Coronal Plane Deformity Research Articles

TWO-YEAR FOLLOW-UP STUDY FOR PATIENTS UNDERGOING VERTEBRAL BODY TETHERING FOR IDIOPATHIC SCOLIOSIS

Anterior vertebral body tethering (AVBT) is a growth modulating procedure used to manage idiopathic scoliosis by applying a flexible tether to the convex surface of the spine in skeletally immature patients. The purpose of this study is to determine the preliminary clinical outcomes for an adolescent patient cohort.18 patients with scoliosis were selected using a narrow selection criteria to undergo AVBT. Of this cohort, 11 had reached a minimum follow up of 2 years, 4 had reached 18 months, and 3 had reached 6 months. These patients all demonstrated a primary thoracic deformity that was too severe for bracing, were skeletally immature, and were analysed in this preliminary study of coronal plane deformity correction.Using open-source image analysis software (ImageJ, NIH) PA radiographs taken pre-operatively and at regular follow-up visits post-operatively were used to measure the coronal plane deformity of the major and compensatory curves.Pre-operatively, the mean age was 12.0 years (S.D. 10.7 – 13.3), mean Sanders score 2.6 (S.D. 1.8-3.4), all Risser 0 and pre-menarchal, with mean main thoracic Cobb angle of 52° (S.D. 44.2-59.8°). Post-operatively the mean angle decreased to 26.4° (S.D. 18.4-32°) at 1 week, 30.4° (S.D. 21.3-39.6°) at 2 months, 25.7° (S.D. 18.7-32.8°) at 6 months, 27.9° (S.D. 16.2-39.6°) at 12 months, and 36.8° (S.D. 22.6– 51.0°) at 18 months and 38.2° (S.D. 27.6-48.7°) at 2 years. The change in curve at 2 years post-operative was statistically significant (P=0.004).There were 4 tether breakages identified that did not require return to theatre as yet, one patient underwent a posterior spinal instrumented fusion due to curve progression.AVBT is a promising new growth modulation technique for skeletally immature patients with progressive idiopathic scoliosis. This study has demonstrated a reduction in scoliosis severity.

Joint awareness after fixed and mobile-bearing total knee arthroplasty with minimum 12 years of follow-up: A propensity matched-pair analysis

BackgroundMany comparative articles studied mobile-bearing (MB) and fixed-bearing (FB) total knee arthroplasties (TKAs). Meta-analyses found no difference in survival or biomechanical outcome. This study aimed to compare long-term clinical results between fixed-bearing (FB) and mobile-bearing (MB) total knee arthroplasty (TKA) as well as patients’ adaptation to their artificial joints. MethodTKAs performed with the same surgical protocol divided into categories according to the insert design preferred. 70 MB design TKAs were compared with 70 FB design TKAs utilizing propensity matching for parameters; gender, age, body mass index, coronal plane deformity, range of motion (ROM) and appropriateness criteria. Forgotten Joint Score-12 (FJS-12) was used to assess patients’ ability to forget their artificial joints in daily life. ResultsPatients had a mean follow-up of 15.6 (±2.2) years. No difference was observed between groups for post-operative ROM, WOMAC, Knee Society Knee and Function Scores. The FJS-12 in the MB and FB groups were 66.1 and 72.8, respectively (P = 0.026). There was no significant difference in survival between both designs. ConclusionThis study suggests that in TKA, joint awareness is higher in MB compared to FB design. FJS-12 appears to be a sensitive measuring tool when comparing two designs and should be implemented in long-term follow-up.

The 'candy cane' technique for construct augmentation and correction of severe angular chin-on-chest kyphoscoliosis.

