Primary Arthrodesis Research Articles

Midterm Outcome of Subtalar Joint Revision Arthrodesis.

The outcomes of revision subtalar arthrodesis have received relatively little focus in research compared with primary subtalar arthrodesis outcomes. This study aimed to assess the midterm clinical and radiologic results of subtalar joint revision arthrodesis and to analyze the risk factors that might influence the outcome of this procedure. We performed a retrospective review of 20 patients after subtalar joint revision arthrodesis for malunion, using interposition of iliac crest bone graft. The mean age was 55.75 years and the average follow-up lasted for 48.93 months. Eighty-five percent of the patients had at least 1 risk factor identified prior to revision. Patients' satisfaction and functional outcomes were evaluated with the American Orthopaedic Foot & Ankle Society Scale (AOFAS), the Foot and Ankle Outcome Score (FAOS), the Foot Function Index (FFI), and dynamic pedobarography. A fusion rate of 80% was recorded whereas 20% of the cases ended with a painful pseudarthrosis requiring additional surgery. Pedobarographic measurements demonstrated that loading has a propensity toward the lateral column, but no substantial effect on the gait of patients. In this group, the following patient-reported outcomes were observed: 70% of the patients were satisfied, 20% of the patients found the result fair, and 10% were not satisfied with the results. Compared with the preoperative evaluation, postoperative functional scores showed significant improvement on the FOAS, AOFAS, and FFI outcome scales. Revision arthrodesis of the subtalar joint remains a challenging issue with a relatively high rate of nonunion, especially in a population of patients with multiple risk factors. Level IV, retrospective case series.

Lisfranc Injuries

Lisfranc injuries represent a heterogenous group of ligamentous and combined osseous-ligamentous injuries to the tarsometatarsal/midtarsal articulations. Higher-energy Lisfranc injuries rarely present delayed. Operative treatments have included percutaneous reduction internal fixation, open reduction internal fixation, and primary arthrodesis (PA). Outcomes in higher-energy injuries can be poor and salvage by secondary arthrodesis, if not performed as primary treatment, remains an option. Subtle, lower-energy injuries, or purely ligamentous Lisfranc injuries may be commonly overlooked. These injuries frequently require multiple imaging modalities to fully define, and optimal treatment continues to be controversial. It is universally agreed that regardless of surgical treatment, anatomic reduction of the affected joints is critical to maximize function and minimize pain. One prospective randomized controlled trial supports PA for ligamentous Lisfranc injuries and 1 retrospective comparative study reported PA results similarly favorable in both ligamentous and combined osseous-ligamentous injuries. One prospective randomized controlled trial and all other retrospective comparative studies and meta-analyses concluded that PA is not superior to open reduction internal fixation for ligamentous or combined injuries. Arthrodesis remains a successful option for failed prior nonarthrodesis treatments. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reoperation Rates Following Total Ankle Arthroplasty Versus Ankle Arthrodesis for Posttraumatic Indications.

This studied aimed to compare rates of reoperation for patients who received primary ankle arthrodesis (AA) versus total ankle replacement (TAR) for posttraumatic indications between 2010 and 2016 Q2 using a nationwide claims database. A retrospective cohort study analyzing patients who received primary AA or TAR for posttraumatic indications was performed using PearlDiver. Reoperations assessed included prosthetic joint infection (PJI), hardware removal, adjacent joint fusion, and local open reduction internal fixation (ORIF). Multivariable logistic regression was used to compare rates of reoperations at 1 and 2 years postdischarge. A total of 862 (74%) patients received AA and 318 (26%) patients underwent TAR for a posttraumatic indication. At 1 year, 305 (35.4%) AA patients had at least 1 reoperation compared with 55 (17.3%) TAR patients (OR 2.32; 95% CI, 1.68-3.26). At 2 years, 364 (42.2%) AA patients and 66 (20.8%) TAR patients had at least 1 reoperation (OR 2.51; 95% CI, 1.84-3.45). ORIF, hardware removal, and adjacent joint fusions were more likely for AA patients at both time intervals (all Ps < .05). Patients who received primary AA for posttraumatic indications exhibited higher rates of major reoperations in the short to medium term compared with patients who underwent TAR. Level III: Retrospective cohort study.

Ankle fractures in older patients : What should we do differently?

