses were implanted in 184 patients by a single surgeon. Demographic and clinical data were collected prospectively and the last available status was recorded for further survival analysis. All surviving patients underwent regular clinical and radiological review. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scoring system. The principal endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan-Meier survival curves were generated with 95% confidence intervals and the rate of failure calculated for each year. RESULTS A total of 84 patients (87 ankles) were alive by the end of this study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis (RA), n = 40; OA, n = 47), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery. A total of 32 implants failed (16%), requiring revision surgery. The mean time to revision was 80 months (2 to 257). The implant survival at 15.8 years, using revision as an endpoint, was 76.16% (95% confidence interval (CI) 64.41 to 87.91). We found a steady but low decrease in survival over the study period. The mean AOFAS score improved from 28 (10 to 52) preoperatively to 61 (20 to 90) at long-term follow-up. CONCLUSION STAR prostheses in the United Kingdom have now been largely superseded by newer design TAAs, potentially with improved characteristics and surgical techniques. The long-term survivorship for the STAR prosthesis can provide a benchmark for these later designs of ankle arthroplasty.
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Affiliation(s)
- T Clough
- Wrightington Hospital, Wigan, UK
| | - K Bodo
- Locum Consultant Foot and Ankle Surgeon, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - H Majeed
- Wrightington Hospital, Wigan, UK
| | | | - M Karski
- Wrightington Hospital, Wigan, UK
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Clough TM, Alvi F, Majeed H. Total ankle arthroplasty: what are the risks?: a guide to surgical consent and a review of the literature. Bone Joint J 2018; 100-B:1352-1358. [PMID: 30295527 DOI: 10.1302/0301-620x.100b10.bjj-2018-0180.r1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent. PATIENTS AND METHODS A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants. RESULTS There were wound-healing problems in nine ankles (3.2%), superficial infection in 20 ankles (7.2%), and deep infection in six ankles (2.2%). Intraoperative fractures occurred in medial malleoli in 27 ankles (9.7%) and in lateral malleoli in four ankles (1.4%). Aseptic loosening and osteolysis were seen 16 ankles (5.8%). Fracture of the polyethylene component occurred in one ankle (0.4%) and edge-loading in seven ankles (2.5%). We observed medial gutter pain in 31 ankles (11.1%). The incidence of thromboembolism occurred in two ankles (0.7%). The results were found to be comparable to the previously reported complications of total ankle arthroplasty in the literature. CONCLUSION Total ankle arthroplasty continues to evolve and improve the ankle function. Despite high overall complication rates with TAA surgery, most complications appear to be minor and do not affect final clinical outcome. Our results and literature review will help in the consent process and provide detailed complication rates for an informed consent. Cite this article: Bone Joint J 2018;100-B:1352-8.
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Affiliation(s)
- T M Clough
- Foot and Ankle Surgery, Wrightington Hospital, Wigan, UK
| | - F Alvi
- Foot and Ankle Surgery, Wrightington Hospital, Wigan, UK
| | - H Majeed
- Foot and Ankle Surgery, Wrightington Hospital, Wigan, UK
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26
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O’Connor K, Klein S, Ebeling P, Flemister AS, Phisitkul P. Total Ankle Arthroplasty. FOOT & ANKLE ORTHOPAEDICS 2018. [DOI: 10.1177/2473011418790003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
| | - Sandra Klein
- Washington University in St Louis, Chesterfield, MO, USA
| | - Patrick Ebeling
- Department of Orthopaedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA
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27
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Kampen WU, Westphal F, Van den Wyngaert T, Strobel K, Kuwert T, Van der Bruggen W, Gnanasegaran G, Jens JH, Paycha F. SPECT/CT in Postoperative Foot and Ankle Pain. Semin Nucl Med 2018; 48:454-468. [PMID: 30193651 DOI: 10.1053/j.semnuclmed.2018.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Postoperative pain is a clinically relevant issue in orthopedic patients, affecting more than 40% 1 year after foot and ankle surgery. Because of the very complex anatomy with many different joints and several motion axes, clinical examination and conventional imaging are sometimes not sufficient to identify a local pain generator. Local uptake of bone-seeking radiopharmaceuticals is known to correlate accurately with sites of pain generating foci and, thus, bone scintigraphy has been an established method to evaluate these respective patients for many years. However, the specificity is rather low if only planar images are acquired. The development of SPECT and especially of hybrid SPECT and CT imaging has significantly enhanced the specificity of this technique. The combination of both functional and morphological imaging, ideally performed with a dedicated SPECT/CT system to minimize misregistration owing to motion artifacts and to enhance image quality by attenuation correction, allows an early and reliable detection of pathologic bone processes, even in patients where radiological imaging with MRI or CT is hampered by metal implants. In diabetic patients with a neuropathic Charcot osteoarthropathy, infection can be differentiated from inflammatory bone alterations (causing bone marrow edema) almost certainly using SPECT/CT with radiolabeled white blood cells and antigranulocyte antibodies, allowing an individual and precise treatment planning either in the initial course of the disease or even after surgery. This article reviews the most frequent clinical challenges in patients after foot and ankle surgery, including a description of the various surgical procedures, the different imaging options with their advantages and disadvantages, and aims to integrate bone SPECT/CT into the clinical diagnostic workup.
