Kempland Walley

Three-Dimensional Morphometric Modeling Measurements of the Calcaneus in Adults with Stage IIB Posterior Tibial Tendon Dysfunction: A Pilot Study

Background: The pathophysiology of adult-acquired flatfoot deformity (AAFD) is not fully explained by degeneration of the posterior tibial tendon alone. While a shortened or dysplastic lateral column has been implicated in flatfoot deformity in pediatrics, there is no study that has quantified the degree of dysplasia in adults with a stage IIb flatfoot deformity, or if any exists at all. Methods: An institutional radiology database was queried for patients with posterior tibial tendon dysfunction (PTTD) who had computed tomography (CT) performed. Controls were patients receiving CT scan for an intra-articular distal tibia fracture without preexisting foot or calcaneal pathology. Clinical notes, physical examination, and weightbearing radiographs were used to find patients that met clinical criteria for stage IIb PTTD. Morphometric measurements of the calcanei were performed involving the length of the calcaneal axis (LCA), height of the anterior process (HAP), and length of the anterior process (LAP). All measurements were performed independently by separate observers, with observers blinded to group assignment. We considered a difference of ±4 mm as our threshold. Results: 7 patients and 7 controls were available for reconstruction and analysis. On average, the LCA was 3.1 mm shorter in patients with stage IIb PTTD compared with controls (P < .05). The LAP was shorter in PTTD patients compared with controls 3.4 mm (P < .001). Conclusions: Our results support the hypothesis that the calcaneus of adult patients with stage IIb AAFD is dysplastic when compared with healthy controls, which further supports the utility of lateral column lengthening. Levels of Evidence: Level III: Case-control study

Short- to Mid-Term Outcomes Following the Use of an Arthroereisis Implant as an Adjunct for Correction of Flexible, Acquired Flatfoot Deformity in Adults

Background. The use of an arthroereisis implant for the treatment of adolescent flatfoot deformity has been described. However, data that address the outcomes of patients treated with an arthroereisis implant in adults are limited. The purpose of this study was to investigate the radiographic and clinical outcomes and complications following the use of a subtalar arthroereisis implant as an adjunct for correction acquired flatfoot deformity secondary to posterior tibial tendon dysfunction. Methods. A retrospective case-control study was performed querying all patients undergoing surgical flatfoot correction between January 1, 2010 and January 1, 2015. The experimental group included patients undergoing arthroereisis augmentation at the time of flatfoot correction. Patients undergoing the same flatfoot correction without the use of an arthroereisis implant were used as controls. Radiographic measurements were evaluated preoperatively and at final radiographic follow-up and included talonavicular (TN) coverage angle, and lateral talar–first metatarsal angle (T1MA). Patient-reported outcomes were assessed using preoperative visual analog scale (VAS) pain scores and postoperative Short Form–36, VAS, and satisfaction at final orthopedic follow-up. Results. A total of 15 patients underwent flatfoot correction and were augmented with an arthroereisis implant and were matched with 30 controls. Postoperative, mid-term T1MA and regional analysis was found to be improved in the experimental group versus control. Patients undergoing adjunct subtalar arthroereisis demonstrated an increased likelihood of achieving radiographically normal talonavicular coverage <7° compared with our control group at follow-up. Conclusions. The adjunct use of an arthroereisis implant resulted in improved and maintained radiographic and clinical measurements in patients undergoing stage II flatfoot. Clinical Significance. These results suggest utility of a subtalar arthroereisis implant as an adjunct to flatfoot correction with little additional risk of harm to the patient. Levels of Evidence: Level III: Case-control study

Prognostic risk factors for complications associated with Tibiotalocalcaneal fusion with a nail

Methods: Clinical and radiographic outcomes for 82 patients from 2012-2016 who underwent TTC fusion with intramedullary nailing were retrospectively evaluated. Postoperative complications of nonunion, infection, reoperation, and hardware failure were included for comparison. Patient dependent variables and surgeon dependent variables were evaluated for association with these postoperative complications.