As a result of the demographic developments ankle fractures in older patients are part of routine trauma surgery. Due to comorbidities, such as diabetes mellitus, reduced bone quality and limited compliance in follow-up treatment, these fractures are prone to complications. The primary goal in the treatment of older patients with ankle fractures is to maintain mobility. In contrast to young patients most fractures are unstable pronation-abduction injuries. In the diagnostics the recognition and optimization of factors influencing the outcome, such as the blood perfusion and the generous use of computed tomography (CT) are recommended. As in the case of younger patients, conservative treatment is reserved for stable fracture forms and, if there are contraindications, should also be initiated in the case of unstable injuries. The choice of approaches is different for surgical treatment, which is adapted to the soft tissues, if necessary minimally invasive and increasingly carried out by a posterolateral approach. The initial transfixation can reduce soft tissue problems. Special surgical techniques and implants that provide ahigh level of stability, such as dorsal plate positioning, hook plates, angular stable plate systems and intramedullary systems as well as additional options, such as tibia pro fibula constructs are used. Primary retrograde nail arthrodesis is reserved as asalvage procedure only for exceptional cases. As part of the follow-up treatment, an interdisciplinary approach with respect for and optimization of concomitant diseases seems to make sense.

A Systematic Review Of Primary Ankle Arthrodesis In The Treatment Of Pilon Fractures

BackgroundPilon fractures are severe, intra-articular and comminuted fractures to the distal tibia. They are uncommon injuries and are often associated with fibular fractures. The optimal management of these fractures is widely debated. Open reduction and internal fixation (ORIF) and external fixation have been used to treat these fractures. Ankle arthrodesis is often used in the latter stages of management for end-stage ankle arthritis. The aim of this systematic review was to identify the outcomes associated with using primary ankle arthrodesis in pilon fractures. MethodsOvid Medline and PubMed were searched from the inception of their databases until October 2018. Eligible literature for use in our review included patient cohorts that had been operated in the form of primary ankle arthrodesis. All relevant data was included that met the inclusion criteria. The demographic of the patients with pilon fractures and this operative management were identified. The outcomes of interest were fusion rate, infection rate, length of follow-up and patient reported outcomes. 8 papers were deemed eligible for review. ResultsOf the 8 papers that were eligible, 6 were retrospective studies, 1 was a case report and 1 was an abstract. There were a total of 109 patients included. Fusion rate was 100% in 5 of the studies. 6 of the 7 studies that reported on infection rate had no post-operative infections. Outcome assessment scores were used in 5 of the studies. The SF-36 score, the FOAS and the AOFAS were used. ConclusionsThis review shows that primary ankle arthrodesis yields reasonable results in the management of pilon fractures. However, the quantity and quality of current literature is not sufficient and further studies with larger cohorts and longer follow-up times are warranted.

Early Experience With Locked Intramedullary Wrist Arthrodesis

The most common method of total wrist arthrodesis is dorsal compression plating, which can require revision for soft tissue or tendon irritation. A locked intramedullary system was developed to reduce this complication. The goal of this study was to investigate the complication rate of total wrist arthrodesis using this system in our center. A retrospective chart review of all patients undergoing intramedullary wrist arthrodesis from January 2016 to February 2018 was performed. Nine wrist arthrodeses were performed with locked intramedullary wrist fusion in 5 women and 4 men. The indications for fusion included posttraumatic arthritis in 7 and inflammatory arthritis in 2. Two patients underwent primary arthrodesis and 7 had revision from prior partial wrist fusions. Local bone graft at the radiocarpal joint was used in all cases. The mean follow-up was 27 weeks. Radiocarpal fusion was achieved in 8 patients after the initial procedure and in the ninth patient after revision. There were 6 complications in 4 patients with revision reoperation required in 3. The complications were metacarpal locking screw migration in 3, metacarpal fracture in 1, radiocarpal nonunion in 1, and symptomatic middle finger carpometacarpal nonunion in 1. The revision surgeries include distal screw removal in 1, distal screw removal with replacement in 1, and bone grafting in the radiocarpal nonunion. Use of the locked intramedullary wrist fusion system yields high fusion rates. However, based on the high complication rate, particularly from distal screw migration, and the high revision rate in this series, we recommend caution with the use of this system. Therapeutic V.

Treatment of hindfoot and ankle infections with Ilizarov external fixator or spacer, followed by secondary arthrodesis.

