Factors associated with outcome after subtalar arthrodesis

Primary subtalar arthrodesis in displaced intra-articular calcaneal fracture: a systematic review

Calcaneus fractures are severe injuries often resulting from traumatic falls or motor vehicle accidents. Surgical treatment through open reduction and internal fixation (ORIF) is considered the standard approach for displaced intra-articular calcaneal fractures (DIACFs), but it is associated with many complications. Our study aimed to review the current literature available on primary subtalar arthrodesis (PSA) as a first-line treatment for DIACFs, mostly Sanders type IV. In this study, we conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The keywords were searched in PubMed, MEDLINE and the Cochrane Library. This review included articles where primary arthrodesis was performed in calcaneal fractures, with or without associated implants. Nine articles were included in the review. The total population comprised 184 patients with 192 calcaneal fractures. The mean age was 44.9 ± 6.9 years old. The mean follow-up period was 30.28 ± 15.29 months when reported. The mean time to surgery was 13.33 ± 7.02 days from injury. All studies reported a good fusion rate (between 94 and 100%) and an average fusion time of 4.05 ± 2.19 months. The mean American Orthopedic Foot & Ankle Society (AOFAS) score was 71.26 ± 8, and the mean Visual Analog Scale (VAS) score for pain was 3.26 ± 0.91. Primary arthrodesis of the subtalar joint for treating DIACFs, mostly Sanders type IV, provides good results due to the avoidance of further procedures, reduced postoperative pain, and a high rate of bony union. However, success heavily depends on factors such as patient comorbidities and addressing hindfoot deformity. Further studies with larger patient populations and more standardized protocols are necessary to draw definitive conclusions about the best management strategies for DIACFs. Systematic review, level III of evidence.

The Association of Cannabis and Tobacco Use With Postoperative Complications after Ankle and Hindfoot Arthrodesis

Background

The purpose of this study was to investigate the association between cannabis use and postoperative complications following ankle and hindfoot arthrodesis.

Methods

A retrospective cohort study using a large national insurance database from 2010 to 2022 was conducted. All patients who underwent ankle or hindfoot arthrodesis with at least 2 years' follow-up were included. Patients were divided into 4 groups: cannabis-only users, tobacco-only users, cannabis and tobacco users, and nonuser controls. Groups were matched 1:4 with nonuser controls based on demographic variables and comorbidities. Also, both cannabis and tobacco users were matched 1:4 with tobacco-only users based on demographics and comorbidities. Medical complications within 90 days of surgery and surgery-specific complications within 2 years were compared between groups with multivariable logistic regressions.

Results

Compared with nonuser controls, cannabis users only were not at increased risk of 90-day medical complications or 2-year surgical complications. Tobacco use alone was associated with increased risk of postoperative admission (OR 1.32, 95% CI 1.21-1.43) and emergency department (ED) utilization (OR 1.57, 95% CI 1.48-1.66) within 90 days as well as infection (OR 1.24, 95% CI 1.18-1.30), hardware removal (OR 1.12, 95% CI 1.07-1.18), nonunion (OR 1.33, 95% CI 1.27-1.40), and wound dehiscence (OR 1.38, 95% CI 1.27-1.49) within 2 years of surgery compared with nonuser controls. Compared with tobacco-only use, combined cannabis and tobacco use was associated with increased risk of ED visits within 90 days (OR 1.45, 95% CI 1.30-1.62) and nonunion within 2 years of surgery (OR 1.19, 95% CI 1.05-1.35).

Conclusion

These findings suggest that although cannabis use alone was not associated with a higher risk of postoperative complications, its concurrent use with tobacco was linked to greater rates of adverse outcomes.

Level of Evidence

Level III, retrospective case control study.

Ilizarov fixator as salvage procedure after frustrating arthrodesis using intramedullary nailing - is there a chance of consolidation?

INTRODUCTION

Arthrodesis of the tibiotalar and subtalar joints is a salvage procedure that has been used successfully for years. Treatment options include internal procedures and external procedures. Retrograde intramedullary nailing is considered a safe procedure with a high degree of stability and comfort. Nevertheless, there are cases in which this internal arthrodesis fails and another procedure must be considered. Ilizarov fixator treatment could be a solution for those patients in whom intramedullary nailing has failed. Even if it means another surgical revision - is it possible to finally achieve consolidation with this method?

MATERIALS AND METHODS

In this single-center, retrospective study all documents of patients who underwent tibiotalar and subtalar joints fusion using the Ilizarov external fixator at our institution from 2003 to 2023 as secondary treatment after frustrated first arthrodesis using an intramedullary nail were reviewed. Nineteen patients (17 men and 2 women), with an average age of 55.7 (standard deviation (SD) 8.7, range 34-75) years were included.

RESULTS

On average, 1.7 (SD 1.3, range 1-6) arthrodesis attempt were performed before final Ilizarov fixator arthrodesis. The average time spent in the Ilizarov fixator was 19 (SD 4, range 14-29) weeks. In seven cases (36.8%), both the tibiotalar and subtalar joints received bony consolidation in the end.

CONCLUSION

If patients have undergone fusion of the tibiotalar and subtalar joints with a retrograde nail and this fails, it is difficult to achieve complete consolidation in the further course. A further attempt at arthrodesis using an Ilizarov fixator is possible, but the overall results are also poor. This procedure must therefore be seen as a last resort before amputation.

Parallel versus Angulated Screw Configuration in Subtalar Arthrodesis for Posttraumatic Arthritis

Background

To compare radiographic union and clinical outcomes between parallel and angulated screw configurations (SCs) for patients undergoing subtalar arthrodesis due to posttraumatic subtalar arthritis (PSA) after displaced intra-articular calcaneal fractures.

Methods

This study retrospectively reviewed 140 consecutive PSA cases from March 2011 to November 2021 (parallel SC: group 1, n = 80; angulated SC: group 2, n = 60). Radiographic union, Foot and Ankle Outcome Score (FAOS), and visual analog scale (VAS) scores were among the outcome assessments. Six months after surgery, nonunion was confirmed based on plain radiographs, clinical evaluation, and computed tomography.

Results

Groups 1 and 2 included 14 (17.5%) and 3 (5.0%) nonunion cases, respectively (p = 0.035). There was no significant difference in preoperative FAOS and VAS scores between the groups. However, group 2 had significantly better clinical outcomes in 2 of the 5 FAOS domains (sports and quality of life), as well as VAS scores at 3 and 6 months postoperatively and at the final follow-up (p < 0.05).

Conclusions

Using the angulated SC for PSA had a lower nonunion rate and superior clinical outcomes than the parallel SC. Obtaining better radiological and clinical outcomes when using the angulated SC, rather than the parallel SC, would be advantageous.

Optimizing Subtalar Arthrodesis: A Human Cadaveric Evaluation of a Novel Partially-Threaded Screw Combination in the Delta Configuration

Background and Objectives: Despite the established role of subtalar joint arthrodesis (SJA) for treatment of subtalar osteoarthritis, achieving bone union remains challenging, with up to 46% non-union rates. Adequate compression and stable fixation are crucial for successful outcomes, with internal screw fixation being the gold standard for SJA. The delta configuration, featuring highly divergent screws, offers stability, however, it can result in hardware irritation in 20-30% of patients. Solutions to solve this complication include cannulated compression screw (CCS) countersinking or cannulated compression headless screw (CCHS) application. The aim of this biomechanical study was to investigate the stability of a delta configuration for SJA utilizing either a combination of a posterior CCHS and an anterior CCS or a standard two-CCS combination. Materials and Methods: Twelve paired human cadaveric lower legs were assigned pairwise to two groups for SJA using either two CCSs (Group 1) or one posterior CCHS and one anterior CCS (Group 2). All specimens were tested under progressively increasing cyclic loading to failure, with monitoring of the talocalcaneal movements via motion tracking. Results: Initial stiffness did not differ significantly between the groups, p = 0.949. Talocalcaneal movements in terms of varus-valgus deformation and internal-external rotation were significantly bigger in Group 1 versus Group 2, p ≤ 0.026. Number of cycles until reaching 5° varus-valgus deformation was significantly higher in Group 2 versus Group 1, p = 0.029. Conclusions: A delta-configuration SJA utilizing a posterior CCHS and an anterior CCS is biomechanically superior versus a standard configuration with two CCSs. Clinically, the use of a posterior CCHS could prevent protrusion of the hardware in the heel, while an anterior CCS could facilitate less surgical time and thus less complication rates.