To manage severe angular chin-on-chest deformity. A single midline incision and periosteal dissection were utilized to expose from C2 to T6. Bilateral C2 pars screws, C3 to C7 lateral mass screws, and T1 to T6 pedicle screws were placed. Following the placement of screws, multiple two column posterior osteotomies and interlaminar decompressions from C6 to T3 were performed to amplify both the sagittal and coronal corrections. Titanium rods were utilized in light of the patient's known osteopenia and nickel allergy. As such, the construct was augmented via the use of a third accessory rod. This third titanium rod was placed into a supplementary translaminar screw with three connectors to the right-sided main rod. Once the lordotic configuration of the contralateral main rod was secured, an additional corrective maneuver of gentle distraction across this third rod was employed to assist with coronal correction. In this patient with osteopenia, a known nickel allergy, and significant cervical imbalance, the Candy Cane construct allowed for a durable correction of the severe sagittal and coronal plane deformity. The chin-brow angle was corrected by 44°. The coronal Cobb angle improved by 10°. On long-term follow-up, the patient reported continued satisfaction with the operation and was able to perform his activities of daily living. A one-stage, posterior approach along with construct augmentation, with a third rod hooked into a supplementary C2 translaminar screw, can be employed for the correction of chin-on-chest kyphoscoliosis.

Assessing the coronal plane deformity in Charcot Marie Tooth Cavovarus feet using automated 3D measurements

BackgroundThis study assesses the coronal-plane deformities in cavovarus feet secondary to Charcot-Marie-Tooth disease (CMT) using Weightbearing-CT (WBCT) and semi-automated 3D-segmentation software. MethodsWBCTs from 30 CMT-cavovarus feet were matched to 30 controls and analysed using semi-automatic 3D-segmentation (Bonelogic, DISIOR). The software used automated cross-section sampling with subsequent straight-line representation of weighted centre points to calculate 3D axes of bones in the hindfoot, midfoot and forefoot. Coronal relationships of these axes were analysed. Supination/pronation of the bones in relation to the ground and within each joint were measured and reported. ResultsThe most significant deformity in CMT-cavovarus feet occurred at the talonavicular joint (TNJ) with 23 degrees more supination than normal feet (6.4 ± 14.5 versus 29.4 ± 7.0 degrees, p < 0.001). This was countered by relative pronation at the naviculo-cuneiform joints (NCJ) of 7.0 degrees (−36.0 ± 6.6 versus −43.0 ± 5.3 degrees, p < 0.001). Combined hindfoot varus and TNJ supination resulted in an additive supination effect not compensated by NCJ pronation. The cuneiforms in CMT-cavovarus feet were therefore supinated by 19.8 degrees to the ground relative to normal feet (36.0 ± 12.1 versus 16.2 ± 6.8 degrees, p < 0.001). The forefoot-arch and 1st metatarsal-ground angles demonstrated similar supination to the cuneiforms suggesting no further significant rotation occurred distally. ConclusionOur results demonstrate coronal plane deformity occurs at multiple levels in CMT-cavovarus feet. Majority of the supination arises at the TNJ, and this is partially countered by pronation distally, mainly at the NCJ. An understanding of the location of coronal deformities may help when planning surgical correction. Level of evidenceLevel III, retrospective comparative study.

Addressing varus and valgus deformity of the ankle: Algorithmic approach to total ankle arthroplasty

Total ankle replacements have become increasingly popular, providing a viable alternative to ankle arthrodesis in patients with end stage ankle arthritis. Continued advancements in implant design have substantially improved long term survival outcomes as well as patient pain relief, range of motion, and quality of life. Surgeons continue to advance the indications for implantation of total ankle replacements in patients with more severe varus and valgus coronal plane deformity. This report of twelve cases demonstrates our algorithmic approach to total ankle arthroplasty in patients with deformity of the foot and ankle. By proposing a clinical algorithm with case examples, we aim to aid clinicians in successfully approaching coronal plane deformities of the foot and ankle when using total ankle replacement to ultimately improve clinical outcomes.

Midterm Outcomes of the INBONETM II Total Ankle Arthroplasty

As the number of total ankle arthroplasties (TAA) performed continues to increase, understanding midterm outcomes can guide both implant selection and preoperative patient counseling. The purpose of this study was to investigate midterm results including the survival rate and reasons for revision for the INBONETM II TAA. Patients undergoing a primary TAA with the study implant and minimum of 4.6 years postoperative follow-up were reviewed from a prospectively collected database. The primary outcome was implant survival. Secondary outcomes included coronal plane radiographic alignment, evaluation for cysts and osteolysis, and failure mode when applicable. Patients were eligible for inclusion in this study if they had a minimum of 4.6-year follow-up TAA with the study implant. Eighty-five TAAs in 83 patients were eligible for inclusion; 75 TAA in 73 patients were included in the study. The mean duration of follow up was 6.2 ± 0.9 years (range 4.7-8.1 years). Thirty-six percent of the TAAs had a preoperative coronal plane deformity of at least 10°, and 12% of the TAAs had at least 20°. There were 6 (8%) implant failures that occurred at a mean 2.0 ± 1.4 years postoperatively. Eighty-one percent of the TAAs had no reoperation events in the follow-up period. Midterm outcomes at a minimum of 4.6 years postoperatively in patients undergoing a TAA using this implant demonstrates acceptable implant survival, an approximately 20% reoperation rate, and maintenance of coronal plane alignment.