An established treatment strategy in surgical site infection after hindfoot and ankle surgery is a two-stage procedure with debridement and placement of a cement spacer, followed by antibiotic treatment and secondary arthrodesis. However, there is little evidence to favor this treatment over a one-stage procedure with debridement, followed by primary arthrodesis with an Ilizarov external fixator and antibiotic treatment. We compared the infection control andclinical and radiological outcome of a two-stage and a one-stage procedure. In this study, 7 patients with a two-stage revision and 11 patients with a one-stage revision between 2005 and 2015 were included. The primary outcome was infection control (absence of the Musculoskeletal Infection Society PJI criteria) 2 years after the ankle or hindfoot arthrodesis. Secondary outcome measures were the AOFAS hindfoot score and radiological consolidation rate. Infection control was 85% (6 out of 7 patients) in the two-stage group and 81% (9 out of 11 patients) in the one-stage group (p = 1.0). One patient (14%) of the two-stage and two patients (18%) in the one-stage group needed below-knee amputation. In the two-stage group, the mean postoperative AOFAS score was 74.8 (SD:±11.3) versus 71.7 (SD:±17.8) in the one-stage group. Radiological consolidation could be achieved in 71% in the spacer group (n = 5) and in 72% in the Ilizarov external fixator group (n = 9). Infection control, AOFAS score, and radiologic consolidation of hindfoot and ankle arthrodesis were comparable in both groups of patients with complicated postsurgical hindfoot or ankle infections.

Arthrodesis or Open Reduction Internal Fixation for Lisfranc Injuries: A Meta-analysis.

The purpose of this study is to determine if arthrodesis, compared with open reduction and internal fixation (ORIF), produces favorable American Orthopaedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS) scores, and to determine if differences in complication, revision surgery, and secondary arthrodesis rates exist for patients with Lisfranc fracture/dislocation injuries. Searches were performed in PubMed using the keywords "Lisfranc fracture," "metatarsal fracture," "ORIF," "open reduction internal fixation," "arthrodesis," and "fusion." These criteria left 183 articles for review. Exclusions left 21 articles and 2 translations of Chinese abstracts. Data analysis was performed using Student's 2-sample t test for samples of equal variance, and chi-square test for goodness of fit. The t test revealed a significant difference (P = .03) between the average AOFAS score for patients who underwent primary arthrodesis (84.7 ± 6.14) compared with those who were treated with ORIF (78.9 ± 5.09). There was no significant difference for the average VAS scores (P = .33) of the arthrodesis and ORIF groups. The complication rate of arthrodesis patients was significantly lower than ORIF patients (P = .04), and the rates of revision surgery (P = .22) and secondary arthrodesis (P = .53) were not significant between the groups. The results of this study indicate that arthrodesis may be a better surgical option than ORIF, due to the higher functional scores and the lower complication rate.Levels of Evidence: Level III: A meta-analysis.

Primary Arthrodesis Versus Open Reduction and Internal Fixation Outcomes for Lisfranc Injuries: An Analysis of Conflicting Meta-analyses Results.

The superiority of primary arthrodesis (PA) versus open reduction and internal fixation (ORIF) in Lisfranc injuries has been debated. Meta-analyses comparing these surgical options have reached contradicting conclusions. The goal of this article is to determine why different conclusions were reached and provide clarity on the comparable outcomes of PA and ORIF in Lisfranc injuries. A systematic literature review was conducted by searching for "meta-analysis" AND "Lisfranc" with keywords such as "ORIF" OR "open reduction" OR "arthrodesis" OR "fusion." Five meta-analysis articles discussing PA and ORIF in Lisfranc injuries were identified. Study outcomes were extracted from each article, and contradicting conclusions were identified for analysis. PA had lower rates of hardware removal. There was no difference between PA and ORIF when considering revision surgery, anatomic reduction, postoperative infection, total complications, and patient satisfaction. However, contradicting conclusions were reached for return to duty, the American Orthopaedic Foot and Ankle Society (AOFAS) score, and visual analogue scale (VAS) score. Conclusions. There was no difference in PA and ORIF for return to work and VAS score. Repeat meta-analysis with truly equivocal outcomes would be necessary to reach a valid conclusion for return to full activity and AOFAS midfoot scores. Level II: Therapeutic studies.

First Metatarsophalangeal Arthrodesis After Failed Distal Chevron Osteotomy for Hallux Valgus.