Subtalar Arthrodesis in Patients With Prior Tibiotalar Arthrodesis for Posttraumatic Osteoarthritis

BACKGROUND

The tibiotalar arthrodesis for end-stage ankle osteoarthritis is a surgical procedure that leads to a modification of the kinematics of the adjacent joints and may result in the development of secondary osteoarthritic degeneration of the subtalar joint. It has previously been observed that subtalar arthrodesis in this context shows a lower fusion rate than isolated subtalar arthrodesis. This retrospective study reports the results of subtalar joint arthrodesis with previous ipsilateral tibiotalar arthrodesis and suggests some factors that may compromise the fusion of the joint.

METHODS

Between September 2010 and October 2021, 15 arthrodeses of the subtalar joint with screw fixation were performed in 14 patients, with a fusion of the ipsilateral tibiotalar joint. Fourteen of 15 cases used an open sinus tarsi approach, 13 were augmented with iliac crest bone graft, and 11 had supplemental demineralized bone matrix (DBM). The outcome variables were fusion rate, time to fusion, and revision rate. Fusion was assessed by radiographs and computed tomography scan.

RESULTS

Twelve of the 15 subtalar arthrodeses (80%) fused at the first attempt with an average fusion time of 4.7 months.

CONCLUSION

In this limited retrospective case series, compared to the fusion rate of isolated subtalar arthrodesis reported in the literature, the rate of subtalar fusion in the presence of an ipsilateral tibiotalar arthrodesis was found to be lower.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Factors influencing successful bone union of isolated subtalar arthrodesis for posttraumatic subtalar arthritis: a multicenter case series

BACKGROUND

The purpose of this study was to find the factors influencing successful bone union for isolated subtalar arthrodesis in posttraumatic subtalar arthritis following calcaneal fracture.

MATERIAL AND METHODS

We retrospectively analyzed the rate of successful bone union of 119 cases of isolated subtalar arthrodesis for posttraumatic subtalar arthritis performed at five university hospitals between January 2010 and December 2019. Multivariate logistic regression analysis was used to find the factors associated with successful bone union. Successful bone union was defined as resolution of hindfoot pain with the presence of osseous trabecular bridging involving more than 50% of the posterior facet within 6 months postoperatively.

RESULTS

There were 77 (64.7%) cases of successful bone union, 11 (9.2%) cases of delayed union, 8 (6.7%) cases of questionable union, and 23 (19.3%) cases of nonunion. Use of fully threaded screws was 5.90 times [odds ratio (OR) = 5.90, 95% confidence interval (CI) = 1.42-24.49, p = 0.02] more likely to achieve successful bone union compared to the use of partially threaded screws. Use of two parallel screws or the two divergent screws were 3.71 times (OR = 3.71, 95% CI = 1.05-13.14, p = 0.04) and 4.65 times (OR = 4.65, 95% CI = 1.23-17.53, p = 0.02) more likely to achieve successful bone union compared to the use of a single screw. Use of cancellous autograft or structural autograft was 4.72 times (OR = 4.72, 95% CI = 1.17-19.06, p = 0.03) and 7.12 times (OR = 7.12, 95% CI = 1.46-34.68, p = 0.02) more likely to achieve successful bone union compared to no graft use.

CONCLUSION

Use of fully threaded screws, autograft, and two screws compared to a single screw were the factors associated with successful bone union within six postoperative months after subtalar arthrodesis for the posttraumatic arthritis.

Surgical Construct Type Is Associated With Time to Fusion and Reoperation Rate in Double and Isolated Talonavicular Arthrodeses

BACKGROUND

This study evaluates the effect of surgical construct on postoperative outcomes in patients undergoing isolated talonavicular (TN) or double (TN and subtalar ST) arthrodesis. TN constructs included plate and screw, screw and staple, and isolated staple constructs. Subtalar constructs included 1- and 2-screw constructs.

METHODS

Retrospective chart review identified 52 patients who underwent double or isolated TN arthrodesis between 2016 and 2021 by a single fellowship-trained foot and ankle surgeon with minimum 6 months of follow-up (mean = 1.62 years, range = 0.50-4.39 years). Data collected included demographics, medical history, surgical indication, surgical constructs used, complications, reoperations, patient-reported outcome measures, and radiographic measures.

RESULTS

Overall complication and reoperation rates were 26.3% and 12.3%, respectively. Among TN constructs, time to ST (P = .026) and TN (P = .018) fusion was significantly slower among patients receiving a plate and screw construct. Complication rate did not differ, but reoperation rate was significantly higher for plate and screw TN constructs (P = .039). Postoperative Foot and Ankle Outcome Score (FAOS) Quality of Life (P = .028) and Total (P = .016) scores were significantly better among plate and screw TN constructs.

CONCLUSION

Utilization of screw and staple or isolated staple construct have significantly quicker time to fusion and lower reoperation rates than plate and screw constructs for the TN joint.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

Rate of progressive healing with a carbon-fiber orthosis in cases of partial union and nonunion after ankle arthrodesis using the Ilizarov external fixator

BACKGROUND

The Ilizarov fixator is a popular device for treating arthrodesis of the ankle joint in complex situations. However, the therapy can fail, with nonunion or partial union that might not be load stable. There is the possibility of follow-up surgery or extended wearing of the fixator. Full weight bearing with a carbon orthosis remains another treatment option, which has not yet been investigated.The aim of the study was to determine the rate of progress that can be obtained with a carbon orthosis in cases of partial union or nonunion after fixator removal.

METHODS

In this retrospective observational study thirty-three patients received a carbon orthosis after fixator removal due to nonunion or partial union. All patients were allowed to walk with the orthosis under full load. The consolidation rate was determined radiologically and compared with the imaging data obtained during the last follow-up. In addition to demographic data, the Foot and Ankle Ability Measure and pain using a numeric rating scale were determined. Nine patients had to be excluded due to insufficient follow-up, and finally n = 24 patients were included in the study.

RESULTS

The average duration of fixator use was 21 weeks (range 15-40 weeks), and the total average follow-up after removal of the fixator was 16 months (range 4- 56). For 14 (58.33%) patients, there was a further increase in consolidation with the orthosis after the fixator was removed.

CONCLUSION

The results show that if there is only partial union or nonunion, further consolidations can be achieved after the application of a carbon orthosis. In a difficult patient population, using an orthosis should therefore be attempted to avoid unnecessary revision operations.

Effect of Simulated Bone Resorption on the Biomechanical Performance of Intramedullary Devices for Foot and Ankle Arthrodesis

Midfoot and subtalar arthrodesis surgeries are performed to correct foot deformities and relieve arthritic pain. These procedures often employ intramedullary (IM) devices. The aim of the present study was to evaluate the biomechanical performance of a sustained dynamic compression (SDC) IM device compared to mechanically static devices in withstanding the effects of simulated bone resorption. Mechanically static and SDC IM devices were implanted in simulated bone blocks (n = 5/device). Compressive loads were measured with a custom-made mechanism to simulate bone resorption. The construct bending stiffness was determined from a 4-point bend test. Resorption was simulated by cutting a 1 mm or 2 mm gap in the midpoint of each construct and repeating the loading (n = 6/device). Initial compressive loads after device insertion were greater in the SDC IM devices when compared to the static devices (p < .01). The SDC device was able to sustain compression from 2 mm to 5.5 mm of simulated resorption depending upon device length, while the static devices lost compression within 1 mm of simulated resorption regardless of implant length (p < .001). In the 4-point bend test, the SDC device maintained its bending stiffness during simulated resorption whereas the static device displayed a significant loss in bending stiffness after 1 mm of simulated resorption (p < .001). The SDC device exhibited a significantly higher bending stiffness than the static device (p < .001). The SDC IM device demonstrated superior biomechanical performance during simulated resorption compared to static devices (p < .001). In conclusion, the ability of SDC IM devices to maintain construct stability and sustain compression across the fusion site while adapting to bone resorption may lead to greater fusion rates and overall quicker times to fusion than static IM devices. Surgeons who perform midfoot and subtalar arthrodesis procedures should be aware of a device's ability to sustain compression, especially in cases where bone resorption and joint settling are prevalent postoperatively.