Plantar plate rupture: aetiology, diagnosis and treatment

The fibrocartilaginous plantar plate is a key static stabilizer of the lesser metatarsophalangeal joints and disruption is associated with metatarsalgia which may progress to significant coronal and sagittal plane deformities, most commonly of the second toe. Chronic attrition is by far the most common mode of injury, though rupture can also occur in acute trauma or in association with erosive rheumatoid arthritis. Focal plantar pain and tenderness, positive drawer test, reduced plantar grip strength and lesser toe deformities are key clinical findings. Diagnosis may be further evaluated with plain radiographs and MRI. Clinical and surgical classification systems have been developed expressing the progression from plantar pain without deformity eventually leading to fixed crossover toe. A range of treatment options have been described in the literature including conservative options, osseous decompression techniques, anatomic plantar plate repair and tendon-transfers. There has been increased focus on anatomic surgical repair as a key treatment strategy over the last decade. Whilst promising results in terms of functional outcome are demonstrated in the literature at the short and mid-term, risks of postoperative stiffness and floating toe deformities should not be ignored when counselling patients regarding surgery and conservative treatment should remain first line.

Ilizarov fixation: As a treatment modality of complex tibial diaphyseal fractures

Introduction: Treating difficult non-unions with the Ilizarov technique has been the gold standard method for the last few decades. Here we have used Ilizarov for treating complex tibial fractures. The temporary management of compound fractures of the tibial diaphysis is commonly done with provisional external fixators which is followed by internal fixation. Ilizarov can also be used as a definitive fixation method besides it is more superior and can be the primary and definite choice of fixation where expertise is available. Materials and Methods: This was a prospective study conducted between august 2020 to august 2021 were 30 patients participated. Patients with complex tibial shaft fractures willing for regular follow up and surgical procedure were part of this study. All 30 0articipants were assessed for fracture union radiological and clinically using ASAMI functional and radiological score. The patients were evaluated at regular intervals until fracture union is observed. Results: From total of 30 patients 90% (26 patients) of fracture healed after Ilizarov ring fixation. The frame removed on an average of 177 days from the point of original injury. The healing time of closed fractures was a mean of 164 days. The open fracture healed in a mean time of 212 days. We encountered non-union in 4 patients after primary fixation. All the 4 cases were high velocity injury, classified under 42C2 or 42C3. All the 4 cases were open fractures. Conclusion: Ilizarov ring fixation is a versatile management option for the management of complex tibial diaphyseal fracture which also helps to manage and correct limb length discrepancies, correction of deformity in sagittal and coronal plane, along with managing fracture with bone gap and bone loss.

Distalization of hinge site with use of hinge wire reduces hinge fracture rates in closing wedge distal femoral osteotomy.

Closing wedge distal femoral osteotomies (CWDFO) are attractive treatment options for unicompartmental knee osteoarthritis with coronalplane deformity. However, it has been traditionally associated with high rates of hinge fracture that can adversely impact recovery and patient outcomes. Appropriate siting of hinge point can be an effective method of reducing the incidence of hinge fractures. This study aims to illustrate a case series of CWDFO with low rates of hinge fracture utilising our preferred hinge point site. A retrospective study of a cohort of 39 CWDFO was performed between May 2019 and May 2022. Both medial and lateral CWDFO were included. The hinge point in all cases was placed at the level of the inferior margin of the metaphyseal flare, and inferior to the gastrocnemius origin, with a hinge thickness of 10mm. Post-operative radiographs were obtained at 2, 4 and 8weeks after surgery to assess for hinge fracture and union. Thirty-nine cases of CWDFO were performed, consisting of eighteen cases of valgus malalignment that underwent medial CWDFO and twenty-one cases of varus malalignment that underwent lateral CWDFO. At surgery, the mean age was 47.6 (± 13.9) years and mean BMI was 29.4 (± 4.9). There were 23 men and 16 women. Three cases of hinge fractures occurred intraoperatively, translating into a hinge fracture rate of 7.69%. However, union was achieved in all three cases and all patients in this case series were able to progress to weight bear as tolerated at 2months post-osteotomy. Distal placement of the hinge at the level of the inferior metaphyseal flare margin with the use of a hinge wire can greatly reduce the rates of hinge fracture in CWDFO. Level III.