The purpose of this study was to compare the clinical outcomes after first metatarsophalangeal (MTP) joint arthrodesis for hallux rigidus between patients who underwent primary arthrodesis and those who had had a prior surgery for hallux valgus. Our design was a retrospective cohort study comparing 29 patients who underwent primary arthrodesis (primary group) and 34 patients with hallux rigidus after hallux valgus surgery (secondary group). The clinical assessment included the American Orthopaedic Foot & Ankle Society (AOFAS) score and a visual analog scale (VAS) for pain. Radiological evaluation was also performed. Overall, the mean postoperative follow-up was 3.4 (range, 2-5) years. At final follow-up, AOFAS and VAS pain scores significantly improved in both groups (P = .001). However, the mean AOFAS (P = .001) and VAS pain (P = .008) scores were significantly better in the primary group than in the secondary group. Radiologically, there were no significant differences between the groups in any angle after arthrodesis. Revision surgeries were not required in the primary group. In the secondary group, there was 1 revision due to deep infection, and 3 other patients required dorsal plate removal. Excluding plate removal, the Kaplan-Meier survival at 3 years was not significantly different between groups (P = .775). Although arthrodesis of the first MTP joint was an effective procedure for hallux rigidus, the clinical outcomes in patients who had prior hallux valgus surgery were worse than those for patients who underwent primary surgery for hallux rigidus. Level III, retrospective cohort study.

Staged surgical treatment of open Lisfranc fracture dislocations using an adjustable bilateral external fixator: A retrospective review of 21 patients.

The aim of this study was to assess the early operative results of a staged progressive reduction technique using a bilateral external fixator in the treatment of patients with open Lisfranc fracture dislocations. In this retrospective study, 21 patients (5 women and 16 men; mean age=44.4 years; age range=24 to 69 years) with open Lisfranc fracture dislocations were included. All the patients were treated in a staged manner from 2012 to 2015. The mean follow-up was 15.4 months (range=12 to 24 months). A two-stage surgical protocol was performed for each patient. At the first stage, a bilateral spanning external fixator was applied across the injured Lisfranc joint, and the length of the disrupted columns was restored by distraction process. Vacuum-assisted closure was used if required. At the second stage, the external fixator was removed, and open reduction and internal fixation were carried out. The time interval between the first and second stages and postoperative complications were documented. To assess the functional status of the patients, the visual analog scale (VAS) and the American Orthopaedic Foot - Ankle Society (AOFAS) midfoot scale were measured at the final follow-up. Radiographic parameters indicating the alignment of the midfoot after the second operation were examined. Deep infection in one patient and superficial infection in 2 patients were observed. Venous thrombosis was detected in 3 patients. The mean interval between the first and second stages was 18.6 days (range=8 to 48 days). The first metatarso-cuneiform step-off (p=0.002) and the second metatarso-cuneiform step-off (p=0.000) significantly improved at the final follow-up. The mean VAS score was 2.4 (range=0-5), and the mean AOFAS score was 76.3 (range=63 to 97). Primary arthrodesis was performed in seven patients, and six of the remaining 14 patients developed post-traumatic arthritis. With a low risk of complications, the staged progressive reduction protocol using an adjustable bilateral external fixator can be an effective treatment to achieve and maintain anatomic reduction for patients with open Lisfranc fracture dislocations in a short-time follow-up. Level IV, Therapeutic study.

Open Reduction and Primary Subtalar Arthrodesis for Acute Intra-articular Displaced Calcaneal Fractures.

To evaluate the rate of subtalar arthrodesis based on a computed tomography (CT) scan after open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneal fractures. Retrospective chart review. Single tertiary care practice. A retrospective chart review was performed to identify patients who sustained an acute, displaced, intra-articular calcaneal fracture and underwent open reduction and primary subtalar arthrodesis. Thirty-five patients participated in the study. Each patient included in the study was treated with open reduction and primary subtalar arthrodesis. All patients were evaluated with CT for arthrodesis of the posterior facet of the subtalar joint, which was quantitated. Other outcome measures included radiographic parameters, the Veterans RAND Item Health Survey, and the Foot and Ankle Ability Measure. The median patient age was 47.8 years (range 21.5-79.5 years). The median patient follow-up was 34.4 months (range 4.6-104.1 months). The Sanders classification was as follows: 3% (1/35) type II, 40% (14/35) type III, and 57% (20/35) type IV. Based on a CT scan, primary subtalar union occurred in 94.3% (33/35) of patients. Open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneus fractures has a high rate of union and good pain and function outcomes. It should be strongly considered for patients with significant cartilage injury and comminution of the posterior facet. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Primary Arthrodesis Versus Open Reduction and Internal Fixation Outcomes for Lisfranc Injuries: An Analysis of Conflicting Meta-analysis Results