Subjective and Objective Outcomes of Ankle Joint Arthrodesis with Either Ilizarov or Internal Fixation

After arthroplasty, arthrodesis of the ankle joint is the most common method to treat advanced ankle osteoarthritis. The goal of the study was to assess the subjective and objective outcomes in 2 different types of fixation for ankle joint arthrodesis. We retrospectively assessed 47 patients who had undergone ankle joint arthrodesis with fixation either via an Ilizarov apparatus (group 1) (n = 21) or cannulated screws (group 2) (n = 26). The outcomes were measured by: (1) the quantity of analgesics administered, (2) the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, (3) general patient satisfaction, (4) the patients' decision to undergo the same procedure given another chance, and (5) the necessity of blood transfusion during hospitalization. Data was collected at the last postoperative follow-up visit. The AOFAS scores in group 1 and group 2 patients were 73.9   ± 13 and 72.7  ±  14.3, respectively. In group 1, 17 patients (81%) were very satisfied with the results, while in group 2, 19 patients (73%) were very satisfied with the results (p = .043). Two group 1 patients (10%) and four group 2 patients (15.3%) reported that they were satisfied with the outcomes (p = .035). Two patients (10%) from group 1 and three patients (11%) from group 2 were fairly satisfied. Seventeen patients (81%) after arthrodesis with Ilizarov fixation and 21 patients (81%) after arthrodesis with internal fixation would choose the same procedure given the opportunity to choose again. In group 1 there were no patients who required blood transfusion; in group 2 one patient (4%) required blood transfusion; the difference was statistically significant (p = .039). Nineteen group 1 patients (90%) were administered an analgesic preoperatively, while postoperatively only 6 (29%) required analgesics. In group 2, 24 patients (92%) were administered analgesics preoperatively, with 8 (31%) of them still requiring analgesics postoperatively. Ankle arthrodesis patients from both group 1 and group 2 achieved good subjective and objective results of treatment. We noted slightly better results in the Ilizarov apparatus group.

Factors associated with nonunion of the posttraumatic subtalar arthrodesis after displaced intra-articular calcaneal fractures

BACKGROUND

This study investigated the incidence of and risk factors for nonunion in patients with posttraumatic subtalar arthrodesis (SA).

METHODS

We retrospectively reviewed 165 posttraumatic SA cases. Nonunion was diagnosed at 6 months after surgery based on the findings of clinical evaluations, plain radiographs, and CT scans. Patient-specific factors and surgeon-specific factors were evaluated as potential risk factors.

RESULTS

The overall nonunion rate was 13.3 % (22 of 165 cases). In the final multivariate logistic regression analysis, smoking (odds ratio [OR] = 3.64; 95 % confidence interval [CI] = 1.23-10.75), parallel screw configuration (OR = 5.70; 95 % CI = 1.62-20.06), and freeze dried iliac crest (OR = 9.16; 95 % CI = 2.28-36.79) were demonstrated as risk factors for nonunion of posttraumatic SA.

CONCLUSION

Patients with a history of smoking, parallel screw configuration fixation, and those who received freeze dried iliac crest as an interpositional graft, had a significantly higher rate of nonunion.

Presurgical Perspective and Postsurgical Evaluation of the Diabetic Foot

Management of the diabetic foot is complex and challenging, requiring a multidisciplinary approach. Imaging plays an important role in the decision-making process regarding surgery. This article discusses the presurgical perspective and postsurgical evaluation of the diabetic foot.

Comparing Rates of Fusion and Time to Fusion in Viable Cellular Allograft and Autograft

BACKGROUND

Autograft or allograft frequently are used to enhance bone union in foot and ankle surgery. Viable cellular bone allograft uses viable cells and bone scaffolding in a gel base, but uncertainty remains around allograft's greater efficacy than autograft regarding rates of fusion (ROF) and time to fusion (TTF).

METHODS

Autograft, viable cellular allograft, and viable cellular allograft with autograft were compared in 199 forefoot, midfoot, and hindfoot arthrodeses performed over a 6-year period. Data collected from electronic medical records and radiographs were analyzed to determine ROF and TTF as well as rates of revision surgery for delayed or nonunion and compared among groups.

RESULTS

Eighty-seven patients comprised the autograft group, 81 the allograft group, and 31 the combined group. No significant differences were noted in patient demographics among the groups. No statistically significant differences in ROF were noted among the 3 groups, with 86% (75 of 87) fusion in the autograft group, 93% (75 of 81) in the allograft group, and 84% (26 of 31) in the combined group (P = .20). After conducting a multivariate analysis, we found no statistically significant difference for allograft or combined graft on TTF (P = .1379 and .2311, respectively). No significant difference was found in rate of revision surgery for nonunion, which was 1.2% (1 of 81) in the allograft group, 3.4% (3 of 87) in the autograft group, and 6.5% (2 of 31) in the combined group (P = .3).

CONCLUSION

No significant difference was found in ROF, TTF, or rate of revision surgery when comparing viable cellular allograft to autograft or combined allograft-autograft. Viable cellular allograft may be a reasonable alternative to the gold standard of autograft and should be considered an option in patients undergoing arthrodesis in foot and ankle surgery.

LEVEL OF EVIDENCE

Level III, therapeutic.

A comparison of outcomes of posterior arthroscopic subtalar arthrodesis with or without bone graft for treatment of subtalar arthritis

BACKGROUND

It remains unclear whether to perform a bone graft is necessary during posterior arthroscopic subtalar arthrodesis. The present research aimed to comparatively analyze the outcomes of arthroscopic subtalar arthrodesis through a 3-portal posterior approach with or without bone graft.

METHODS

A total of 93 patients with subtalar arthritis who underwent posterior arthroscopic subtalar arthrodesis were retrospectively examined. The patients were divided into two groups according to whether they received bone graft or not. The clinical outcomes were compared for analysis.

RESULTS

Among the 93 patients included, 53 received bone graft and 40 did not. The union rate and time to osseous fusion suggested no significant difference between the two groups. The improvement of clinical outcomes were comparable between the two groups at the final follow-up.

CONCLUSIONS

In the present study, bone graft could not effectively reduce the risk of nonunion and improve the outcome.

Persistent Pain After Hindfoot Fusion

One of the most challenging problems facing orthopedic surgeons is persistent pain after surgery and certainly is just as frustrating following hindfoot fusion. The hindfoot joints consist of the subtalar, talonavicular, and calcaneocuboid (CC) joints. These joints are commonly fused for degenerative changes, deformity correction, inflammatory or neuropathic arthropathy, tarsal coalition, or primarily after trauma. Goals of hindfoot fusion are a painless plantigrade foot capable of fitting in shoes without orthotics or a brace. Many believe that deformity correction is achievable without inclusion of the CC joint. Managing patient expectations is important when counseling a patient especially regarding potential complications.

Patient and Surgical Factors Affecting Fusion Rates After Arthroscopic and Open Ankle Fusion: A Review of a High-Risk Cohort

ABSTRACT

We present a case series with the objective of identifying risk factors for nonunion after open and arthroscopic primary ankle arthrodesis. Eighty-seven patients who underwent primary ankle arthrodesis and met inclusion criteria were divided into open (N = 46) and arthroscopic (N = 41) groups. Patient and operative characteristics were retrospectively analyzed as possible risk factors for nonunion within each technique. The nonunion rate was 11% in the open and 12% in the arthroscopic group. Obesity, smoking, and ASA class 3 were highly prevalent in both groups. In the arthroscopic group, a remote history of infection and the use of headed screws had notably higher risk of nonunion, though not statistically significant. In the open group, use of bone graft trended toward lower risk of nonunion, though also not statistically significant. The results of this study demonstrated, nonunion rates are comparable between open and arthroscopic ankle arthrodesis in high-risk patients. For patients with a remote history of infection, open ankle arthrodesis may be preferable, and bone graft importance may vary with open versus arthroscopic technique.

LEVEL OF EVIDENCE

III.

Orthobiologics in Foot and Ankle Arthrodesis: A Systematic Review

Orthobiologics are biologically-derived materials intended to promote bone formation and union. We review evidence on effectiveness and harms of orthobiologics compared to no orthobiologics for foot and ankle arthrodesis. We searched multiple databases (1995-2019) and included clinical trials and other studies with concurrent controls, English language, and reporting patient-centered outcomes, union/time to union, costs/resource utilization, or harms. Studies were organized by orthobiologic used. We describe quality and limitations of available evidence but did not formally rate risk of bias or certainty of evidence. Most of the 21 studies included were retrospective chart reviews with orthobiologics used at surgeon's discretion for patients considered at higher risk for nonunion. Ten studies compared autologous bone graft versus no graft and 2 compared remote versus local graft with few studies of other orthobiologics. All studies reported a measure of fusion and about half reported on function/quality of life. Few studies reported harms. Due to limited reporting, we were unable to assess whether effectiveness varies by risk factors for nonunion (eg, age, gender, smoking status, obesity, diabetes) or whether orthobiologics were cost-effective. Available evidence is of poor quality with small sample sizes, inadequate reporting of risk factors for nonunion, variations in orthobiologics, surgical techniques used, and outcome assessment, and potential selection bias. Research is needed to adequately inform surgeons about benefits and harms and guide patient selection for use, or type, of orthobiologics. Careful assessment of individual patient risk for nonunion is critical prior to orthobiologic use.