Total Ankle Arthroplasty in Ankle Arthritis with Coronal Plane Deformity

Total Ankle Arthroplasty in Ankle Arthritis with Coronal Plane Deformity

Meta-analysis on the efficacy and safety of anterior vertebral body tethering in adolescent idiopathic scoliosis.

In this meta-analysis, we analyzed the efficacy and safety of anterior vertebral body tethering in patients with adolescent idiopathic scoliosis. We performed a literature search and analyzed the following data: baseline characteristics, efficacy measures (corrections of the main thoracic curve, proximal thoracic curve, and thoracolumbar curve, thoracic kyphosis, lumbosacral lordosis, rib hump, lumbar prominence and SRS-22 scores, and complications. Analyses were performed with Cochrane's Review Manager version 5.4. Twelve studies met the inclusion criteria. Significant corrections of the main thoracic (MD 22.51, 95% CI 12.93 to 32.09) proximal thoracic (MD 10.14°, 95% CI 7.25° to 13.02°), and thoracolumbar curve (MD 12.16, 95% CI 9.14 to 15.18) were found. No statistically significant corrections were observed on the sagittal plane assessed by thoracic kyphosis (MD - 0.60°, 95% CI - 2.45 to 1.26; participants = 622; studies = 4; I2 = 36%) and lumbosacral lordosis (MD 0.19°, 95% CI - 2.16° to 2.54°). Significant corrections were identified for rib hump (MD 5.26°, 95% CI 4.19° to 6.32°) and lumbar prominence (MD 1.20°, 95% CI 0.27° to 2.13°) at final follow-up. Significant improvements of total SRS-22 score (MD - 0.96, 95% CI - 1.10 to - 0.83) were achieved at final follow-up. The most common complication was overcorrection (8.0%) and tether breakage (5.9%), with a reoperation rate of 10.1%. Anterior vertebral body tethering is effective to reduce the curve in the coronal plane and clinical deformity. Maximum correction is achieved at one year. The method should, however, be optimized to reduce the rate of complications.

Radiographic findings involved in knee osteoarthritis progression are associated with pain symptom frequency and baseline disease severity: a population-level analysis using deep learning.

To (1) develop a deep-learning (DL) algorithm capable of producing limb-length and knee-alignment measurements, and (2) determine the association between limb-length discrepancy (LLD), coronal-plane alignment, osteoarthritis (OA) severity, and patient-reported knee pain. A multicenter, prospective patient cohort from the Osteoarthritis Initiative between 2004 and 2015 with full-limb standing radiographs at 12month follow-up was included. A convolutional neural network was developed to automate measurements of the hip-knee-ankle (HKA) angle, femur, and tibia lengths, and LLD. At 12month follow-up, patients reported their frequency of knee pain since enrollment and current level of knee pain. A total of 1011 patients (2022 knees, 52.3% female) with an average age of 61.2 ± 9.0years were included. The algorithm performed 12,312 measurements in 5.4h. ICC values of HKA and LLD ranged between 0.87 and 1.00 when compared against trained radiologist measurements. Knees producing pain most days of the month were significantly more varus (mean HKA:-3.9° ± 2.8°) or valgus (mean HKA:2.8° ± 2.3°) compared to knees that did not produce any pain (p < 0.05). In varus knees, those producing pain on most days were part of the shorter limb compared to nonpainful knees (p < 0.05). Baseline Kellgren-Lawrence grade was significantly associated with HKA magnitude, LLD, and pain frequency at 12month follow-up (p < 0.05 all). A higher frequency of knee pain was associated with more severe coronal plane deformity, with valgus deviation being one degree less than varus on average, suggesting that the knee tolerates less valgus deformation before symptoms become more consistent. Knee pain frequency was also associated with greater LLD and baseline KL grade, suggesting an association between radiographically apparent joint degeneration and pain frequency. IV case series.