Category:Midfoot/ForefootIntroduction/Purpose:The superiority of Primary arthrodesis (PA) versus open reduction and internal fixation (ORIF) in Lisfranc injuries has been debated for decades. In recent years, researchers have attempted to use meta-analyses to reach a definitive conclusion. However, they have reached uncertain and contradicting conclusions when comparing these treatment options, which has led to more confusion. The goal of this paper is to navigate the primary source data of each meta-analyses to determine why different conclusions were reached and provide surgeons with more clarity on the comparable outcomes of PA and ORIF treatment options in Lisfranc injuries.Methods:A systematic literature review was conducted by searching for ‘meta-analysis’ AND ‘Lisfranc’ with keywords such as ‘ORIF’ OR ‘open reduction’ OR ‘Arthrodesis’ OR ‘fusion’. Five meta-analysis articles discussing PA and ORIF in Lisfranc injuries were identified. Study outcomes were extracted from each article for comparison. Contradicting conclusions were identified, and the primary sources used by each meta-analysis was analyzed.Results:All meta-analyses agreed that PA had lower rates of hardware removal and that there is no significant difference between PA and ORIF when considering revision surgery, anatomic reduction, postoperative infection, total complications, and patient satisfaction. However, contradicting conclusions were reached regarding functional patient outcomes such as return to duty, the American Orthopaedic Foot & Ankle Society (AOFAS) score, and visual analogue scale (VAS) score.Conclusion:PA has favorable rates of hardware removal compared to ORIF, while no difference between PA and ORIF was found for revision surgery, anatomic reduction, postoperative infection, total complications, and patient satisfaction.While certain meta-analyses had contradicting conclusion as to which treatment option is favorable for returning to duty, AOFAS score, and VAS score, it was determined there was no significant difference in PA and ORIF for return to work and VAS score. Repeat meta- analysis with truly equivocal outcomes would be necessary to reach a valid conclusion for return to full activity and AOFAS midfoot scores.

Arthrodesis Tarsometatarsal in Lisfranc Fracture: Comparison of Different Fixing Methods

Category:Midfoot/Forefoot; TraumaIntroduction/Purpose:Lisfranc fractures are rare, but with a high degree of morbidity. Post-traumatic degenerative changes that result in pain and deformity, are common; with arthrodesis being a treatment option. There are several implants for midfoot arthrodesis, but with little literature regarding the best method for achieve bone fusion. We analice the fusion rates, comparing different joint stabilization techniques.Methods:A retrospective descriptive study of 20 patients with post traumatic osteoarthritis of the midfoot was performed, who underwent midfoot arthrodesis, between January 2016 - January 2018. The comparison between arthrodesis techniques with compression plate (CP) vs plates and / or screws (PS) was made. Data analysis was performed with SPSS software.Results:The fusion times were compared between the 2 groups, CP 18.7 (+- 8.01) vs PT 16.86 (+- 11.5) weeks, without significant differences. There were also no significant differences when comparing the discharge times between the 2 groups, CP 8 (+- 1.84) vs PS 9 weeks (+- 2.36) (p = 0.312). However, when comparing the proportion of complications between both groups, the CP group has lesser than the PS group (42.8% vs 83.3%). This difference was not statistically significant (p = 0.95) although there is a tendency for CP to have fewer complications. In addition, the proportion of complications in primary vs. secondary arthrodesis, 25% vs. 75% respectively, was compared, finding statistically significant differences (p = 0.028)Conclusion:At the moment, there is a lack of evidence to recommend the exclusive use of implants. However, when comparing complications between both groups, there would be a tendency that the use of compression plates would have fewer complications. In addition, it could be inferred that in patients with lesions with greater joint destruction, primary arthrodesis is valid as an option.

Complications Associated with Lisfranc Injury Open Reduction Internal Fixation versus Primary Arthrodesis: A Matched Cohort Study