Assessment of Lower Limb Load Distribution in Patients Treated with the Ilizarov Method for Tibial Nonunion

Background

Successful treatment of tibial nonunion should lead to a complete bone union, lack of pain, and pathological mobility of the lower extremity, as well as to the achievement of satisfactory joint mobility and muscle strength, which in turn improves its biomechanics. The objective of this study was to assess the load placed on the lower limbs in patients subjected to treatment with the Ilizarov method due to aseptic tibial nonunion.

Material/Methods

This research involved 24 participants (average age, 55 years). All were diagnosed with aseptic tibia nonunion and treated with the Ilizarov external fixator between 2000 and 2017. The control group was matched to the treated group in terms of sex and age. This study used pedobarography evaluation to assess lower limb load distribution.

Results

No differences were found in the distribution of the load over the entire foot or of the forefoot and hindfoot of the treated limb in comparison to the non-dominant limb of the controls, or in the healthy limb of the treated group compared to the dominant limb of the control group. Similarly, differences in load distribution between the operated and healthy limbs of the treated group were insignificant.

Conclusions

Patients subjected to treatment with the Ilizarov external fixator for aseptic tibial nonunion show symmetrical load distribution on both lower limbs following treatment, which does not differentiate them in this respect from healthy individuals. Treated patients presented with a symmetrical distribution of the load on the lower extremities over the entire foot surface, including the forefoot and hindfoot. Finally, the Ilizarov external fixator enables restoration of correct static biomechanics of the treated limbs over the period of aseptic tibial nonunion therapy.

Nonunion Rates in Hind- and Midfoot Arthrodesis in Current, Ex-, and Nonsmokers

BACKGROUND

Nonunion rates in hind or midfoot arthrodesis have been reported as high as 41%. The most notable and readily modifiable risk factor that has been identified is smoking. In 2018, 14.4% of the UK population were active smokers. We examined the effect of smoking status on union rates for a large cohort of patients undergoing hind- or midfoot arthrodesis.

METHODS

In total, 381 consecutive primary joint arthrodeses were identified from a single surgeon's logbook (analysis performed on a per joint basis, with a triple fusion reported as 3 separate joints). Patients were divided based on self-reported smoking status. Primary outcome was clinical union. Delayed union, infection, and the need for ultrasound bone stimulation were secondary outcomes.

RESULTS

Smoking prevalence was 14.0%, and 32.2% were ex-smokers. Groups were comparable for sex, diabetes, and body mass index. Smokers were younger and had fewer comorbidities. Nonunion rates were higher in smokers (relative risk, 5.81; 95% CI, 2.54-13.29; P < .001) with no statistically significant difference between ex-smokers and nonsmokers. Smokers had higher rates of infection (P = .05) and bone stimulator use (P < .001). Among smokers, there was a trend toward slower union with heavier smoking (P = .004).

CONCLUSION

This large retrospective cohort study confirmed previous evidence that smoking has a considerable negative effect on union in arthrodesis. The 5.81 relative risk in a modifiable risk factor is extremely high. Arthrodesis surgery should be undertaken with extreme caution in smokers. Our study shows that after cessation of smoking, the risk returns to normal, but we were unable to quantify the time frame.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The influence of smoking on foot and ankle surgery: a review of the literature

The effect of tobacco smoking on foot and ankle procedures is likely to be more pronounced when compared to other orthopaedic surgery. This is due to the peripheral nature of the vasculature involved. This paper reviews the current clinical evidence on the effects of smoking foot and ankle surgery. In the trauma setting, the evidence suggests that wound complications and non-unions are significantly higher in the smoking population. In the elective setting there is a significantly increased risk of non-union in ankle and hindfoot arthrodeses in smokers. In the setting of diabetes, ulceration rate in smokers is higher and there may be a higher risk of amputation.

Common Pitfalls in Subtalar Joint Preparation for Arthrodesis via Sinus Tarsi Approach

This cadaveric study assessed factors that could lead to nonunions in subtalar joint arthrodesis. The purpose of this study was to assist surgeons in achieving sufficient joint preparation in hopes to achieve more frequent arthrodesis of the subtalar joint. We evaluated the influence of experience in regard to cartilage preparation of the joint. We also assessed which quadrants of the subtalar joint were more likely to have unprepared cartilage. The subtalar joints in 17 cadaveric limbs were prepared by 17 participants with differing levels of experience. After the cartilage was denuded, the percentage of unprepared cartilage in each subtalar joint was calculated. The medial quadrants were more likely to have unprepared surfaces. There was also a learning curve present with subtalar joint preparation, as seen by the significantly larger percentage of unprepared cartilage in cadavers prepared by first year residents.

Cost of Headless vs Headed Screw Fixation for Calcaneal Osteotomy and Subtalar Arthrodesis

Background:

Screw head prominence in the heel following fixation for calcaneal osteotomy or subtalar arthrodesis has resulted in high rates of symptomatic hardware and screw removal. A cost analysis was performed to determine the financial implications of screw removal. Furthermore, we compared the rate of nonunion following fixation.

Methods:

Current Procedural Terminology codes were used to identify all patients who had a subtalar arthrodesis or calcaneal osteotomy (with screw fixation) performed between 2010 and 2016. The cohort was divided into 2 groups: 7.0-mm headless screw or 6.7-mm headed screw. The primary outcome measure was the rate of symptomatic screw removal. Secondary outcomes included the rate of nonunion. The expense associated with symptomatic hardware removal was determined by cost analysis.

Results:

Seventy-six patients underwent headless screw fixation, and 2 patients (2.6%) required screw removal. Fifty-four patients underwent headed screw fixation and 12 patients (22.2%) required screw removal. Symptomatic hardware removal was performed more frequently in the headed screw group (P < .001). There was no difference in the rate of nonunion after subtalar arthrodesis between the 2 groups (P = .363). The calcaneal osteotomy united in 100% of patients. There was a $51 755 cost savings per 100 cases using headless screw fixation.

Conclusion:

The rate of symptomatic screw removal was lower with headless screw fixation. The calcaneal osteotomy healed in 100% of patients, and there was no difference in the rate of subtalar nonunion between the 2 groups. Cost analysis demonstrated a significant benefit when the expense of hardware removal was considered.

Level of Evidence:

Level III, retrospective cohort study.

Tibiotalocalcaneal Arthrodesis Using a Novel Retrograde Intramedullary Nail

Background. Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for complex hindfoot pathology. Overall union rates range from 50% to 86% but can be even lower in certain populations. A novel retrograde intramedullary nail has recently been developed. The purpose of this study was to report fusion rates, time to weight-bearing, and complications with the use of the A3 Fusion Nail. Methods. All patients 18 years or older who underwent TTC arthrodesis with an A3 Fusion Nail at a single institution from 2010 to 2015 with a minimum 3-month follow-up were included in this study. Rates of successful fusion, time to union, time to weight-bearing, and complications were evaluated. A total of 20 patients with an average age of 58.1 years and an average follow-up of 12.5 months met inclusion criteria. Results. Successful TTC arthrodesis was achieved in 14 of 20 patients (70%) overall. Average time to union was 8.1 months, and average time to weight-bearing was 6.8 weeks. Of 20 patients, 17 (85%) required femoral head allograft for bulk bone defects, and the union rate in this subset of patients was 76.5%. The rates of revision surgery (10%) and complications were low. Conclusion. The A3 Fusion Nail demonstrated a favorable safety profile and achieved TTC arthrodesis at a rate consistent with historical data despite being used in a patient population at high risk for nonunion. In patients with bulk bone defects at high risk for nonunion, the A3 Fusion Nail demonstrated superior rates of fusion (76.5%) to those reported in the literature (50%).Level of Evidence: Level III: Retrospective cohort study.

Outcome After Modified Grice-Green Procedure (SAMBB) for Arthritic Acquired Adult Flatfoot

BACKGROUND

Adult acquired flatfoot deformity is a well-known and recognized cause of pain and disability. The purpose of this retrospective study was to describe radiographic and clinical outcomes of the modified mini bone block distraction subtalar arthrodesis (SAMBB) in adult patients affected by adult flatfoot with subtalar joint osteoarthritis at a midterm mean follow-up.

