Luigi Manzi

Clinical Outcome and Fusion Rate Following Simultaneous Subtalar Fusion and Total Ankle Arthroplasty

Background: Patients with arthritis or severe dysfunction involving both the ankle and subtalar joints can benefit from tibiotalocalcaneal (TTC) arthrodesis or total ankle replacement and subtalar fusion. TTC fusion is considered by many as a salvage operation resulting in a stiff ankle and hindfoot, considerably limiting global foot function. With the evolution of prosthetic design and operative techniques, total ankle replacement (TAR) has become a reasonable alternative to arthrodesis. The aim of this study was to investigate the fusion rate of the subtalar joint in patients simultaneously treated with total ankle replacement (TAR) and subtalar joint fusion. Methods: This study included 25 patients who underwent primary TAR and simultaneous subtalar fusion between May 2011 and November 2014. Sixteen males (64%) and 9 females (36%) were enrolled with a mean age of 58 years (25-82). Patients were clinically assessed preoperatively and at 6 and 12 months postoperatively. Total follow-up time was 24.2 ± 11.6 months. Radiographic examination included a postoperative computed tomographic (CT) scan obtained 12 months after surgery. Three surgeons independently reviewed the CT scans and interobserver reliability was calculated. Functional scores were also assessed. Results: At 12 months postoperatively, the subtalar fusion rate in patients treated with TAR and simultaneous subtalar fusion was 92%. There was a statistically significant increase in American Orthopaedic Foot & Ankle Society ankle/hindfoot score from 27.9 to 75.1. Ankle range of motion significantly increased from 12 to 32.8 degrees. Additionally, there was a statistically significant decrease in visual analog scale pain score from 8.6 to 2.1. Conclusions: TAR and simultaneous subtalar joint fusion were reliable procedures for the treatment of ankle and subtalar joint arthritis. Furthermore, CT scans showed an excellent reliability among orthopedic surgeons in determining the degree of successful fusion of subtalar arthrodesis. Level of Evidence: Level IV, case series.

Posterior Talar Shifting in Mobile-Bearing Total Ankle Replacement

Background: End-stage ankle osteoarthritis frequently involves multiplanar malalignment in both the coronal and the sagittal planes. Sagittal malalignment often includes anterior translation of the talus relative to the tibia. Restoration of the correct tibial and talar alignment is essential for the long-term survival of total ankle replacement. Methods: This study includes 66 consecutive patients who underwent total ankle arthroplasty with the Hintegra prosthesis from May 2011 to April 2014. There were 28 females (42.4%) and 38 males (57.6%) with a mean age of about 57 years (25-82 years). Patients were clinically and radiologically assessed preoperatively and at 2, 6, and 12 months postoperatively. Results: At 12 months postoperatively, there was a statistically significant increase in American Orthopaedic Foot & Ankle Society scores from 31.9 to 72.3. Range of motion significantly increased from 9.5 to 25.4 degrees. In addition, there was a statistically significant decrease in visual analog scale (VAS) pain score from 8.9 to 2.2. Furthermore, there was a significant increase in the Tibio-Talar ratio from 2 to 6 months postoperatively (34.6%-37.2%). Conclusions: This study demonstrated significant improvements in clinical and radiologic outcomes after Hintegra total ankle arthroplasty. Significant movement of the talus occurs within the first 6 months postoperatively. This may be the result of rebalancing of muscle and ligament forces after surgery. Level of Evidence: Level IV, case series.

Total ankle replacement through a lateral approach: surgical tips

Purpose: Recently, the Zimmer Trabecular Metal Total Ankle Replacement (Zimmer TM TAR) was developed to be used through a lateral transfibular approach. The purpose of this paper is to describe the surgical technique and early outcomes of the TAR via the lateral approach using the Zimmer TM TARs. Methods: Sixty-seven patients underwent primary TAR using the Zimmer TM TAR between May 2013 and May 2015. Patients were clinically evaluated preoperatively and postoperatively at six and twelve months and annually using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot scores, visual analogue scale (VAS) pain score, and the Short Form Health Survey (SF-12) questionnaire. The minimum follow-up was 12 months. Results: The mean AOFAS hindfoot score increased from 32.8 preoperatively to 85.0 at the latest follow-up (p-value < 0.001). The mean VAS pain score decreased from 8.0 to 2.0 at the latest follow-up (p-value < 0.001). The Physical and Mental Health Composite Scale scores (PCS and MCS) of the SF-12 passed from a mean value of 30.2 preoperatively to 43.1 (p-value < 0.001) and from a mean value of 44.6 to 53.5 at the latest follow-up (p-value < 0.001), respectively. Conclusions: We present our surgical tips and the early results of this prosthetic design which are encouraging. They could be useful as an adjunct to the manufacturer’s surgical technique guidance for surgeons who utilize these implants.