Category:Trauma; Midfoot/ForefootIntroduction/Purpose:Lisfranc injuries are complex injuries of the midfoot in which the optimal course of treatment remains controversial. The objective of this study was to identify whether open reduction and internal fixation (ORIF) was associated with greater risk for surgical complications and/or greater financial burden in comparison to a primary arthrodesis (PA).Methods:A retrospective database review was conducted using the PearlDiver database to identify all Medicare patients who underwent a Lisfranc ORIF or PA in an inpatient setting from 2006-2013. Exclusion criteria included age >85 years and a prior history of foot or ankle trauma/infection/malignancy within 5 years of index surgery. Patients were matched in a 1:1 statistical manner to precisely control for potential influence of comorbidities and demographics, resulting in two cohorts with 2746 patients in each. Perioperative complications (within 30 days) were compared between the cohorts, in addition to the respective costs associated with each procedure. Complications were broken down into major (PE/DVT, MI, CVA, sepsis, mortality, nerve injury) or minor (UTI, PNA, hardware failure, transfusion, wound complications) categories.Results:No significant differences in major perioperative complications were noted between the two procedures. Significant differences were however noted in the incidence of minor perioperative complications, including higher rates of hardware failure (OR 0.26 (CI 95%, 0.07-0.752, P=0.021) and transfusion (OR 0.37 (CI 95%, 0.13-0.94, P=0.045) in the ORIF cohort. There was additionally a higher incidence of 30 day readmission (OR 0.35 (CI 95%, 0.24-0.51, P<0.001) with ORIF. Length of hospital stay (LOS) was shorter in the PA cohort (x̅; = 2.59 days) compared to the ORIF cohort (x̅; = 5.58 days, p < 0.001). Higher mean total hospital costs were noted for ORIF (x̅ = $66,342.56) compared to PA (x̅ = $40,761.65, p < 0.001).Conclusion:Within our study population, ORIF has a significantly higher rate of hardware failure and transfusion, and 2.5 times the risk of readmission within 30 days. When comparing the total cost of care, there was a significantly greater cost with ORIF. LOS was also significantly longer in the ORIF group. One weakness of this study was the ability to account for patients <65, as these were pooled into a single age group by the database. While revealing with regard to the aforementioned variables, further research still needs to be conducted on the functional outcomes of these procedures.

Arthroscopic Tibiotalar Arthrodesis versus Open Arthrodesis with Anterior Locking Plate: A Retrospective Case Series

Category:Ankle; Ankle Arthritis; ArthroscopyIntroduction/Purpose:Tibiotalar arthrodesis is a common procedure for the treatment of ankle arthritis. Arthroscopic arthrodesis with screw fixation has become increasingly popular with reported shorter hospital stays, shorter time to fusion, and equivalent patient reported outcomes to open arthrodesis with screw fixation. However, there is limited research comparing arthroscopic arthrodesis to open arthrodesis with a modern anterior locking plate. The aim of this study was to determine if the use of a modern anterior locking plate in primary ankle arthrodesis would have a similar time to fusion versus arthroscopic arthrodesis with screw fixation.Methods:We performed a retrospective case review of primary ankle arthrodesis cases from 2009 to 2018 that utilized either an open approach with an anterior locking plate or an arthroscopic approach with screw fixation. All open cases were performed by a single surgeon using an anterior locking plate; all arthroscopic cases were performed by another surgeon using cannulated screw fixation. Post-operative protocol was similar for both patient groups, with at least 6 weeks of casting and protected weight- bearing followed by a transition to removable cast-boot and progressive weight-bearing. Exclusion criteria included combined tibiotalar/subtalar arthrodesis, hindfoot arthrodesis, cases where infection was suspected pre-operatively, and revision arthrodesis for any reason (IE, infection, failed total ankle arthroplasty, prior nonunion). Time to fusion was based on evaluation of post- operative radiographs performed at six and ten weeks.Results:28 open and 25 arthroscopic arthrodesis cases met inclusion criteria. The fusion rate at six weeks was 82.1% (open) versus 72% (arthroscopic). At ten weeks the fusion rate was 100% (open) versus 91% (arthroscopic). 4/28 open arthrodesis cases experienced continued pain versus 8/25 arthroscopic. For the open procedure, one patient required reoperation for skin grafting away from the incision due to a poor-fitting workboot. Two patients had removal of painful hardware; one of these patients required a second reoperation for symptomatic neuroma resection. For arthroscopic cases, two patients had removal of hardware and one patient had an elective below-knee amputation for intractable pain. Average patient age was 53.3 years (open) versus 48.4 (arthroscopic). Average length of hospital admission was 2.3 days (open) versus 0.9 (arthroscopic).Conclusion:Open tibiotalar arthrodesis with a modern anterior locking plate resulted in faster time to radiographic fusion and a lower incidence of continued pain compared to arthroscopic arthrodesis in this study. The faster time to fusion may be due to the superior biomechanical stability of a locking construct. Arthroscopic arthrodesis resulted in shorter hospital admissions, and neither group had any incision-related complications. In this case series, open and arthroscopic fusion had comparable outcomes.