METHODS

A retrospective review of our database identified patients. Radiological imaging was used to evaluate angular corrections (Meary's angle [MA], talar coverage angle [TC], and calcaneal pitch angle [CP]) to assess the rate of union and highlight the possible progression of arthritis in nearby joints. Clinical evaluation was performed at the time of surgery and at the final follow-up using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. Sixty-two feet were evaluated at a mean follow-up of 6.2 ± 4.2 years.

RESULTS

The AOFAS score improved from a mean value of 48.1 ± 6.1 to a postoperative average score of 87.7 ± 5. CP, TC, and MA showed a postoperative improvement to 17.7 ± 2.1, 2.9 ± 0.7, and 0.6 ± 0.6 degrees, respectively, at the final follow-up, and all deformities were corrected. Five complications (8%) were reported: 1 major and 4 minor. No graft reabsorption, sural nerve neuralgia, or donor site morbidity was recorded.

CONCLUSION

To our knowledge, this study is the first report of a modified Grice-Green technique (SAMBB) that is a safe and effective treatment of flatfoot in the adult with subtalar arthritis.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Effects of teriparatide on fusion rates in patients undergoing complex foot and ankle arthrodesis

BACKGROUND

Here, we determined whether teriparatide treatment would increase fusion rates after foot and ankle arthrodesis by comparing treatment results between patients with high-risk factors for nonunion who received teriparatide against those who did not.

METHODS

We retrospectively reviewed 66 consecutive patients who underwent foot and ankle arthrodesis. The inclusion criterion was the presence of at least one of the following risk factors for nonunion after previous foot and ankle arthrodesis: deformity, bone defects, avascular necrosis, and nonunion. Sixteen patients were finally enrolled and divided into 2 groups: 8 patients received teriparatide treatment after fusion surgery (PTH group), and 8 patients did not (control group).

RESULTS

The fusion rate was significantly greater in the PTH group than in the control group (100% vs 50%). Four patients in the control group developed nonunion, 3 of whom underwent revision fusion; however, all patients received the teriparatide treatment after revision surgery and subsequently achieved union. No significant differences in demographics, fusion sites, and complication rates were found.

CONCLUSION

Though the sample size was small, the current study suggests that teriparatide administration may improve fusion rates in patients with high-risk factors for nonunion after foot and ankle arthrodesis.

How many screws are necessary for subtalar fusion? A retrospective study

BACKGROUND

Biomechanical studies have shown a higher compressive force and higher torsional stiffness for fixation with three screws compared to two screws. However, clinical data to compare these fixation techniques is still lacking.

METHODS

A retrospective analysis of 113 patients was performed, who underwent isolated subtalar fusion between January 2006 and April 2018.

RESULTS

Revision arthrodesis was required in 8% (n=6/36) for 3-screw-fixation and 38% (n=35/77) for 2-screw-fixation. For 3-screw-fixation, non-union, was observed in 14% (n=5/36) compared to 35% (n=27/77) in 2-screw fixation. Non-union (p=.025) and revision arthrodesis (p=.034) were significantly more frequent in patients with 2 screws. A body mass index ≥30kg/m² (p=.04, OR=2.6,95%CI:1.1-6.3), prior ankle-fusion (p=.017,OR=4.4,95%CI:1.3-14.5) and diabetes mellitus (p=.04,OR=4.9,95%CI:1.1-17.8) were associated with a higher rate of revision arthrodesis.

CONCLUSIONS

Our findings suggest that successful subtalar fusion is more reliably achieved with use of three screws. However, future prospective studies will be necessary to further specify this recommendation.

Melatonin-stimulated MSC-derived exosomes improve diabetic wound healing through regulating macrophage M1 and M2 polarization by targeting the PTEN/AKT pathway

Background

After surgery, wound recovery in diabetic patients may be disrupted due to delayed inflammation, which can lead to undesired consequences, and there is currently a lack of effective measures to address this issue. Mesenchymal stem cell (MSC)-derived exosomes (Exo) have been proven to be appropriate candidates for diabetic wound healing through the anti-inflammatory effects. In this study, we investigated whether melatonin (MT)-pretreated MSCs-derived exosomes (MT-Exo) could exert superior effects on diabetic wound healing, and we attempted to elucidate the underlying mechanism.

Methods

For the evaluation of the anti-inflammatory effect of MT-Exo, in vitro and in vivo studies were performed. For in vitro research, we detected the secreted levels of inflammation-related factors, such as IL-1β, TNF-α and IL-10 via ELISA and the relative gene expression of the IL-1β, TNF-α, IL-10, Arg-1 and iNOS via qRT-PCR and investigated the expression of PTEN, AKT and p-AKT by Western blotting. For in vivo study, we established air pouch model and streptozotocin (STZ)-treated diabetic wound model, and evaluated the effect of MT-Exo by flow cytometry, optical imaging, H&E staining, Masson trichrome staining, immunohistochemical staining, immunofluorescence, and qRT-PCR (α-SMA, collagen I and III).

Results

MT-Exo significantly suppressed the pro-inflammatory factors IL-1β and TNF-α and reduced the relative gene expression of IL-1β, TNF-α and iNOS, while promoting the anti-inflammatory factor IL-10 along with increasing the relative expression of IL-10 and Arg-1, compared with that of the PBS, LPS and the Exo groups in vitro. This effect was mediated by the increased ratio of M2 polarization to M1 polarization through upregulating the expression of PTEN and inhibiting the phosphorylation of AKT. Similarly, MT-Exo significantly promoted the healing of diabetic wounds by inhibiting inflammation, thereby further facilitating angiogenesis and collagen synthesis in vivo.

Conclusions

MT-Exo could promote diabetic wound healing by suppressing the inflammatory response, which was achieved by increasing the ratio of M2 polarization to M1 polarization through activating the PTEN/AKT signalling pathway, and the pretreatment of MT was proved to be a promising method for treating diabetic wound healing.

Graphical abstract: MT-Exo promotes diabetic wound healing by regulating M1 and M2 macrophage polarization.

Comparison of Tibiotalocalcaneal Arthrodeses Using a Sustained Dynamic Compression Nail Versus Nondynamized Nails

Background. Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for hindfoot arthritis and deformity. Loss of compression over time with statically locked nails may contribute to nonunion. A novel retrograde intramedullary nail with an internal pseudoelastic component has recently been used to provide sustained dynamic compression (SDC). The purpose of this study was to compare fusion rates and time to union between the SDC and nondynamized (ND) nails. Methods. All patients who underwent TTC arthrodesis with an intramedullary nail at a single institution from 2013 to 2017 and who had at least 1 year of follow-up were included in this study. Baseline patient and operative characteristics were collected and compared between the sustained SDC and ND nail groups. The rate of successful fusion, time to union, and complications were compared between the groups. Results. The SDC cohort had a significantly faster time to union by 3.9 months (P = .049). The SDC cohort had a higher fusion rate (78.0%) compared with the ND nail cohort (75.0%), although this was not statistically significant (P = .75). The SDC nail was used significantly (P < .05) more often in patients with known risk factors for nonunion, including female sex, smoking, revision surgery, prior trauma, and patients requiring 3D cage implants for significant bone loss. There were no differences between the groups in terms of complications. Conclusion. The SDC nail has been shown to achieve successful arthrodesis in a population at high risk for nonunion, using less hardware, and at a faster rate than ND nails. Level of Evidence: Level III: Retrospective, comparative study.

Mid-term results of hindfoot arthrodesis with a retrograde intra-medullary nail in 24 patients with diabetic Charcot neuroarthropathy

Background and purpose - Hindfoot arthrodesis using retrograde intramedullary nailing assumes a critical role in limb salvage for patients with diabetic Charcot neuro-arthropathy (CN). However, this procedure is compelling and fraught with complications in diabetic patients. We report the mid-term clinical and radiological outcomes of retrograde intramedullary nailing for severe foot and ankle deformity in patients with diabetic CN.Patients and methods - Hindfoot arthrodesis was performed using a retrograde intramedullary nail in 24 patients (15 females) with diabetic Charcot foot. The mean age of the patients was 62 years (33-82); the mean follow-up was 45 months (24-70). The primary outcomes were rates of fusion, limb salvage, and complications.Results - The overall fusion rate was 23/24, and none of the patients needed amputation. The rate of superficial wound infection was 4/24, and no deep infection or osteomyelitis was observed postoperatively.Interpretation - For selected cases of diabetic CN with severe foot and ankle deformity, hindfoot arthrodesis using a retrograde intramedullary nail seems to be a good technique in achieving fusion, limb salvage, and avoidance of complications.