Prognostic Risk Factors for Complications Associated with Below the Knee Amputations

Category: Other Introduction/Purpose: Below the knee amputation (BKA) is an effective surgical procedure for individuals with severe injury or infection to their lower extremities. However, patients who receive these procedures are subject to significant morbidity and a high rate of postoperative complications due to the presence of multiple concomitant comorbidities. Despite the wide practice of this intervention, prognostic risk factors aiding in predicting surgical outcomes in these patients are poorly understood. The purpose of this study is to evaluate risk factors that may contribute to the outcomes of BKA procedures. Methods: The clinical and radiographic outcomes for 89 patients ages 19-90 who underwent BKA were retrospectively evaluated from 2012-2017. Postoperative complications of mortality, infection, and reoperation were evaluated with patient and surgical variables. Patient variables included: age, ambulatory status, obesity, diabetes, HbA1C2 levels, neuropathy, smoking, Charlson Comorbidity Index (CCI), and American Society of Anesthesiologists (ASA) classification. Surgical variables evaluated included: presence of pre-op infection, pre-op ambulatory status, tourniquet time, tourniquet pressure, and usage of prophylactic antibiotics. Results: Of the patients evaluated there was an overall complication rate of 49% (44/89) and a mortality rate of 19% (17/89). Patients with diabetes (p=.035), a greater score on the Charlson Comorbidity Index (p=.001), and an ASA classification =3 (p=.005) were associated with a greater risk of mortality. Operative values (i.e. tourniquet time, tourniquet pressure etc.) did not affect patient mortality rates in a significant way, but there was a higher incidence of complications (i.e. mortality, post-op infections, and reoperations) with patients with pre-operative infections. Conclusion: Diabetes, a higher CCI score and a greater ASA value were found to be significant predictors of patient mortality after BKA (p<0.05). Future perioperative optimization in these patients identified as high risk may improve patient outcomes in the future.

Morphometric Measurements of the Calcaneus in Adults with Stage IIb, Posterior Tibial Tendon Dysfunction: Is the Lateral Column Short?

Category: Hindfoot Introduction/Purpose: The pathophysiology of adult-acquired flatfoot deformity (AAFD) is not fully explained by degeneration of the posterior tibial tendon alone. While a shortened or dysplastic lateral column has been implicated in flatfoot deformity in pediatric population, there is no study that has quantified the degree of shortening or dysplasia in adults with a stage IIb flatfoot deformity, or if any exists at all. The purpose of this study was to use reconstructive 3D modeling from computed tomography (CT) scans of the calcaneus in order to perform three-dimensional morphometric measurements of the lateral column in patients with stage IIb posterior tibial tendon dysfunction (PTTD) compared to controls in an effort to better understand the morphology of patients with AAFD. Methods: After IRB approval, an institutional radiology database was queried for patients with PTTD who had CT performed between January 2011 and June 2016. Controls were patients receiving CT scan for an intraarticular distal tibia fracture without preexisting foot or calcaneal pathology. Clinical office notes, physical examination, and weight-bearing radiographs were used to identify patients that met clinical criteria for stage IIb PTTD. A 1:1 match was performed using age, laterality, gender, and BMI. Morphometric measurements of the calcanei were performed involving the length of the calcaneal axis (LCA), height of the anterior process (HAP), and length of the anterior process (LAP) (Figure 1). Linear mixed-effects models were used to assess the differences between control and PTTD patients with respect to LAP, HAP, and LCA measurements, with also considering measurements from 3 independent observers. We considered a difference of ± 4 mm as our threshold of clinical significance. Results: Of the 3586 CT within our institutional database, a total of 14 patients were available for reconstruction and analysis. There were no statistical differences detected between patient characteristics or demographics between these groups. On average, the long axis of the calcaneus (LCA) was 3.1 mm shorter (95% confidence interval: 0.43-5.76 mm) in patients with stage IIb PTTD compared to controls (p<0.05). Additionally, the distance from the articular margin of the posterior facet to the anterior process (LAP) was shorter in PTTD patients compared to controls 3.35 mm (p<0.001; 95% confidence interval: 1.82- 4.88). Comparison of observers demonstrated high agreement between LCA and LAP measurements, as illustrated by satisfactory concordance correlation coefficients. Conclusion: Our results support the hypothesis that the calcaneus of adult patients with stage IIb AAFD is, indeed, dysplastic when compared to healthy controls, which further supports the utility of LCL. Analysis of these results, taken together with previous literature, may suggest the use of a smaller graft between 4-6 mm as ideal when performing this procedure.