Results of Hallux Metatarsophalangeal Joint Arthrodesis with and without Calcaneus Autograft

Category:Bunion; OtherIntroduction/Purpose:Hallux rigidus is the most common degenerative arthropathy of the foot. Primary hallux metatarsophalangeal (MTP) joint arthrodesis is the most common surgical treatment for end-stage hallux rigidus and can also be utilized for correction of hallux valgus. Though satisfaction rates following hallux MTP joint arthrodesis are very favorable, nonunion rates have been reported as high as 12%. Several studies have investigated how pathology, fixation techniques and joint preparation affect hallux MTP arthrodesis union rates. Many surgeons use orthobiologics and/or autograft to augment arthrodeses about the foot and ankle in an effort to increase union rates. The purpose of this study is to retrospectively compare union rates of hallux MTP joint arthrodesis with and without calcaneus autograft.Methods:A query of our institution’s administrative database was performed to identify patients who underwent a primary hallux MTP joint arthrodesis between February 2016 and February 2017. We compared patients who underwent arthrodesis with and without calcaneus autograft. Surgeon preference dictated use of autograft, as some in our group routinely use graft while others do not. Patients 18 years and older who underwent a primary hallux MTP arthrodesis were included. Patients were excluded if they had radiographic evidence of significant bone loss or if allograft or biologic therapies were used. Patient charts and final radiographs were reviewed. The primary outcome was successful union of the hallux MTP joint arthrodesis. Secondary outcomes included preoperative diagnosis, type of surgical fixation and surgical complications. Data was compared using a student T-test.Results:There were 130 feet included in the final analysis, and 55 underwent hallux MTP arthrodesis with calcaneus autograft. Mean follow-up time was 14.8 weeks. Among all patients, 90.8% had a successful union. There was no difference in union rates between those who underwent arthrodesis with calcaneus autograft (90.9%) compared to without autograft (90.7%; p = 0.96). Hallux valgus was the preoperative diagnosis in 46.1% of cases followed by hallux rigidus (34.6%). The most common fixation method was a lag screw with a dorsal plate (83.8%). Overall, 19 patients (14.6%) had a complication requiring a reoperation with painful hardware (10 patients) being most common. In the autograft group, there were no complications related to the calcaneus autograft donor site.Conclusion:As orthobiologics and local bone autograft gain popularity in foot and ankle surgery, it is important to report clinical outcomes and establish evidence-based guidelines for use. In this relatively large retrospective comparison, the use of calcaneal graft was noted to be safe (no complications from graft site). However, there was no difference in union rate when comparing hallux MTP arthrodesis with and without calcaneus autograft.

A Retrospective Analysis of Outcomes from Foot and Ankle Arthrodesis and Open Reduction and Internal Fixation using Cellular Bone Allograft Augmentation

Category:Other; Ankle; Basic Sciences/Biologics; Hindfoot; Midfoot/ForefootIntroduction/Purpose:Surgical arthrodesis of joints in the foot and ankle is common in patients who have failed nonoperative management for a variety of conditions. ViviGen is an allogeneic cellular bone matrix product that contains lineage-committed bone cells, and can be used as an alternative to autograft bone or other augments in order to aid in arthrodesis or to enhance bony healing in open reduction and internal fixation (ORIF) procedures. However, compared with autograft bone, ViviGen does not introduce potential for donor site morbidity. Due to the lack of studies examining outcomes following foot and ankle surgeries in which ViviGen is utilized, further investigation is required to determine its efficacy and safety for use in foot and ankle joint arthrodesis and skeletal fracture fixation.Methods:This study included 153 consecutive patients undergoing ankle, midfoot or hindfoot arthrodesis or ORIF procedures in which ViviGen was used as an augment. Pediatric patients and cases involving structural allografts or metal wedges were excluded. Patients were not excluded based on the amount of ViviGen used, type of instrumentation or implants used, or due to comorbidity. This series included revision as well as primary arthrodesis procedures and included various fixation types. Retrospective chart review was used to identify patient demographic factors and medical comorbidities, as well as to evaluate clinical and radiographic data to determine outcome.Results:135 patients were available for analysis at final evaluation. 113 patients underwent arthrodesis (mean age of 56.29 years, mean body mass index of 32.19). 22 patients underwent an ORIF procedure (mean age of 36.35 years, mean body mass index of 32.79). The fusion rate for the arthrodesis cohort was 97/113 (85.8%). Table 1 demonstrates the fusion rate stratified by region of the foot. Smokers had significantly lower rates of fusion compared to nonsmokers (p=0.01). There was not a statistically significant difference in the rate of fusion between primary and revision arthrodesis (p=0.8650). The rate of fusion was significantly lower in patients with Charcot foot in comparison to patients without Charcot foot (p=0.0076). The bony healing rate for the ORIF cohort was 19/22 (86.4%).Conclusion:This large case series of patients undergoing a wide variety of procedures about the ankle, hindfoot, and midfoot with ViviGen bone graft augmentation demonstrates satisfactory outcomes with regard to fusion rate and successful union, as well as minimal complications. To date, this is the largest case series in the literature of patients undergoing foot and ankle procedures with an allogenic cellular bone matrix product that contains lineage-committed bone cells. Our findings help to introduce ViviGen as a safe and efficacious alternative to other forms of augmentation for fusion and ORIF procedures about the foot and ankle.