Effects of tension band plating on coronal plane alignment of lower extremities in children treated for idiopathic limb length discrepancy.

One of the most common treatment methods for moderate limb length discrepancy in children is growth modulation using tension band plating. Coronal plane deformities after tension band plating for limb length discrepancy have been documented as an important complication in articles involving heterogeneous groups consisted of both idiopathic cases and patients with pathological physes. The aim of the study was to determine the rate of coronal plane deformities after treatment of a homogeneous group of idiopathic limb length discrepancy cases with tension band plating and to compare screw constructs of medial and lateral plates. Patient files were retrospectively reviewed for amount of limb length discrepancy, anatomical femorotibial angle, mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, and inter-screw angles of each plate on both sides of the tibiae and femora. Measurements at each follow-up period were compared to each other. A total of 26 patient files (37 bones) were included to the study. The mean age was 10.5 years. The mean limb length discrepancy was 27.5 mm. Implants were removed after mean 34.5 months. The mean follow-up period was 58.5 months. There was no significant difference in inter-screw angle on each side of the bones at the time of implantation and in lower limb alignments during follow-up. Treatment of mild-to-moderate idiopathic limb length discrepancy with tension band plating in children was found to be safe against any coronal plane deformity during follow-up until skeletal maturity. Level IV.

Tibiofemoral lift-off and resulting laxity following total knee arthroplasty: Frequency in a series of 906 continuous cases and functional consequences at 4 years’ follow-up in a case-control study

BackgroundTibiofemoral instability is one reason for early revision of total knee arthroplasty. It can be the consequence of tibiofemoral laxity, especially in the coronal plane with tibiofemoral lift-off. But does femoral condyle lift-off on conventional postoperative radiographs suggest the presence of laxity or potential instability? To our knowledge, this question has not yet been answered. This led us to conduct a retrospective study to evaluate (1) the frequency of lift-off on postoperative radiographs, (2) the relationship between lift-off and laxity in the short term and (3) the functional consequences of lift-off. HypothesisPostoperative lift-off is a rare event that is predictive of laxity. MethodsWe carried out a single-center retrospective study using postoperative radiographs from patients who underwent primary total knee arthroplasty between 2014 and 2016. The sample consisted of 906 patients. Lift-off was defined as a tibiofemoral angle of 3° or more on immediate postoperative radiographs (day 0) that were non-weightbearing and had no stress applied. The functional outcomes were determined in the 17 patients identified as having lift-off who had been operated in the first year (2014) to ensure the follow-up was long enough. These patients were compared to 34 matched control patients who were operated the same year and chosen randomly among patients not having lift-off. The matching ratio was 2 controls to 1 case. Preoperative and surgical data were compiled from each patient's electronic medical record. Patients were evaluated at 4 years postoperatively using the subjective Oxford-48, objective HSS score, IKS score, overall patient satisfaction and stress radiographs of the knee. The cases of lift-off observed in 2014 (n=17) were paired with a control group of patients selected randomly during 2014. ResultsThe frequency of the lift-off event was 63/906 or 7%. The frequency was consistent over the three years studied: 7.1% in 2014 (19/269), 6.2% in 2015 (22/354) and 7.8% in 2016 (22/283). There was no significant difference between the two groups (17 with lift-off and 34 without) in the sex, age, body mass index and coronal plane deformity (preoperative HKA angle). At a mean follow-up of 4 years (range 12–49 months), the knees with postoperative lift-off had more laxity (p=0.002), particularly laxity when varus stress was applied (p=0.009). There were no other significant differences in the outcomes. DiscussionImmediate postoperative lift-off after total knee arthroplasty is not a rare event, with a 7% frequency in our study. While it reveals that laxity is present in the particular compartment, there is no evidence of functional consequences at 4 years’ follow-up; however, a long-term assessment is required to verify this finding. Level of evidenceIII – case-control study.

