Andrew Haskell

Osteoarthritis of the Ankle: The Role of Arthroplasty

Abstract Total ankle arthroplasty was developed to reduce pain and retain motion of the ankle joint in patients with osteoarthritis. The ankle joint has unique, complex anatomic and biomechanical characteristics that must be considered in a successful total ankle arthroplasty prosthesis. Initial designs from the 1960s to the 1970s had many failures. Current designs use two or three components, and recent reports on total ankle arthroplasty show consistent good to excellent intermediate clinical results, with up to 90% decreased pain and high patient satisfaction. The follow‐up time of these studies is limited, however, and long‐term studies with 10‐ to 15‐ year follow‐ups are needed. Also, a wide variety of complications has been reported, including osteomyelitis and osteolysis. To limit the number of complications and improve clinical outcome of total ankle arthroplasty, careful patient selection and surgeon experience are important.

Subtalar joint arthrodesis using a single lag screw.

Background: This study tested the hypotheses that fusing the subtalar joint with a single lag screw from the posteroinferior calcaneus to the anterior talar neck is an effective technique and that factors affecting the time to fusion can be identified. Methods: Between October, 1995, and July, 2002, the senior author (RAM) performed 101 isolated subtalar arthrodeses using a technique of single lag-screw fixation from posteroinferior to anterosuperior across the posterior facet of the subtalar joint combined with the application of an autograft taken from the floor of the sinus tarsi and anterior process. The average patient age was 52 (range 17 to 82) years. There were 52 women (53 arthrodeses) and 48 men (48 arthrodeses). Eight of 101 (8%) arthrodeses were revisions. The indications included posttraumatic arthritis (45), posterior tibial tendon dysfunction (18), failed prior ankle joint fusion (14), idiopathic disorders (12), hindfoot coalition (7), rheumatoid arthritis (3), and Charcot-Marie-Tooth disease (2). Fifteen of 101 patients (15%) smoked an average of 0.9 ± 0.5 pack of cigarettes per day. Results: Two of 101 joints did not fuse, resulting in an overall fusion rate of 98%. The average time to fusion was 12.3 ± 3.4 weeks. The presence of a prior ankle fusion significantly prolonged the time to fusion of the subtalar joint (11.9 ± 2.3 vs. 14.9 ± 7.0, p = .003). Other factors, including smoking, revision surgery, patient age, and patient sex, did not affect time to fusion. The fixation screw was removed in 13 of 101 (13%) joints at an average of 8.8 ± 0.5 months. Conclusions: Using a single 7.0-mm lag screw across the posterior facet of the subtalar joint results in fusion of the subtalar joint in 98% of patients. A prior ankle arthrodesis delays the time to fusion of the subtalar joint by 3 weeks. This is a simple and reliable technique for achieving fusion of the subtalar joint.

The University of California at San Francisco international orthopaedic elective.

International volunteerism helps remedy global inequities in orthopaedic care and provides relief for increasing professional disillusionment experienced by many orthopaedic surgeons in the United States. From 1992 to 1998, 41% of residents from the Department of Orthopaedic Surgery at the University of California, San Francisco volunteered overseas. Approximately one half of those have continued volunteering internationally after residency, including many who led later trips with residents. Based on the success of these trips, the University of California, San Francisco Department of Orthopaedic Surgery established a 1-month elective rotation in Umtata, South Africa in conjunction with Orthopaedics Overseas. Seventy-six percent of residents have chosen this opportunity since the programs inception in 1998. The University of California, San Francisco experience suggests that early exposure to international volunteerism during residency promotes continued participation in volunteer activities after graduation. By providing residents with the opportunity to volunteer overseas, the University of California, San Francisco hopes to enhance resident education, foster a lifelong spirit of volunteerism, and serve as a model for other orthopaedic training programs.

Metachronous multicentric giant cell tumor: a case report and literature review.

Metachronous multicentric giant cell tumors of bone are rare. The case of a 47-year-old woman who had a giant cell tumor of the ilium develop 24 years after resection of a giant cell tumor of the proximal tibia is reported. The initial and current surgical approaches for this patient are described. A literature review is presented to show that this patient had the longest disease-free interval documented for a patient with metachronous multicentric giant cell tumors.

