Ariel Palanca

Assessment of compromised fracture healing.

&NA; No standard criteria exist for diagnosing fracture nonunion, and studies suggest that assessment of fracture healing varies among orthopaedic surgeons. This variability can be problematic in both clinical and orthopaedic trauma research settings. An understanding of risk factors for nonunion and of diagnostic tests used to assess fracture healing can facilitate a systematic approach to evaluation and management. Risk factors for nonunion include medical comorbidities, age, and the characteristics of the injury. The method of fracture management also influences healing. Comprehensive evaluation includes an assessment of the patients symptoms, signs, and immune and endocrine status as well as the biologic capacity of the fracture, presence of infection, and quality of reduction and fixation. Diagnostic tests include plain radiography, CT, ultrasonography, fluoroscopy, bone scan, MRI, and several laboratory tests, including assays for bone turnover markers in the peripheral circulation. A systematic approach to evaluating fracture union can help surgeons determine the timing and nature of interventions.

Correlation of intra-articular ankle pathology with cytokine biomarkers and matrix degradation products.

Background: Articular cartilage degeneration is mediated by inflammatory cytokines and fragments of structural matrix proteins. Few studies have examined the role of these biomarkers in intra-articular pathology of the ankle. Methods: Four groups of patients with increasing ankle pathology were enrolled. Group 1 included controls with no pain who underwent unrelated forefoot surgery. Group 2 included patients undergoing arthroscopy with intraoperative mild chondrosis. Group 3 included patients undergoing arthroscopy with moderate/severe chondrosis, osteochondral lesions, impingement, or loose bodies. Group 4 included positive controls with severe arthrosis undergoing ankle arthrodesis/arthroplasty. Ankle fluid was obtained by intra-articular aspiration and was assayed for IL-6, IFN-γ, MCP, MIP-1β, and fibronectin-aggrecan complex (FAC), a matrix-degradation marker. There were 36 patients total, 21 males and 15 females with a mean age 45 (±16; range 18 to 76) years and a mean VAS for pain of 4.7 (±3.5; range 0 to 9). In groups 1 through 4, there were 11, 6, 15 and 4 patients respectively. Results: The mean values of MCP-1 were 49.8 (±8.0) for minimal pathology and 133.9 (±33.0) for substantial pathology (pg/ml). The mean values of the FAC were 2.83 (±1.16) for minimal pathology and 9.62 (±2.23) for substantial pathology (optical density at 450 nm). The groups differed significantly in age, preoperative VAS, FAC, IL-6, and MCP-1 (p < 0.05). Conclusion: There are differences in FAC and MCP-1 with increasing grades of severity of intra-articular pathology. Clinical Relevance: These tests may play a role in determining the necessity for arthroscopy or intra-articular procedures in equivocal candidates. Level of Evidence: II

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.

The Effects of Limb Elevation on Muscle Oxygen Saturation: A Near-Infrared Spectroscopy Study in Humans

Orthopaedic and rehabilitation physicians often instruct patients to elevate a traumatized or postoperative lower extremity. Elevation is thought to improve patient comfort, as well as decrease swelling, wound complications, and the risk of compartment syndrome. Elevating a limb with increased compartment pressures, however, has been shown to reduce perfusion pressure and contribute to tissue ischemia. This investigation aims to advance our understanding of the tissue effects of limb elevation using a healthy patient model.

Sport and physical activities in patients with Chronic Achilles tendon rupture reconstruction using flexor hallucis longus transfer

Category: Sports Introduction/Purpose: Neglected or chronic Achilles tendon ruptures can be significantly disabling to patients if the muscle-tendon unit is stretched beyond its normal passive limit. Chronic rupture of the Achilles tendon (delayed diagnosis of more than 4 weeks) can result in retraction of the tendon and inadequate healing. Direct repair may not be possible and clinical results may not be satisfactory especially if the distal stump is grossly tendinopathic and when the defect exceeds 5-6 cm. Methods: We evaluated 9 patients (mean age 63) who underwent flexor hallucis longus transfer for treatment of chronic Achilles tendinopathy between May 2014 and January 2017 at a 12 months follow-up. Our results were measured with the SF-12 survey, AOFAS Ankle-Hindfoot Scale and VAS. Activity levels were determined using the Halasi ankle activity scale and the UCLA score obtained preoperatively and 12 months after surgery. Wound complications and tip-toe stance were also assessed. Results: All patients had a significant improvement of AOFAS, VAS and SF-12 scores. The Halasi activity scale and UCLA score were 5.8 and 8.2 respectively 12 months after surgery. Patient reported outcome measures consistently demonstrated improvement in clinical putcomes at 12 months follow-up. The patients went back to full daily function, could single leg heel raise and were gradually returning to sport. No major complications were recorded. Conclusion: Reconstruction of chronic tears of the Achilles tendon with flexor hallucis longus transfer can achieve satisfactory improvements in clinical outcomes at 1 year follow-up.