Lateral Trans-Fibular Total Ankle Replacement Capability in Correcting Ankle Osteoarthritis Deformities and Improving Clinical Outcomes

Category: Ankle; Ankle Arthritis; Hindfoot; Other Introduction/Purpose: Total ankle replacement (TAR) has been shown as a viable surgical option to reduce pain, improve function, and preserve ankle joint range of motion in patients with Ankle osteoarthritis (AO). Standard anterior approach TAR capability in correcting deformities is already established by several studies. However, there is a paucity of literature evaluating patient outcomes as well as the potential to correct alignment using a lateral approach TAR. Therefore, the primary objective of this study was to assess the capability of lateral trans-fibular approach TAR in correcting coronal and sagittal plane deformity and secondarily to report the ability to improve patient-reported outcomes (PROs) following lateral TAR. Methods: This IRB-approved, retrospective comparative study included 14 consecutive patients that underwent lateral trans- fibular approach TAR for end-stage AO. Average age and BMI were 63.9 years (range 43-83) and 32.7 kg/m2 (SD 7.5). All patients had received pre- and post-operative weight-bearing CT imaging on the affected foot and ankle. Foot and Ankle Offset (FAO), Talar Tilt Angle (TTA), Hindfoot Moment Arm (HMA), and Lateral Talar Station (LTS) were performed. PROs were collected pre- and post-operatively at the latest clinical follow-up including: PROMIS Global Physical Health score, the Tampa Scale of Kinesiophobia (TSK), the European Foot and Ankle Society (EFAS) score, the Pain Catastrophizing Scale (PCS) and the Foot and Ankle Ability Measure (FAAM) Daily Living Score. One-way ANOVA and Wilcoxon tests were used for comparison at each interval time period. A multivariate regression analysis was then performed to evaluate the association between change in alignment and improvements of PROs. Results: Three of 14 patients (21.4%) underwent a concomitant osseous re-alignment procedure. At an average of 16.1 months (range 11 to 24), all patients demonstrated a significant deformity correction in measurements performed: FAO (7.73% - 3.63%, p=0.031), HMA (10.93mm - 5.10mm, p=0.037), TTA (7.9o - 1.5o, p=0.003), and LTS (5.25mm - 2.83mm, p=0.018). Four of the PROs demonstrated significant improvement postoperatively: TSK (42.7-34.5, p=0.012), PROMIS Global Physical Health (46.1- 54.5, p=0.011), EFAS (5-10.3, p=0.004), and FAAM (60.5-79.7, p=0.04). PROMIS was associated (p=0.0015) with optimization of FAO (p=0.00065) and LTS (p=0.00436), R2 of 0.98). Improvements in TSK were associated with changes in the HMA (p=0.0074), R2 of 0.66. Improvements in FAAM correlated (p=0.048) with improvements in FAO (p=0.023) and TTA (p=0.029), and an R2 of 0.78. Conclusion: In this retrospective comparative cohort study, the results suggest that the lateral trans-fibular TAR can correct different aspects of AO deformity. Clinical benefit was also demonstrated by the impacted PROs, particularly TSK, PROMIS Global Physical Health, EFAS, and FAAM Daily Living. Direct and strong correlations between deformity correction measurements and the significantly improved PROs were found. The obtained data might help surgeons when planning treatment and may serve as the basis for future comparative prospective studies.

Patient Specific Instrumentation and Total Ankle Arthroplasty

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total Ankle Arthroplasty (TAA) can now be performed using Patient Specific Instrumentation (PSI). Advantages include the ability to pre-operatively plan bone resections and implant position and reduce the number of intra- operative surgical steps. The aim of this study was to compare PSI with Standard Instrumentation (SI) in a non-randomised retrospective cohort study with respect to patient reported outcomes, tourniquet time, fluoroscopy time and post-operative alignment. Methods: 159 patients (111 male, 48 female) undergoing a total of 168 INFINITY TAA using PSI (Prophecy, Wright Medical Technology) or SI between 2014 and 2020 were included with a minimum follow up of 12 months. Patient reported outcome measures (PROMS) were obtained pre-operatively and at one year and included the Manchester-Oxford Foot Questionnaire (MOXFQ), Ankle Osteoarthritis Scale (AOS) and EQ-5D Index. Coronal plane deformity correction was assessed using the midline tibiotalar angle (MTTA). Demographics, tourniquet time and intra-operative fluoroscopy times were obtained from the hospital records. Results: There were 106 TAA in the SI group and 62 TAA in the PSI group. The was no significant difference in total MOXFQ, AOS or EQ5D. There was however a significant difference (p=.032) in favour of PSI in the walking/standing domain of the MOXFQ at 12 months. There was a significantly reduced tourniquet time (PSI mean: 95.39 mins, SI mean: 116.87 mins, p&lt;.001) and radiation exposure (PSI mean: 31 seconds, SI mean: 53 seconds, p&lt;.001). Angular correction was more accurate in the PSI group (PSI mean: 1.29°, SI mean: 2.26°, p=.005). Conclusion: This study supports the use of patient specific instrumentation to decrease operative time, reduce intraoperative fluoroscopy and improve accuracy of implantation in TAA. The walking/standing domain of the MOXFQ has been shown to be the most sensitive to change and in this study demonstrated a further potential benefit.