Managing Severely Malunited Calcaneal Fractures and Fracture-Dislocations

Severe calcaneal malunions are debilitating conditions owing to substantial hindfoot deformity with subtalar arthritis and soft tissue imbalance. Type III malunions are best treated with a subtalar distraction bone block fusion. Additional osteotomies may be required for severe varus or superior displacement of the calcaneal tuberosity. Type IV malunions result from malunited calcaneal fracture-dislocations and require a 3-dimensional corrective osteotomy. Type V malunions warrant additional ankle debridement and reconstruction of the calcaneal shape to provide support for the talus in the ankle mortise. Accompanying soft tissue procedures include Achilles tendon lengthening, peroneal tendon release, and rerouting behind the lateral malleolus.

Mini Bone Block Distraction Subtalar Arthrodesis (SAMBB) in the Management of Acquired Adult Flatfoot with Subtalar Arthritis: A Modification to the Grice-Green Procedure

Adult acquired flatfoot encompasses a wide range of deformities. The goal of surgical treatment of adult acquired flatfoot is to achieve proper alignment of the hindfoot and maintain as much flexibility as possible in the foot and ankle complex; nevertheless, if subtalar arthritis is present, subtalar arthrodesis is usually mandatory. A lateral approach over the sinus tarsi is performed and subtalar joint is prepared removing remaining cartilage, reduced up to 5 degrees of heel valgus, and stabilized with a Kirschner wire. The site of insertion of the corticocancellous bone graft, harvested from the ipsilateral proximal tibia, is prepared carving a vertical groove into the talar and calcaneal edges. Additional autologous cancellous chips, harvested from the proximal tibia, can be positioned and pressed with a beater into the sinus tarsi to enhance fusion. The technique described is a modification of the extra-articular arthrodesis originally proposed by Grice. mini bone block distraction subtalar arthrodesis is a simple and effective technique which permits a subtalar fusion with a restored orientation of the hindfoot and ankle alignment in acquired flatfoot with subtalar arthritis.

Effects of NSAID use on bone healing: A meta-analysis of retrospective case–control and cohort studies within clinical settings

Introduction

This meta-analysis aims to determine whether non-steroidal anti-inflammatory drug (NSAID) use is significantly associated with adverse bone healing outcomes within clinical settings, including trauma and elective spine settings. It will also explore bone healing outcomes with the type, route, dosage and duration of NSAID exposure and aims to demonstrate the effects of various other confounding factors on bone healing outcomes.

Methods

Electronic databases including MedLine, Embase and Cochrane were searched from January 1975 to December 2017. A distinct analysis of observational long bone and spine studies in adult populations was performed, assessing the effects of NSAID exposure on bone healing. Studies from paediatric population and randomised trials also underwent separate assessment in the synthesis. Meta-analysis was conducted in compliance with QUORUM and PRISMA guidelines.

Results

Quantitative assessment of observational studies suggested a significant risk of bone healing complications with NSAID exposure across each clinical group: long bone (p = 0.0004) and spine (p = 0.02). Analysis of paediatric studies revealed a non-significant association of poor outcomes with NSAID use (p = 0.36), while assessment of randomised trials demonstrated a statistically significant risk of complications following NSAID administration (p = 0.04). Meta-regression further suggested smoking to be a substantial confounder associated with adverse bone healing outcomes (p < 0.00001).

Conclusion

Inclusion of only fair and moderate-quality retrospective cohort and case–control studies in the current synthesis limits the clinical application of its findings and therefore warrants the need for further research. Thus, attempts to conduct high-quality prospective cohort and randomised trials to study the effects of NSAID use on bone healing would be very helpful and will provide a basis for more extensive research in future.

Smoking Effects in Foot and Ankle Surgery: An Evidence-Based Review

BACKGROUND

The purpose of this article was to review the basic science pertaining to the harmful effects of cigarette smoke, summarize recent clinical outcome studies, and examine the benefits of smoking cessation and the efficacy of current smoking cessation strategies.

METHODS

The literature concerning basic science, clinical outcomes, and smoking cessation was reviewed; over half (56%) of the 52 articles reviewed were published in the last 5 years.

RESULTS

Smoking is associated with low bone mineral density, delayed fracture union, peri-implant bone loss, and implant failure. Orthopedic surgical patients who smoke have increased pain and lower overall patient satisfaction, along with significantly increased rates of wound healing complications.

DISCUSSION/CONCLUSION

Active smoking is a significant modifiable risk factor and should be discontinued before foot and ankle surgery whenever possible. Orthopedic surgeons play an important role in educating patients on the effects of smoking and facilitating access to smoking cessation resources.

LEVEL OF EVIDENCE

Level V, expert opinion.

Durability of Smoking Cessation for Elective Lower Extremity Orthopaedic Surgery

INTRODUCTION

Smoking tobacco is a risk factor for impaired wound healing, infection, delayed fracture healing, and prolonged hospital stay. Smoking cessation before surgery has shown a 40% relative risk reduction in total perioperative complications. The primary purpose of this study was to evaluate the effectiveness of preoperative smoking cessation on long-term smoking habits in patients undergoing elective lower extremity orthopaedic surgery. The secondary outcome is patient-reported effectiveness of the smoking cessation method.

METHODS

A retrospective cohort study was performed by identifying all patients who were smokers that were required to quit and subsequently had a normal nicotine/cotinine serum test before lower extremity orthopaedic surgery. Attempts were made to contact all patients and administer a survey inquiring about their demographics, medical history, smoking history, smoking cessation process, and the current smoking status.

RESULTS

Of 36 eligible patients, 23 completed the survey. Eleven patients identified as current nonsmokers (48%) at the time of survey follow-up (mean follow-up was 55 months with a range of 12 to 88 months). Of these 11, 82% said they were very likely to continue to refrain from smoking. Twelve patients identified as current smokers at the time of survey, and more than half of them stopped smoking for at least three months perioperatively. The most effective smoking cessation techniques reported were "cold turkey," "nonnicotine medication," and "transdermal nicotine patches."

DISCUSSION

Elective surgery offers a unique opportunity for smoking cessation. Of 23 patients required to quit smoking before surgery, 48% maintained smoking cessation for at least one year postoperatively. Of the 12 patients who relapsed, 55% stated that they did not resume smoking until at least 3 months postoperatively, suggesting that this particular period may be an important time for intensified smoking cessation counseling.

LEVEL OF EVIDENCE

Therapeutic level III.

Clinical evaluation of ankle arthrodesis with Ilizarov fixation and internal fixation

Background

Ankle arthrodesis may have internal or external stabilization.

We assessed whether the type of stabilization after ankle arthrodesis will affect: (1) functional outcome in Foot and Ankle Ability Measure (FAAM) scale, (2) pain level, (3) period of hospitalization, (4) rate of complications.

Methods

We retrospectively studied 47 individuals after ankle arthrodesis with Ilizarov fixation (group 1, n = 21) and internal stabilization (group 2, n = 26) at our institution in years 2007–2015. Clinical outcomes were measure by: (1) functional outcome in FAAM scale, (2) pain level, (3) period of hospitalization, (4) rate of complications.

Results

Total number of complications in Ilizarov group was 13, which corresponded to 0.62 complications per patient on average. In group 2 there were 15 complications, which corresponded to 0.58 complications per patient on average. The intergroup difference in rate of complications was not statistically significant (p = 0.066). In group 1 the mean VAS pain level before treatment was 4.69 and after treatment was 1.5 (p = 0.037). In group with internal stabilization the mean VAS pain level before treatment was 4.71 and after treatment was 2.9 (p = 0.044). In group 1 the mean period of hospitalization was 5.29 days, in group 2 was 5.71 days (p = 0.517). In group 1 the mean functional outcome in FAAM scale was 79.38, in group 2 was 70.11 (p = 0.458).

Conclusions

Ankle arthrodesis with Ilizarov stabilization is associated with lower prevalence of VAS pain level after surgery than after internal screws stabilization. Rate of complications, FAAM functional score and period of hospitalization were not statistically significant between group 1 and 2. Clinical outcome was satisfactory in group 1 and 2, but outcomes in Ilizarov group were slightly better than after internal stabilization.