Scandinavian Total Ankle Replacement: 15-Year Follow-up:

Background: Over the past decade, total ankle arthroplasty (TAA) has become a mainstay in the treatment of end-stage ankle arthritis. Currently in its fourth generation, the Scandanavian Total Ankle Replacement (STAR) is the only 3-piece mobile bearing ankle prosthesis available in the United States. Our current study reports implant survivorship at 15 years and patient outcomes for a subset of these survivors available for study. Methods: Eighty-four TAAs were performed between 1998 and 2000. Metal component survivorship at 15 years was calculated with a Kaplan-Meier curve. Twenty-four (29%) of 84 patients were available for participation with a minimum 15-year follow-up. Any radiographic changes were documented. All additional procedures and complications were recorded. Clinical findings, self-reported performance and pain evaluations, and AOFAS ankle/hindfoot scores were noted. Results: Metal implant survival was 73% at 15 years. Of the 24 patients available for clinical evaluation, 18 of 24 patients (70.7%) had no change in prosthetic alignment from the immediate postoperative radiograph. Only 1 subtalar fusion was required for symptomatic adjacent joint arthritis. Three patients sustained a broken polyethylene component. AOFAS scores improved from an average of 39.6 points preoperatively, to an average of 71.6. More than half (52.4%) of patients with retained implants required an additional surgical procedure; 3 required 2 additional procedures. The average time to subsequent procedure was 10.2 years. Conclusion: Our small cohort demonstrated STAR ankles with retention at 9 years were highly likely to survive to 15 years, and patients continued to have significant improvement in pain relief and minimal decrease in function. At 15 years from TAA, metal survivorship was 73%. As with all ankle replacements, supplementary procedures were common. Level of Evidence: Level IV, case series.

Implementation of Patient-Reported Outcomes Measurement Information System Data Collection in a Private Orthopedic Surgery Practice

Background: The authors describe a method of collecting patient-reported outcomes (PROs) using computerized adaptive tests (CATs) in a high-volume orthopedic surgery practice with limited resources and no research coordinator. Methods: Patient-Reported Outcomes Measurement Information System CATs were collected prospectively for all clinic patients using a tablet and recorded in the electronic medical record. Scores were compared with validated national norms using single-variable t tests. Linear regression was used to assess age effects. Preoperative and postoperative pain scales were compared using paired t tests. Results: In total, 4,524 CATs were administered during 10,719 visits (42%), reaching 70% as more tablets were introduced. Completing the CATs required 157 seconds. Older patients took more time than younger ones (P < .05). Compared with normalized t scores of 50 ± 10 for the US population, pain intensity was 48.0 (95% confidence interval [CI], 47.8-48.2), pain interference 58.9 (95% CI, 58.6-59.1), physical function 40.1 (95% CI, 39.9-40.3), global physical health 43.4 (95% CI, 41.9-44.9), and global mental health 41.1 (95% CI, 40.89-41.4) (P < .05 for all). Age had a small effect on all domains (P < .05). Approximately 20 patients would be required to demonstrate a 15% change for a 2-tailed, paired study with α = 0.05 and 80% power. After surgery, pain intensity improved from 51.9 ± 8.2 to 44.1 ± 8.5, pain interference improved from 62.5 ± 6.9 to 55.7 ± 8.4, and physical function improved from 37.3 ± 8.9 to 41.5 ± 7.9 (P < .05 for all). Conclusions: Using tablets to administer CATs and entering the data in the electronic medical record for later retrieval was an effective technique to collect PROs. An adequate number of tablets are needed for acceptable completion rates. Modest sample size requirements for comparative studies highlight the potential of these tools and techniques. Level of Evidence: Level II, Prospective Comparative Study

Patient-Reported Outcomes Demonstrate The Value Of Non-Operative And Operative Orthopedic Treatments And Predict The Odds Of Improvement With Surgery