The Role of 3D Reconstruction True-Volume Analysis in Osteochondral Lesions of the Talus: A Case Series

Background: Evaluation and management of osteochondral lesions of the talus (OLTs) often warrant advanced imaging studies, especially in revision or cases with cystic defects. It is possible that orthopedic surgeons may overestimate the size and misinterpret the morphology of OLT from conventional computed tomography (CT), thereby influencing treatment strategies. The purpose of this study was to determine the utility of a novel means to estimate the true-volume of OLTs using 3D reconstructed images and volume analysis. Methods: With Institutional Review Board approval, an institutional radiology database was queried for patients with cystic OLTs that failed previous microfracture, having compatible CT scans and magnetic resonance imaging (MRI) between 2011 and 2016. Fourteen patients met inclusion criteria. Of these, 5 cases were randomly selected for 3D CT reconstruction modeling. Ten orthopedic surgeons independently estimated the volume of these 5 OLTs via standard CT. Then 3D reconstructions were made and morphometric true-volume (MTV) analysis measurements of each OLT were generated. The percent change in volumes from CT were compared to MTVs determined from 3D reconstructive analysis. Results: On average, the volume calculated by conventional CT scanner grossly overestimated the actual size of the OLTs. The volume calculated on conventional CT scanner overestimated the size of OLTs compared to the 3D MTV reconstructed analysis by 285% to 864%. Conclusions: Our results showed that conventional measurements of OLTS with CT grossly overestimated the size of the lesion. The 3D MTV analysis of cystic osteochondral lesions may help clinicians with preoperative planning for graft selection and appropriate volume while avoiding unnecessary costs incurred with overestimation. Level of Evidence: Level IV, case series.

Mid-term Outcomes & Complications Following the Use of an Arthroereisis Implant to Aid in Stage II Flat-Foot Correction in Adults: A Case-Control Study

Category: Hindfoot Introduction/Purpose: The use of an arthroereisis implant to augment a stage II, flat-foot reconstruction in adults has been described and may improve postoperative alignment. Yet, painful hardware has been reported. Additionally, there are no reports of mid-term follow up on these implants. The purpose of this study is to describe the mid-term clinical and radiographic outcomes as well as complications with the use of an arthroereisis implant as an adjunct procedure for patients undergoing surgical correction of a flexible acquired, stage II, flat-foot deformity as compared to controls Methods: With IRB approval, all patients undergoing stage II, flat-foot reconstruction by the senior author were identified from 2010-2015. A search was conducted to identify patients within this group undergoing implantation of an adjunctive arthroereisis implant during reconstruction. A 2:1 match using age and gender was performed to identify controls undergoing flexor digitorum longus transfer, medial calcaneal osteotomy, spring ligament repair, and Strayer lengthening during the study period. Demographic information, patient records, operative reports, and follow-up radiographs were reviewed. Preoperative and final follow-up, AP and lateral, weightbearing, radiographs measuring talo-1st metatarsal angle, talo-2nd metatarsal angle, and talo-navicular coverage angle were reviewed and recorded. Clinical follow-up was performed to administer satisfaction SF-36 scoring, and to determine survivorship. Patients undergoing additional corrective procedures at the initial surgery or incomplete records were excluded. Results: 48 patients, age 49.7 (range, 16-68), were included, 16 patients received an arthroereisis implant, 4 were metallic and 12 were bioabsorbable. Follow-up was conducted at 3.54 years (range, 1.4-6 years). Radiographic analysis demonstrated significant improvement in alignment from preoperative to mid-term follow-up in both groups. In addition, arthroereisis patients had a statistically significant improvement in correction of talo-navicular coverage angle at final follow-up, 5 degrees ± 3.9, compared to controls, 10.6 degrees ± 6.8. Average SF-36 scores at mid-term follow-up were comparable with no significant difference between cases, 74.6 ± 21.8, and controls, 76.1 ± 15.3 p=0.89. Overall, 84% of patients noted good or excellent satisfaction. Complications included one arthroereisis failure from painful hardware (1/16), one infection in the controls (1/32), and an unrelated mortality. Conclusion: Arthroereisis implants as an adjunct to stage II, flat-foot correction result in improved and maintained radiographic alignment with comparable clinical results to controls at mid-term follow-up. Additionally, the use of the implant demonstrates improved talo-navicular coverage on mid-term radiographs. While painful hardware was noted in a metallic implant, bioabsorbable implants have demonstrated few complications and may be a safe adjunct to stage II, flat-foot correction in adults.