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Affiliation(s)
| | - Florian Westphal
- Department of Endoprothetic and Joint Surgery, Tabea Hospital, Hamburg, Germany
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium.; Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Klaus Strobel
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Torsten Kuwert
- Clinic of Nuclear Medicine, University Hospital Erlangen, Germany
| | - Wouter Van der Bruggen
- Department of Radiology and Nuclear Medicine, Slingeland Hospital, Doetinchem, The Netherlands
| | - Gopinath Gnanasegaran
- Department of Nuclear Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Jan-Hauke Jens
- Department of Endoprothetic and Joint Surgery, Tabea Hospital, Hamburg, Germany
| | - Frédéric Paycha
- Department of Nuclear Medicine, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
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Wei X, Li F, Zhao G, Chhonker YS, Averill C, Galdamez J, Purdue PE, Wang X, Fehringer EV, Garvin KL, Goldring SR, Alnouti Y, Wang D. Pharmacokinetic and Biodistribution Studies of HPMA Copolymer Conjugates in an Aseptic Implant Loosening Mouse Model. Mol Pharm 2017; 14:1418-1428. [PMID: 28343392 DOI: 10.1021/acs.molpharmaceut.7b00045] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
N-(2-Hydroxypropyl) methacrylamide (HPMA) copolymers were previously found to represent a versatile delivery platform for the early detection and intervention of orthopedic implant loosening. In this article, we evaluated the impact of different structural parameters of the HPMA copolymeric system (e.g., molecular weight (MW), drug content) to its pharmacokinetics and biodistribution (PK/BD) profile. Using 125I, Alexa Fluor 488, and IRDye 800 CW-labeled HPMA copolymer-dexamethasone (P-Dex) conjugates with different MW and dexamethasone (Dex) contents, we found the MW to be the predominant impact factor on the PK/BD profiles of P-Dex, with Dex content as a secondary impact factor. In gamma counter-based PK/BD studies, increased MW of P-Dex reduced elimination, leading to lower clearance, longer half-life, and higher systemic exposure (AUC and MRT). In the semiquantitative live animal optical imaging evaluation, the distribution of P-Dex to the peri-implant inflammatory lesion increased when MW was increased. This result was further confirmed by FACS analyses of cells isolated from peri-implant regions after systemic administration of Alexa Fluor 488-labeled P-Dex. Since the in vitro cell culture study suggested that the internalization of P-Dex by macrophages is generally independent of P-Dex's MW and Dex content, the impact of the MW and Dex content on its PK/BD profile was most likely exerted at physiological and pathophysiological levels rather than at the cellular level. In both gamma counter-based PK/BD analyses and semiquantitative optical imaging analyses, P-Dex with 6 wt % Dex content showed fast clearance. Dynamic light scattering analyses unexpectedly revealed significant molecular aggregation of P-Dex at this Dex content level. The underlining mechanisms of the aggregation and fast in vivo clearance of the P-Dex warrant further investigation.
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Affiliation(s)
- Xin Wei
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center , Omaha, Nebraska 68198, United States
| | - Fei Li
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center , Omaha, Nebraska 68198, United States
| | - Gang Zhao
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center , Omaha, Nebraska 68198, United States
| | - Yashpal Singh Chhonker
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center , Omaha, Nebraska 68198, United States
| | - Christine Averill
- Hospital for Special Surgery , New York, New York 10021, United States
| | - Josselyn Galdamez
- Hospital for Special Surgery , New York, New York 10021, United States
| | - P Edward Purdue
- Hospital for Special Surgery , New York, New York 10021, United States
| | - Xiaoyan Wang
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center , Omaha, Nebraska 68198, United States
| | - Edward V Fehringer
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center , Omaha, Nebraska 68198, United States
| | - Kevin L Garvin
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center , Omaha, Nebraska 68198, United States
| | - Steven R Goldring
- Hospital for Special Surgery , New York, New York 10021, United States
| | - Yazen Alnouti
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center , Omaha, Nebraska 68198, United States
| | - Dong Wang
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center , Omaha, Nebraska 68198, United States.,Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center , Omaha, Nebraska 68198, United States
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