Category: Outcomes Measurement Introduction/Purpose: The importance of patient reported outcomes (PROs) has become increasingly recognized as an important tool to measure our clinical value. The National Institute of Health (NIH) created the Patient-Reported Outcomes Measurement Information System (PROMIS), a series of validated item banks, to help clinicians and researches measure key clinical domains. The PROMIS computer adaptive tests (CAT) may be administered with minimal resources or administrative burden. This study describes the results of administering computer adaptive tests (CAT) to every patient in a high volume Orthopedic Surgery practice. We test the hypotheses that both non-operative treatment and operative treatments improve PRO scores. Furthermore, we test the hypothesis that preoperative scores in these domains may be used to predict chances of improvement after surgery. Methods: The PROMIS CAT was administered prospectively for all patients as part of standard clinic intake and recorded in the patient’s electronic medical record (EMR) at each clinic visit. The PROMIS item banks are normalized to mean 50±10 for the US population. De-identified data was retrospectively extracted from the EMR including PROMIS scores, demographic information, as well as surgery specific information. As of this submission, 1688 PROMIS CATs from March 2015 to September 2016 have been analyzed. Data for initial and final clinic visits, as well as for the final preoperative visit for patients who had surgery, are compared using Wilcoxon Matched Pairs Test for paired samples and Mann-Whitney U Test for unpaired samples. Linear regression is used to assess the association of initial values to change in value after treatment. The effect of stratified initial clinic domain value on odds of improving with surgery is assessed using Analysis of Variance. Results: Non-surgical and surgical patients present with similar pain intensity (49.6±7.9 vs. 49.4±7.8). Surgical patients do not improve prior to surgery, but both improve by their final visit (45.7±7.5, 43.7±8.8, p<0.05). Non-surgical and surgical patients present with similar pain interference (60.0±8.4 vs. 60.3±8.9). Surgical patients do not improve prior to surgery, but both improve by their final visit (56.9±8.8, 54.3±9.4, p<0.05). For surgical patients, change in pain intensity and pain interference correlate with initial values (R2 0.32 and 0.27, p<0.05). The percentage whose pain intensity improves after surgery when initial value is over one SD worse than mean is 96%, within one SD worse than mean is 81%, within one SD better than mean is 56%, and over one SD better than mean is 40% (p<0.05). Conclusion: Both non-operative and operative orthopedic treatments improve patient reported pain intensity and pain interference. For patients that have surgery, patients that present with more severe symptoms tend to improve more with surgery. Furthermore, the odds of improving after surgery can be calculated based on preoperative PRO scores. This may allow surgeons to counsel patients about the potential benefits of surgery with personalized precision that is currently unavailable. Measuring PROs using PROMIS CATs demonstrates the value of both non-operative and operative Orthopedic Surgery care for our patients. Preoperative PRO scores may predict the odds of successful surgical intervention.

Distal Tibial Bone Grafting for Talar Dome Osteochondral Lesions Novel Technique and Clinical Results