Treatment of osteochondral lesions of the talus with autologous collagen-induced chondrogenesis: Clinical and magnetic resonance evaluation at one-year follow-up

PURPOSE the aim of this study is to report the clinical and imaging results recorded by a series of patients in whom osteochondral lesions of the talus (OLTs) were repaired using the autologous collagen-induced chondrogenesis (ACIC) technique with a completely arthroscopic approach. METHODS nine patients (mean age 37.4±10 years) affected by OLTs (lesion size 2.1±0.9 cm(2)) were treated with the ACIC technique. The patients were evaluated clinically both preoperatively and at 12 months after surgery using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and a visual analog scale (VAS). For morphological evaluation, the magnetic resonance observation of cartilage repair tissue (MOCART) score was used. RESULTS the AOFAS score improved from 51.4±11.6 preoperatively to 71.8±20.6 postoperatively, while the VAS value decreased from 6.9±1.8 to 3.2±1.9. The mean MOCART score was 51.7±16.6 at 12 months of follow-up; these scores did not directly correlate with the clinical results. CONCLUSION use of the ACIC technique for arthroscopic repair of OLTs allowed satisfactory clinical results to be obtained in most of the patients as soon as one year after surgery, with no major complications or delayed revision surgery. ACIC is a valid and low-invasive surgical technique for the treatment of chondral and osteochondral defects of the talus. LEVEL OF EVIDENCE therapeutic case series, level IV.

Tibial slope in total ankle arthroplasty: Anterior or lateral approach ☆

BACKGROUND A new total ankle arthroplasty (TAA) system performed through a lateral approach provides direct visualization of the centre of rotation, allowing for accurate reconstruction of the joint alignment and less bone resection. Radiographic references are needed to describe deformities and plan the surgical procedures. The tibial slope is an important factor when treating malalignment. The aim of this study is to show if there is any difference regarding the post-operative tibial slope (β angle) measurement comparing a fixed-bearing TAA through a lateral approach and a mobile-bearing TAA through an anterior approach. METHODS The study included 217 ankles. Between May 2011 and April 2015, 77 patients underwent a TAA with a mobile-bearing implant through an anterior approach and 45 with a fixed-bearing implant through a lateral approach: in these patients the β angle was measured 2 and 12 months postoperatively. 95 subjects with unilateral post-traumatic ankle arthritis composed the control group: in these patients we measured the anterior distal tibial angle (ADTA) of the controlateral, non arthritic tibiotalar joint. RESULTS In the mobile-bearing group, the mean β angle at 2 and 12 months postoperatively was 86.4±3.1 and 86.8±3.1 (p-value=0.12). In the fixed-bearing group, the mean β angle at 2 and 12 months postoperatively was 83.1±5.4 and 83.9±6.5 (p-value=0.26). A statistically significant difference was found between the β angle of the two groups. In the control group the mean ADTA was 84.9±2.5. A non-statistically significant difference was observed only between β angle of the fixed-bearing group and the ADTA of the control group. CONCLUSIONS Regarding the tibial slope, fixed-bearing TAA through a lateral approach showed a more anatomic placement. In contrast, β angle in mobile-bearing group appeared more reproducible than fixed-bearing group.