MRI Utilization by Orthopaedic and Non-orthopaedic providers for acute or chronic ankle pain

Category: Ankle Introduction/Purpose: The use of MRI poses a significant expense in the ever-increasing cost of healthcare. The American College of Radiology (ACR) recommends obtaining ankle radiographs within 6 months prior to MRI in the assessment of patients with acute or chronic ankle pain. In this retrospective utilization study, we examine the compliance rate of both orthopedic and non-orthopedic providers at two academic centers. We hypothesize that there is an over utilization of resources by non- orthopaedic surgeons. Methods: We retrospectively reviewed 721 patient charts (4/2015-11/2016) who had an ankle MRI. We analyzed the preceding conservative management and subsequent non-operative or surgical care of the patient, and made note of the ordering physician and whether or not radiographs were obtained prior to ordering an MRI. We also performed an analysis of diagnosis and identified common diagnoses that were associated higher levels of non-compliance to the ACR criteria. Results: Overall, we determined that 222 of the 259 (85.7%) of the orthopedic providers obtained radiographs prior to MRI while only 271of 462 (58.7%) non-orthopedic providers followed these criteria (p<0.0001). In total, we found that 493 out of 721 (68.4%) providers ordered ankle radiographs prior to MRI. Among orthopedic providers showing non-compliance with the ACR criteria, the most common patient diagnoses were tendinopathy and not obtaining new radiographs when radiographs were older than 6 months. Among non-orthopedic providers, the most common diagnoses were edema and tendinopathy. Conclusion: We found that orthopedic providers adhered much more closely to the ACR criteria, and that there is a significant over-utilization of resources by all providers, with an overall inappropriate use percentage of 32.1%. Increasing the compliance rate could prove to be an effective mechanism for decreasing the cost healthcare in the treatment of ankle pain.

STAR™ Ankle Patient Outcomes at 15 Year Follow Up

Category: Ankle Arthritis. Introduction/Purpose: 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 design available in the United States. Current studies show 89-94% survivorship of the STAR™ at 9-12 years follow-up. We report patient outcomes at a minimum of 15 years. Methods: 24 patients from the initial U.S. STAR™ FDA trial who had undergone no metal revision at 10 year follow-up were available for participation. Radiographic examinations were performed for all patients. Changes in prosthetic position, coronal and sagittal plane alignment, osteolysis, adjacent joint arthritis, and heterotopic ossification were documented. Clinical examinations were performed for 14 patients. Clinical findings, AOFAS ankle/hindfoot scores and SF-36 scores were recorded. All secondary procedures and complications were noted. Implant failure was defined as revision or explant of either the tibial or talar component. Results: 87.5% (21/24) of participants had metal survivorship at a minimum of 15 years. Two patients required revision surgery for aseptic loosening and one required a tibiotalocalcaneal fusion for a progressive coronal plane deformity. Of the 21 patients with metal survivorship, the AOFAS ankle/hindfoot rating scale improved from an average of 39.6 points preoperatively, to an average of 71.6 points at latest follow up (range 42-89). The average SF-36 score was 49.0. Postoperative range of motion averaged 17 degrees (range 5-30°). Adjacent joint arthritis was seen radiographically in 5 patients (23.8%), one which required a subtalar fusion. Two patients required exchange for a broken polyethylene spacer. 11/21 (52.4%) of patients required an additional surgical procedure, 3 of whom required two additional procedures. Average time to subsequent procedure was 10.2 years. Conclusion: Our data shows that if the STAR™ ankle has survived for 10 years, it will likely survive for 15 years. On the whole, patients reported good subjective outcomes, maintaining a near 30 point improvement in AOFAS scores. Revisions after 10 years were seen for aseptic loosening and coronal plane deformity. Patients should be counseled that it is common to have a subsequent procedure, which averaged 10 years postoperative from our experience. Further advancement in instrumentation, polyethylene wear characteristics, and revision implants will likely be the next stage in the advancement of TAA.

Clarification of the History and Use of the STAR Prosthesis

Dear Editor: We recently read the article entitled “Registry Data Trends of Total Ankle Replacement Use,” by Drs. Roukis and Prissel (1), which appeared in the November/December 2013 issue of your journal. We feel the article misrepresents the history and use of the STAR Prosthesis . First, the authors failed to include all of the current and relevant data required to accurately portray the data trends of total ankle replacements. Second, they failed to distinguish between the STAR Prosthesis in the Swedish registry and the STAR Prosthesis available for use in the United States and Canada, leading to a confusing picture about the implant’s use. The most notable omission is “STAR ankle: long-term results” by Mann et al (2), published in May 2011, which reported on 10-year results of its use in the United States. We understand that Roukis and Prissel’s reviewwas based on registry data that did not include our results, but the article is not even mentioned in the discussion section. Thus, their review gives a false picture of the actual usage trends and revision rates associated with the implant. It is a gross oversight on both the part of the authors and the reviewers. Registry data is good historically, but lacks a mechanism to factor in improvements in an implant’s design. For example, some data could be based on the use of an outdated prosthesis, and does not accurately reflect current use trends. This is the case with the STAR Prosthesis , which originally had a single hydroxyapatite (HA) coating over a smooth CoCr surface. The Link Company manufactured this version of the product until 1999, and its use continued for an additional period. Hintermann’s first HINTEGRA prostheses were also HA coated on a smooth CoCr substrate, and these had similar failure rates. The loosening observed was a result of the first generation press-fit HA having an inferior surface for bone adhesion once the HA was resorbed. Link subsequently launched a second version of an HA coated press-fit implant with a rough titanium plasma spray coating under the HA for proper bone adhesion after HA resorption. This is the version of the STAR implant that is currently used in outside the United States, although is not the prosthesis available in the United States. The Norwegian Arthroplasty Registry, as referenced by Dr. Roukis in his letter demonstrated that this newer double-coated version of the STAR had better results specific to the incidence of prosthetic loosening. In the article by Hintermann et al (3), 100% of the STAR ankle revisions he performed were on the discontinued single HA coated prostheses. This was similar to the 23 of 51 HINTEGRA