Intramedullary Fixation of Calcaneal Fractures: Early US Experience

Category:Hindfoot; TraumaIntroduction/Purpose:The fixation of displaced intraarticular fractures of the calcaneus have posed many challenges for the surgeon, including an anatomic reduction, fracture stabilization, and soft tissue concerns. The extensible lateral and sinus tarsi approaches must be delayed until soft tissues concerns resolve and despite this are susceptible to wound necrosis and skin infections. Intramedullary fixation allows immediate fixation without soft tissue compromise.Methods:The retrospective case series is comprised of 23 patients; 19 intramedullary fixation of the calcaneus and 4 primary arthrodesis with the FH Orthopedics CalcaNail. Fracture classification, timing to surgery, accuracy of reduction, complications, and outcome were recorded.Results:There were zero wound complications. Bohler’s angle was restored as well as articular surface. One patient required implant removal after healing seconding to prominent hardware. One patient required conversion to a subtalar arthrodesis. There were no implant mechanical failures.Conclusion:The intramedullary fixation of calcaneus fractures has been performed extensively outside the US with documented success. This series of early US experience exhibits similar utility. The ability to reduce the fracture intrafocally and stabilize with a minimally invasive approach have proven useful with no incidence of wound complications. Not to mention no delay from time of injury to surgery is needed.

Functional Outcomes of Open Reduction and Internal Fixation Treatment of Lisfranc Injuries

Category:Midfoot/Forefoot; Sports; TraumaIntroduction/Purpose:Prior reports have suggested that primary partial arthrodesis may be superior to open reduction and internal fixation (ORIF) for the ligamentous Lisfranc injury. Although this may be true for the high energy Lisfranc injury, little has been studied regarding outcomes after operative fixation of low energy Lisfranc injuries. The purpose of this study is to present a large case series of patients who underwent ORIF for low energy ligamentous Lisfranc injuries including functional outcomes, complications, and reoperation rates.Methods:We included adult patients who underwent ORIF for low-energy Lisfranc injuries with fellowship-trained foot and ankle surgeons at our institution within 6 weeks of injury. Patients were excluded if the mechanism of injury or initial radiographs were consistent with a high-energy mechanism such as significant subluxation of multiple tarsometatarsal joints rather than subtle diastasis with weight-bearing images. Patients were also excluded if there were any significant fractures aside from avulsion fractures, other associated injuries, or underlying neuropathic pathophysiology. Patients completed the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscales, Visual Analog Scale for Pain (VAS), and Short Form-12 questionnaires before their procedures and then at least 2 years post-operatively. Standard demographic data was collected. Spearman’s correlations and Student’s t-tests were performed to evaluate outcomes after surgery and any relationship between patient characteristics and functional scores.Results:Eighty-seven patients completed functional scores an average of 4.9 years following their procedure (range 2.0 - 8.9), with average age of 41 and average BMI of 27.5. Fifty-two patients (59.8%) were female, and average time from injury to procedure was 15.2 days (range 1-36). Average FAAM-ADL improved from 27.83 to 88.36 postoperatively (p<.001), average FAAM-Sports improved from 7.47 to 76.36 (p<.001), and average VAS pain rating was reduced from 62.83 to 21.78 (p<.001). Hardware removal was performed in 36 cases (41.4%). One patient required removal of hardware and revision ORIF 30 days after the index procedure as a result of hardware complication. Both age at the time of surgery and BMI were negatively correlated with followup SF-12 Physical Health scores (r=-0.254, p=0.018; r=-0.263, p=0.014 respectively).Conclusion:This study is one of the largest case series of low energy Lisfranc injuries. We demonstrate that ORIF for low- energy Lisfranc injuries results in significant functional improvement and pain reduction while maintaining low rates of loss of correction or reoperation. Further investigation is necessary to evaluate this subset of Lisfranc injuries in terms of optimal surgical treatment patient functional outcomes following the use of primary arthrodesis in the treatment of Lisfranc procedures, and to assess the efficacy of the various hardware choices available for the procedure.