Category: Arthroscopy Introduction/Purpose: Osteochondral lesions (OCLs) of the talar dome are very common and often cause disabling pain. Smaller lesions are treated successfully with bone marrow stimulation techniques such as arthroscopic microfracture. Controversy exists, however, about the optimal treatment for larger, cystic lesions. Osteochondral grafting, either allograft or autograft, is the most common technique but is not optimal, as it requires allograft tissue or donor autograft from another joint. This procedure often requires a malleolar osteotomy for access to the talus, which carries inherent morbidity. We describe a technique of treating large, cystic OCLs by transferring structurally intact autograft from the distal tibia to the talus, which can be performed without osteotomy, does not require allograft tissue, and can be obtained from a local donor site. Methods: Twenty-three ankles in 22 patients underwent distal tibial bone grafting procedure for treatment of large, cystic OCLs of the talus. A cancellous autograft bone plug was harvested from the ipsilateral distal tibial metaphysis and implanted into the drilled out talar lesion through a small anterior arthrotomy. The graft may be placed oblique to the talar surface and contoured to match the level of the surrounding subchondral bone. Allograft bone chips were used to backfill the distal tibia donor site. Pre-operative and final post-operative data was available for 11 patients with a minimum of 6 months follow-up. Validated patient reported outcomes scores and other data collected included Foot Function Index (FFI), AOFAS hindfoot score, SF-12, and Visual Analog Scale (VAS) pain. Final postoperative data also included VAS patient satisfaction and PROMIS validated and normalized lower extremity function and pain scores. Comparisons were made by paired t-Test and data reported mean±SD. Results: Mean patient age was 47 (range 15-70). Seven of 11 patients were female. Lesions were all medial and measured 122 mm2 (range 80-160) by 8 mm depth (range 6-9). Average follow-up was 23 months (range 7-33). There were no complications or reoperations. Significant improvement (p < 0.05) occurred in AOFAS Hindfoot score (67±16 to 88±12), FFI (55±20 to 22±17), VAS pain score (6.3±2.4 to 1.4±1.5), and SF-12 (31±9 to 50±10). Final VAS patient satisfaction was 8.5±1.8/10, and 10 of 11 patients reported they would have the procedure again. PROMIS scores (normalized to population mean 50±10) at final follow-up were physical function: 53±6; pain intensity: 40±10; and pain interference: 45±6. Eight of 9 patients who were employed were able to return to full duty without limitation. Conclusion: Distal tibial bone grafting is a safe and effective treatment for large talar OCLs. This technique avoids the need for allograft tissue, distant donor site morbidity, and malleolar osteotomy. Early to mid-term clinical outcomes, including validated outcomes scores, are encouraging. Our results are comparable if not better than the results reported with other described techniques for large talar OCLs. Further follow-up is necessary to define longer-term results, to assess cartilage healing with advanced imaging or second look arthroscopy, and to help define the exact role for this technique in treatment of talar osteochondral lesions.

Association of Short-term Complications With Procedures Through Separate Incisions During Total Ankle Replacement.

Background: Surgeons disagree about the safety of adding adjuvant procedures requiring separate incisions during total ankle replacement (TAR). This study tested the hypothesis that complication rates for patients in the first year after TAR would be greater when combined with procedures through separate incisions. Methods: A retrospective review was performed on a consecutive series of 124 patients who underwent total ankle replacement between 2007 and 2013. Demographics, case-specific data, and postoperative complications over the first year were collected. A chi-square analysis was performed to compare differences in complication rates among patients with and without additional procedures requiring a separate incision. The average patient age was 67±10 years. Fourteen patients (11%) were diabetic and 2 patients (2%) were current smokers. Eighty-seven (70%) had prior trauma leading to arthritis. Ninety-seven (78%) cases used the Scandinavian Total Ankle Replacement (STAR), 16 (13%) Salto Talaris, and 11 (9%) In Bone implants. Ten (8%) cases were revisions. Excluding percutaneous Achilles lengthening, 35 of 124 patients (28%) had a total of 54 adjuvant procedures requiring a separate incision during TAR. These included 9 (7%) calcaneal osteotomies, 8 (6%) medial malleolar fixation, 6 (5%) subtalar fusions, 5 (4%) lateral ligament repair, 4 (3%) open Achilles lengthening, 4 (3%) removal of hardware, 2 (2%) first metatarsal osteotomy, and 8 other procedures. Results: Overall, 32 (26%) of the 124 patients had a complication, including 15 (12%) delayed wound healing, 6 (5%) malleolar fracture, and 11 other complications. At 1 year, 24 (27%) of 89 patients without additional incisions and 8 (23%) of 35 patients with additional incisions, excluding percutaneous Achilles lengthening, had any complication (P = .64). Discussion: This study did not demonstrate an association between additional procedures requiring a separate incision during TAR and early complications. Overall complication rates were similar to previously reported series of TAR. This study suggests that surgeons can add adjuvant procedures during TAR to improve alignment, stability, or treat adjacent segment arthritis without affecting short-term complication rates. The necessity or utility of these adjuvant procedures requires further study. Level of Evidence: Level III, comparative series.