Charcot Arthropathy Limb Salvage with 3D Custom Cage and Dynamic Hindfoot Fusion Nail Combination Fixation: A Case-Series

Category: Diabetes; Ankle; Hindfoot Introduction/Purpose: Patients with Charcot arthropathy with hindfoot collapse present a difficult challenge for foot and ankle surgeons. While traditional limb salvage options include tibiotalocalcaneal (TTC) arthrodesis with accepted shortening, thin wire external fixation, or TTC arthrodesis with bulk femoral head allograft, new 3-dimensional (3D) custom patient specific implants offer a new treatment modality for limb salvage for this difficult issue. The purpose of this case-series is to offer one surgeon's experience with this new treatment technique for limb salvage. Methods: All patients undergoing limb salvage procedures for hindfoot collapse between 2018 and 2022 with a custom 3D hindfoot cage with TTC hindfoot fusion intramedullary nail were included for analysis. Along with patient demographics and length of follow up, patients were asked a series of questions on a telephone survey in order to measure patient reported outcomes including current ambulatory status and whether they would have elected to undergo the same treatment modality again. Complications were also tracked. Finally, radiographs were analyzed to evaluate the degree of deformity correction on both coronal and sagittal planes as well as degree of deformity correction maintenance at last radiographic follow up. Results: 13 patients were included in the analysis. 10 of the 13 patients had Charcot arthropathy. 2 patients had deep infections that ultimately required below knee amputation. 11 out of 13 patients had successful limb salvage as defined by the maintenance of a functional limb without need for amputation. Interestingly, both patients who failed limb salvage and required below knee amputations reported that they would prefer to have undergone the same attempt at limb salvage even with the resulting amputation. Radiographically, the average amount of coronal plane deformity correction was 25 degrees while the average amount of sagittal plane deformity correction was 6 degrees. The average amount of deformity correction maintenance seen at last radiographic follow up was high with a loss of only 0.5 degrees in coronal plane deformity correction loss throughout the time period and an average of 2 degrees of sagittal plane deformity correction loss. Conclusion: While still a challenging pathology to treat, custom patient specific 3D implants combined with TTC hindfoot fusion nail is a viable construct for patients with Charcot arthropathy undergoing limb salvage for hindfoot collapse.