Endoscopic Revision Subtalar Arthrodesis

Varus malunion after subtalar arthrodesis is considered to be the worst deformity in hindfoot alignment. Poor clinical outcome is expected if there is more than 10° of varus malunion with lateral column overload. Open revision subtalar arthrodesis is associated with high rates of complications, especially involving soft tissue and nonunion. The purpose of this Technical Note is to describe the technical details of endoscopic revision subtalar arthrodesis in which the correction of varus malunion is performed with a minimally invasive technique, which may reduce the risk of soft tissue complications and nonunion.

Pedobarographic analysis of body weight distribution on the lower limbs and balance after ankle arthrodesis with Ilizarov fixation and internal fixation

BACKGROUND

A number of various techniques were proposed to stabilized ankle arthrodesis, among them external and internal fixation. Appropriate balance and adequate distribution of lower limb loads determine normal biomechanics of the locomotor system. We hypothesized that various techniques used to stabilize ankle arthrodesis may exert different effects on (1) balance and (2) distribution of lower limb loads.

METHODS

Retrospective analysis included 47 patients who underwent ankle arthrodesis with external stabilization with Ilizarov fixator (group 1, n = 21) or internal stabilization with screws (group 2, n = 26) between 2007 and 2015. Balance and distribution of lower limb loads were determined with a pedobarographic platform.

RESULTS

In group 1, average load of the operated and non-operated limb amounted to 48.8% and 51.2%, respectively, and in group subjected to internal stabilization to 48.4% and 51.6%, respectively. Neither the intragroup nor the intergroup differences in the distribution of lower limb loads were statistically significant. Mean length of the center of gravity (COG) path was 137.9 cm for group 1 and 134 cm for group 2, and mean COG area amounted to 7.41 cm2 and 6.16 cm2, respectively. The latter intergroup difference was statistically significant.

CONCLUSIONS

Balance after ankle arthrodesis with Ilizarov fixation is worse than after the same procedure with internal stabilization. Despite correction of ankle deformity, musculoskeletal biomechanics still remains impaired. While ankle fusion with either Ilizarov or internal fixation provide appropriate distribution of lower limb loads, none of these procedures normalize patients' balance.

Arthroscopic posterior subtalar arthrodesis for salvage of posttraumatic arthritis following calcaneal fractures

BACKGROUND

Subtalar arthrodesis is a treatment option for pain due to posttraumatic arthritis following calcaneal fractures. The goal of this study is to examine the results of arthroscopic subtalar arthrodesis for posttraumatic arthritis following calcaneal fractures.

PATIENTS AND METHODS

We performed a retrospective case series reviewing 37 consecutive patients (36 male) treated for posttraumatic arthritis following calcaneal fractures by arthroscopic subtalar arthrodesis. The fractures were due to high-energy injuries in 81% of cases, and 12 fractures (32.4%) had been previously treated with internal fixation. Average follow-up was 57.5 months.

RESULTS

Average American Orthopedic Foot and Ankle Society (AOFAS) scores significantly improved from 49.0 ± 10.9 points preoperatively to 76.0 ± 8.0 points at final follow-up. Average time to union was 12.5 weeks. Six patients (16.2%) suffered complications: superficial wound infection (2.7%), symptomatic hardware that warranted removal (5.4%) and nonunion (8.1%) presented nonunion. All three cases had prior internal fixation through an extensile lateral approach, and fused after a repeat surgery.

CONCLUSION

Arthroscopic subtalar arthrodesis offers consistent improvement in cases of posttraumatic arthritis following calcaneal fractures, with a union rate similar to published series of open arthrodesis. We observed more nonunions in patients who had been treated previously with internal fixation. In spite of this, we continue to recommend arthroscopic subtalar arthrodesis, as it preserves the soft tissue envelope better than open techniques.

Factors Influencing Functional Outcomes of Subtalar Fusion for Posttraumatic Arthritis After Calcaneal Fracture

BACKGROUND

Subtalar arthrodesis is a common salvage operation for posttraumatic subtalar arthritis. This study aimed to identify factors associated with functional outcomes and quality of life after subtalar fusion for posttraumatic subtalar arthritis after calcaneal fracture.

METHODS

This is a retrospective study with follow-up by questionnaire in two level 1 trauma centers. Patients who underwent subtalar arthrodesis for posttraumatic arthritis after a calcaneal fracture between 2001 and 2016 were identified and contacted for completion of a survey consisting of the Foot and Ankle Ability Measure (FAAM), Maryland Foot Score (MFS), Patient-Reported Outcomes Measurement System Physical Function (PROMIS PF, Short Form 10a) questionnaire, EuroQol 5-dimensional (EQ-5D) questionnaire, and EuroQol visual analog scale (EQ-VAS). Exclusion criteria were initial subtalar arthrodesis at an outside facility, primary arthrodesis for fracture, initial arthrodesis earlier than 2001, amputation of the fused foot or leg, younger than 18 years at time of fusion, and inability to communicate in English. A total of 159 patients met our inclusion criteria. Eighty-four patients completed the questionnaires, resulting in a response rate of 59%.

RESULTS

Median FAAM score was 79 (interquartile range [IQR], 48-90), median MFS was 74 (IQR, 56-86), and median PROMIS PF was 45 (IQR, 38-51). Quality of life was significantly lower when compared to a reference population ( P = .001). Smoking was independently associated with worse outcomes. Complications after fusion (such as nonunion, implant failure, and infectious complications), high-energy trauma, and ipsilateral injury were also predictors for poorer outcomes.

CONCLUSION

Acceptable functional outcomes and quality of life were observed after subtalar fusion. Smoking, complications after subtalar fusion, high-energy trauma, and presence of ipsilateral injuries were independently associated with worse functionality and quality of life.

LEVEL OF EVIDENCE

Prognostic level III, comparative series.

Living Cryopreserved Bone Allograft as an Adjunct for Hindfoot Arthrodesis

Hindfoot arthrodesis is a frequently performed procedure by foot and ankle surgeons. The relatively high nonunion rate associated with these procedures has led surgeons to use adjunctive bone graft to help augment osseous union. Cellular bone allografts are a specific type of graft that incorporates osteoconductive, osteoinductive, and osteogenic properties while also eliminating the common disadvantages of autografts and traditional allografts. This article discusses the role of cellular bone allografts in hindfoot arthrodesis procedures, a review of current literature, and a comparison of available products.

Balance and lower limb loads distribution after Ilizarov corticotomy

INTRODUCTION

Normal balance and symmetric distribution of lower limb loads are associated with adequate muscle strength, joint mobility and proprioception. The aim of this study was to analyze the distribution of lower limb loads and balance prior to and after axis correction and lengthening with Ilizarov method.

MATERIALS AND METHODS

The prospective analysis included 20 patients from our clinic, who have been subjected to distraction-corrective lower limb corticotomies with the Ilizarov method in 2014-2015. Balance and distribution of lower limb loads were determined with a pedobarographic platform.

RESULTS

Prior to the surgery, mean loads on affected and non-affected limbs corresponded to42%and58%of body weight, respectively. Mean loads on affected and non-affected limbs during the postoperative examination did not differ significantly. Mean path length of the center of gravity prior to and after the surgery amounted to143.27 cm and 125.11 cm, respectively. Mean area of the center of gravity was 7.81 cm²prior to the surgery and 5.81 cm²after the procedure.

DISCUSSION

Our present study showed that distraction-corrective Ilizarov corticotomy may provide more symmetric distribution of lower limb loads and improvement of balance. This outcome should be considered satisfactory from the perspective of the locomotor system statics. Corticotomies with Ilizarov method provide symmetric distribution of loads between non-affected and operated limb.

Preoperative Risk Factors for Complications in Elective Ankle and Hindfoot Reconstruction

BACKGROUND

The purpose of this study was to examine medical, social, and psychological factors associated with complications and reoperation after foot and ankle reconstruction.

METHODS

A retrospective chart review was conducted of 132 patients (135 feet; 139 operative cases) who had elective foot and ankle reconstruction. Medical, social, and psychological variables were documented. Primary outcomes included complications and reoperations.

RESULTS

The overall complication rate was 28% (39/139), and the reoperation rate was 17% (24/139). Alcohol use (P = .03) and preoperative narcotic use (P = .02) were risk factors for complications, with delayed wound healing more frequent in alcohol users (P = .03) and deep infection (P = .045) and nonunion (P = .046) more frequent preoperative narcotic use. Deep infection also was more frequent in tobacco users (P < .01). Older patients were less likely to undergo reoperation (risk of reoperation increased with age). Other variables were not associated with increased complications.