Autologous Microfractured and Purified Adipose Tissue for Arthroscopic Management of Osteochondral Lesions of the Talus

In recent years, regenerative techniques have been increasingly studied and used to treat osteochondral lesions of the talus. In particular, several studies have focused their attention on mesenchymal stem cells derived from adipose tissue. Adipose-derived stem cells (ADSCs) exhibit morphological characteristics and properties similar to other mesenchymal cells, and are able to differentiate into several cellular lines. Moreover, these cells are also widely available in the subcutaneous tissue, representing 10 - 30% of the normal body weight, with a concentration of 5,000 cells per gram of tissue. In the presented technique, the first step involves harvesting ADSCs from the abdomen and a process of microfracture and purification; next, the surgical procedure is performed entirely arthroscopically, with less soft tissue dissection, better joint visualization, and a faster recovery compared with standard open procedures. Arthroscopy is characterized by a first phase in which the lesion is identified, isolated, and prepared with microperforations; the second step, performed dry, involves injection of adipose tissue at the level of the lesion. Between January 2016 and September 2016, four patients underwent arthroscopic treatment of osteochondral lesion of the talus with microfractured and purified adipose tissue. All patients reported clinical improvement six months after surgery with no reported complications. Functional scores at the latest follow-up are encouraging and confirm that the technique provides reliable pain relief and improvements in patients with osteochondral lesion of the talus.

Reliability of the Phi angle to assess rotational alignment of the talar component in total ankle replacement

BACKGROUND The purpose of this study was to investigate the test-retest reliability of the Phi angle in patients undergoing total ankle replacement (TAR) for end stage ankle osteoarthritis (OA) to assess the rotational alignment of the talar component. METHODS Retrospective observational cross-sectional study of prospectively collected data. Post-operative anteroposterior radiographs of the foot of 170 patients who underwent TAR for the ankle OA were evaluated. Three physicians measured Phi on the 170 randomly sorted and anonymized radiographs on two occasions, one week apart (test and retest conditions), inter and intra-observer agreement were evaluated. RESULTS Test-retest reliability of Phi angle measurement was excellent for patients with Hintegra TAR (ICC=0.995; p<0.001) and Zimmer TAR (ICC=0.995; p<0.001) on radiographs of subjects with ankle OA. There were no significant differences in the reliability of the Phi angle measurement between patients with Hintegra vs. Zimmer implants (p>0.05). CONCLUSIONS Measurement of Phi angle on weight-bearing dorsoplantar radiograph showed an excellent reliability among orthopaedic surgeons in determining the position of the talar component in the axial plane. LEVEL OF EVIDENCE Level II, cross sectional study.

Adipose-derived stem cells in orthopaedic pathologies

Introduction To examine the current literature regarding the clinical application of adipose-derived stem cells (ADSCs) for the management of orthopaedic pathologies. Sources of data MEDLINE,SCOPUS, CINAHL and EMBASE (1950 to April 14, 2017) were searched by two independent investigators for articles published in English. Reviews, meta-analyses, expert opinions, case reports, mini case series and editorials were excluded. Furthermore, we excluded animal studies, cadaveric studies and in vitro studies. Areas of agreement ADSCs seem to produce excellent clinical results. However, the length and modalities of follow-up in the different conditions are extremely variable. Nevertheless, it appears that the use of adipose-derived stem cells is associated with subjective and objective clinical improvements and minimal complication rates. Areas of controversy None of the studies identified is a randomized double-blinded trial, and most of the selected studies present major limitations, and different methods, confounding the results of our review. Growing points It is necessary to conduct more and better studies to ascertain whether ADSCs really play a role in orthopaedic surgery with particular attention to ADSCs harvesting method, type of administration and the conditions treated. Areas timely for developing research The current literature regarding the use of ADSCs for orthopaedic pathologies is limited. At present, long-term safety is the biggest challenge of ADSCs based regenerative medicine. Level of evidence Level IV-Study of Level I, II, III, IV.

Treatment of Ankle Osteoarthritis with Total Ankle Replacement Through a Lateral Transfibular Approach

Total ankle replacement (TAR) is a valid option for the treatment of ankle osteoarthritis. The traditional surgical approach for TAR is the anterior approach. Recently, the lateral transfibular approach to the ankle has gained popularity since a new TAR implant was designed to be performed via this approach that results in an ideal visualization of the center of rotation of the ankle and curved resections that allow for sparing bone cuts. The aim of the present paper is to present our preoperative, operative, and postoperative protocols for the treatment of the osteoarthritis of the ankle with TAR via lateral approach. We present our preoperative clinical and radiographic protocol. In addition, we describe our surgical technique with some technical tips. Finally, we report our follow-up schedule that includes the collection of clinical, functional, and radiographic data. The results of this procedure are encouraging: TAR through a lateral transfibular approach provides reliable pain relief and improvements in functional outcomes in patients with ankle osteoarthritis.

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.