Use of Pro in Evaluating TAA and its Indications

Category: Ankle Introduction/Purpose: The indications for total ankle arthroplasty (TAA) have greatly expanded over the past decade. This rapid growth has been made possible with evidence-based medicine. Patient-reported outcomes (PROs) have been the primary outcome measure in many of these studies. To evaluate the quality of the evidence underlying expanded indications for TAA, we must first understand what PROs have been used in the evaluation of outcomes of TAA. Methods: The goal of this study was to conduct a systematic review of the literature from 2010 to 2021 capturing all studies of TAA to determine what PRO instruments were used, and what facets of TAA practice were studied. Studies reporting on outcomes and PROs following a TAA procedure were selected to review from the PubMed database between January 2010 and July 2021. Results from one hundred sixty-three studies were reviewed and pooled for analysis for this study. Results: After the evaluation of one hundred sixty-three studies, twenty-four separate PRO measures were identified in the literature. The PROs that were most reported in the literature from 2010 to 2021 were American Orthopedic Foot and Ankle Score (AOFAS) (49.1%), 36-Item Short Form Survey (SF-36) (40.5%), visual analog scale - pain (VAS) (35.6%), Ankle Osteoarthritis Scale (AOS) Questionnaire (17.8%), and Short Musculoskeletal Function Assessment (SMFA) (14.7%). The independent variables in these studies included a wide range of modifiable and unmodifiable patient factors such as age (27 studies), BMI (23 studies), smoking (8 studies), and preoperative coronal plane deformity (5 studies). A significant portion of the studies (41%) advocating for expanded indications did so based on the failure to find a difference in groups. Conclusion: The most commonly used PROs for TAA were AOFAS, SF-36, and VAS. The AOFAS score which had been the most commonly used PRO in 2009, is still today despite the determination in 2011 that it is not valid and there is a substantial risk for bias. Newer, validated PRO instruments, such as PROMIS, have not yet attained significant implementation in studies of TAA. The vast majority of the evidence supporting the expanded indications for TAA has come from studies with negative results. Caution should be exercised in interpreting these results and their study implications.

Reliability improvement in Hallux Valgus measurement using weight-Bearing CT scan.

Background: Radiographic assessment of hallux valgus is an essential process. Residual rotational deformity was shown associated with higher recurrent rate. This study aims to comprehensively assess reliability of measurement of various parameters from plain films and weight-bearing CT scan. Methods: A total of 40 pre-operative plain radiographs, 40 post-operative plain radiographs, and 37 weight-bearing CT scan were evaluated to determine reliability of hallux valgus parameters. Results: TSP and head shape representing coronal plane deformity showed lower inter-observer reliability compared to other parameters using for transverse plane evaluation especially in post-operative period. (post-op TSP amongst 3 assessors: κ = 0.386, 0.520, 0.340; post-op head shape: κ = 0.374, 0.375, 0.295) Using α angle for evaluation 1st metatarsal rotation in weight-bearing CT scan demonstrated very good reliability for inter-observer (ICC = 0.853 (95% CI = 0.715-0.925)) and intra-observer (ICC = 0.902 (95% CI = 0.844-0.939)). Conclusion: Weight-bearing CT scan can improve reliability in post-operative coronal plane assessment.

Curve Characteristics and Surgical Outcomes in Scoliosis Associated With Childhood Sternotomy or Thoracotomy.

The purpose of this study is to describe curve characteristics and postoperative outcomes in patients undergoing spinal fusion (SF) to treat thoracogenic scoliosis related to sternotomy and/or thoracotomy as a growing child. A retrospective review of electronic medical records of all patients with Post-Chest Incision scoliosis treated with SF was performed at 2 tertiary care pediatric institutions over a 19-year period. Curve characteristics, inpatient, and outpatient postoperative outcomes are reported. Thirty-nine patients (62% female) were identified. Eighteen had sternotomy alone, 14 had thoracotomy alone, and 7 had both. Mean age at the time of first chest wall surgery was 2.5 years (range: 1.0d to 14.2y). Eighty-five percent of patients had a main thoracic curve (mean major curve angle 72 degrees, range: 40 to 116 degrees) and 15% had a main lumbar curve (mean major curve angle 76 degrees, range: 59 to 83 degrees). Mean thoracic kyphosis was 40 degrees (range: 4 to 84 degrees). Mean age at the time of SF was 14 years (range: 8.2 to 19.9y). Thirty-six patients had posterior fusions and 3 had combined anterior/posterior. Mean coronal curve correction measured at the first postoperative encounter was 53% (range: 9% to 78%). There were 5 (13%) neuromonitoring alerts and 2 (5%) patients with transient neurological deficits. Mean length of hospital stay was 9±13 days. At an average follow-up time of 3.1±2.4 years, 17 complications (10 medical and 7 surgical) were noted in 9 patients for an overall complication rate of 23%. There was 1 spinal reoperation in the cohort. 2/17 (12%) complications were Clavien-Dindo-Sink class III and 5/17 (29%) were class IV. Kyphotic thoracic curves predominate in patients with Post-Chest Incision scoliosis undergoing SF. Although good coronal and sagittal plane deformity can be expected after a fusion procedure, postoperative complications are not uncommon in medically complex patients, often necessitating longer postoperative stays. Level III.