CONCLUSION

Patients who consumed alcohol or had been prescribed any amount of narcotic within 3 months preoperatively were at increased risk for complications. Patients who smoked were more likely to have a wound infection. Surgeons should be aware of these factors and counsel patients before surgery.

LEVELS OF EVIDENCE

Level III: Retrospective comparative study.

Functional outcomes and quality of life in patients with subtalar arthrodesis for posttraumatic arthritis

INTRODUCTION

Subtalar arthrodesis is a common salvage operation for posttraumatic subtalar arthritis, a condition frequently seen in patients who suffered major trauma. Functional outcomes in trauma patients may be influenced by concomitant injuries and the severity of the initial trauma. The aim of this study was to evaluate quality of life and functional outcomes of subtalar arthrodesis for posttraumatic arthritis in patients with severe or complex foot injuries.

MATERIALS AND METHODS

This is a retrospective single center study with prospective follow-up. Patients who underwent subtalar arthrodesis for posttraumatic arthritis between 2000 and 2016 were included and invited to complete a Maryland Foot Score (MFS), a EuroQol five-dimensional (EQ-5D™) and Visual Analog Scale (EQ-VAS™) questionnaire, and four additional questions.

RESULTS

Forty patients were included in the study, functional outcome scores were available for 30 patients (response rate 75%). Additional surgery of the fused foot was performed in 29 patients and 15 suffered multiple lower extremity injuries. Six patients were polytraumatized. Ninety percent of all patients would recommend the procedure to others, walking abilities improved in 69% and less pain was experienced in 76%. Median MFS score was 61 (IQR 53-72). Quality of life was significantly lower when compared to a reference population (p<0.001).

CONCLUSION

Satisfaction was high, as 90% of all patients would recommend subtalar fusion to others, even though the relatively poor outcome measures would suggest differently. Existing functional outcomes measures were influenced by concomitant injuries and additional procedures. This demands development of instruments suitable for severely injured patients with multiple or complex injuries.

Radiological evaluation of ankle arthrodesis with Ilizarov fixation compared to internal fixation

INTRODUCTION

We asked whether the type of ankle joint arthrodesis stabilization will affect: (1) rate of union, (2) rate of adjacted-joint arthritis, (3) malalignment of the ankle joint.

MATERIAL AND METHODS

We retrospectively radiological studied 62 patients who underwent ankle arthrodesis with Ilizarov external fixator stabilization (group 1,n=29) or internal stabilization (group 2,n=33) from 2006 to 2015. Radiologic outcomes were mesure by: (1) rate of union, (2) rate of adjacent-joint arthritis, (3) malalignment of the ankle joint. The Levene's test,Mann-Whitney U test and Students t-test were used to the statistical analyses.

RESULTS

Ankle fusion was achieved in 100% of patients treated with external fixation and in 88% with internal stabilization. Desired frontal plane alignment was achieved in 100% of patients with external fixation and 76% with internal stabilization. Desired sagittal plane alignment was achieved in 100% of external fixation and 85% of internal stabilization. A total of 14 (48.3%) patients from group 1 showed a radiographic evidence of pre-existing adjacent-joint OA. The radiographic evidence of pre-existing adjacent-joint OA was also found in 27(81.8%) subjects from group 2. Alterations of adjacent joints were also found on postoperative radiograms of 19 (65.5%) patients subjected to Ilizarov fixation and in all 33 patients from group 2.

DISCUSION

Ilizarov fixation of ankle arthrodesis is associated with lower prevalence of adjacent-joint OA and ankle joint misalignment,and with higher fusion rates than after internal fixation.Although achieving a complex ankle fusion is generally challenging,radiological outcomes after fixation with the Ilizarov apparatus are better than after internal stabilization.

Is It Worth Discriminating Against Patients Who Smoke? A Systematic Literature Review on the Effects of Tobacco Use in Foot and Ankle Surgery

Although numerous studies have linked smoking with lower extremity wound and bone healing complications, a comprehensive study on the effects of smoking in foot and ankle surgery has not yet been reported. The purpose of the present study was to report the results of our systemic literature review, identifying the effects of tobacco use on common foot and ankle procedures. The systematic literature review was performed according to guidelines set by the PRIMSA statement (Preferred Reporting Items for Systematic Review and Meta-Analyses). Smoking, as a single risk factor, was analyzed and used to compare adverse outcomes in the postoperative setting of foot and ankle surgery. We reviewed 528 abstracts that met our initial identification criteria. After an extensive review process, 46 of the articles (8.71%) met the eligibility requirements to be included in the present study. Distal bunionectomy with osteotomy, first metatarsophalangeal joint arthrodesis, Lapidus bunionectomy, toe amputation, transmetatarsal amputation, Syme's amputation, open reduction internal fixation (ORIF) of calcaneal fractures, ankle fracture ORIF, pilon fracture ORIF, subtalar arthrodesis, rearfoot arthrodesis, tibiocalcaneal arthrodesis, ankle arthrodesis, total ankle arthroplasty, and plastic surgery procedures and their respective negative association with smoking was identified and described in our review. Our systematic literature review revealed that procedures involving arthrodesis, fracture ORIF, and plastic surgery were associated with negative outcomes in smokers. Procedures that did not involve osseous unions such as total ankle arthroplasty and amputations did not appear to have negative outcomes associated with smoking.

Subtalar arthroscopic arthrodesis: Technique and outcomes

PURPOSE

The goal of this study was to describe the surgical technique and our results with arthroscopic posterior subtalar arthrodesis.

MATERIAL AND METHODS

Retrospective case series of 65 patients (38 men and 27 women) averaging 50 years of age (range 21-72 years) undergoing posterior arthroscopic subtalar arthrodesis using one or two percutaneous 6.5-7.3mm screws between May 2004 and February 2011, with a mean follow-up of 57.5 months (range 24-105 months).

RESULTS

We achieved a 95.4% union rate after an average of 12.1 weeks (range 9 to 16 weeks). 12.3% of patients suffered complications, including superficial infection, nonunion and need for hardware removal. The AOFAS score improved from 51.5 points (19-61 points) preoperatively to 81.9 points (60-94 points) in the postoperative period.

CONCLUSIONS

We describe the surgical technique for arthroscopic subtalar arthrodesis, which as proven to be a safe and reliable technique in our experience, with consistent improvements in AOFAS scores.

Efficacy of a Cellular Bone Allograft for Foot and Ankle Arthrodesis and Revision Nonunion Procedures

BACKGROUND

Bone graft substitutes are often required in patients at risk for nonunion, and therefore, an allograft that most closely mimics an autograft is highly sought after. This study explored the utility and efficacy of a cellular bone allograft used for foot and ankle arthrodesis and revision nonunion procedures in a patient population at risk for nonunion.

METHODS

An institutional review board-approved retrospective review of consecutive patients who underwent arthrodesis and revision nonunion procedures with a cellular bone allograft was performed at a single academic institution. No external sources of funding were provided for this study. Inclusion criteria included patients who were more than 1 year after surgery or less than 1 year after surgery if they had undergone a second operative procedure for nonunion or if they had computed tomography-documented union. Forty operative procedures in 36 patients with a mean follow-up of 13 months (range, 6-25 months) were included for data analysis. All patients had at least one of the following risk factors associated with nonunion: current smoker, diabetes, avascular necrosis (AVN) of the involved bone, active same-site operative infection, history of nonunion, previous same-site surgery, or gap of 5 mm or greater after joint preparation. The primary outcome was radiographic union.

RESULTS

The union rate in this high-risk population was 83% (33/40). Univariate analysis demonstrated that the use of a cellular bone allograft helped mitigate the presence of risk factors known to cause nonunion. There was no significant difference in fusion rates among groups with current smoking, AVN of the involved bone, active same-site operative infections, history of nonunion, rheumatoid arthritis on medication, previous same-site operative procedures or infections, or a gap of 5 mm or greater after joint preparation. However, in this population, diabetic and female patients remained at a high risk of recurrent nonunion ( P = .0015), despite the use of a cellular bone allograft. Chi-square analysis of patients with increasing numbers of risk factors directly correlated with an increased risk of nonunion ( P = .025). Four wound complications were reported in this cohort that required irrigation and debridement (10%).

CONCLUSION

These data demonstrated a union rate of 83% in patients with risk factors known to cause nonunion. The benefits of the use of a cellular bone allograft allowed for the avoidance of morbidity associated with autograft harvesting while still improving the local biology to facilitate fusion in a difficult patient population to attain a successful fusion mass.

LEVEL OF EVIDENCE

Level IV, retrospective case series.