Weight bearing cone beam CT scan versus gravity stress radiography for analysis of supination external rotation injuries of the ankle.

For AO 44-B2 ankle fractures of uncertain stability, the current diagnostic standard is to obtain a gravity stress radiograph, but some have advocated for the use of weight-bearing radiographs. The primary aim was to compare measures of medial clear space (MCS) on weight-bearing cone beam computed tomography (CBCT) scans versus gravity stress radiographs for determining the state of stability of ankle fractures classified as AO SER 44-B2 or Weber B. The secondary aim was to evaluate the details offered by CBCT scans with respect to other findings that may be relevant to patient care. Nine patients were enrolled in this cross-sectional study between April 2016 and February 2017 if they had an AO SER 44-B2 fracture of uncertain stability, had a gravity stress radiograph, and were able to undergo CT scan within seven days. The width of the MCS was measured at the level of the talar dome on all radiographs and at the mid coronal slice on CT. Wilcoxon signed-ranks tests were used to compare MCS between initial radiographs, gravity stress radiographs and weight-bearing CBCT scans. MCS on weight-bearing CBCT scan (1.41±0.41 mm) was significantly less than standard radiographs (3.28±1.63 mm, P=0.004) and gravity stress radiographs (5.82±1.93 mm, P=0.02). There was no statistically significant difference in MCS measured on standard radiographs versus gravity stress radiographs (P=0.11). Detailed review of the multiplanar CT images revealed less than perfect anatomical reduction of the fractures, with residual fibular shortening, posterior displacement, and fracture fragments in the incisura as typical findings. Similar to weight-bearing radiographs, weight-bearing CBCT scan can predict stability of AO 44-B2 ankle fractures by showing restoration of the MCS, and might be used to indicate patients for non-operative treatment. None of the fractures imaged in this study were perfectly reduced however, and further clinical research is necessary to determine if any of the detailed weight-bearing CBCT findings are related to patient outcomes.

A radiographic and clinical comparison of reamer-irrigator-aspirator versus iliac crest bone graft in ankle arthrodesis.

PURPOSE: We evaluated radiographic fusion at follow-up and complication rates in patients who had either iliac crest (ICBG) or femoral reamer-irrigator-aspirator (RIA) bone graft for tibiotalar fusion. METHODS: We retrospectively reviewed charts and radiographs of all patients who had a tibiotalar fusion from August 2007 to February 2011. Records were analysed for patient demographics, complications, and clinical symptoms. Radiographs were reviewed in sequential order by two fellowship-trained foot and ankle surgeons and one orthopaedic surgeon who specialises in foot and ankle surgery to determine radiographic fusion at routine follow-up. Patients were contacted to determine current visual analog scores (VAS) at their graft site. RESULTS: Mean patient age was 49.4 ± 12.1 years in the RIA group and 49.3 ± 15.4 years in the ICBG group (p = .97). Pre-operative characteristics showed no significant differences between groups. The ICBG group had significantly more nonunions than the RIA group (six vs. one, p = 0.04). Two patients in the ICBG had chronic pain at their graft site based on their VAS score; there were none in the RIA group. Radiographic fusion at follow-up was similar between groups, with no significant difference (12.48 ± 3.85 weeks vs.12.21 ± 3.19 weeks, p = .80). CONCLUSIONS: There was a significantly higher nonunion rate in the ICBG group, but both groups had a solid radiographic bony fusion at similar follow-up time points. Our results suggest RIA bone graft is a viable alternative to ICBG for tibiotalar fusion.

Short to midterm clinical and radiographic outcomes of the Salto total ankle prosthesis.

BACKGROUND: Total ankle arthroplasty (TAA) has become an increasingly effective treatment option for tibiotalar arthritis. The purpose of this study was to evaluate the short to midterm clinical and radiographic outcomes of the Salto fixed bearing total ankle prosthesis. METHODS: We retrospectively reviewed the radiographs and patient records of 74 consecutive patients with 75 TAA implants from January 2007 to April 2011. The average age was 60.6 years (range, 41-82) with 41 females and 33 males. The average clinical follow-up was 43 months (range, 24-73 months). Radiographs were reviewed for areas of radiolucency and cystic changes around the talar and tibial implants, as well as for implant migration using standardized tibal, talar, talocalcaneal, and tibial slope angular measurements. The validated Foot and Ankle Outcome Score (FAOS), Short Form-12 (SF-12), and Visual Analog Scale (VAS) were used as subjective patient outcome measures. Kaplan Meier (K-M) curves were created for implant survivorship with revision of components as an endpoint and for return to the operating room for any reason. RESULTS: Total ankle survivorship was 98%. Thirteen patients returned to the operating room for any reason. There was 1 deep infection, and no ankles were converted to an arthrodesis. Average ankle dorsiflexion and plantarflexion improved from 4.3 ± 3.3 to 8.7 ± 5.6 degrees (P = .0008) and 24 ± 11 to 29 ± 7 degrees (P = .04), respectively. Patients showed significant improvements in all subscales of the FAOS (P < .0001). The physical component of the SF-12 significantly improved from 30 ± 8 to 41 ± 13 (P < .0001), but this was not observed with the mental component (52 ± 1 vs 53 ± 1, P = .55). The mean VAS for patient satisfaction was 9 (range, 2-10). Two patients had component migration (1 tibial and 1 talar component), neither of which required a revision procedure. Six ankles had a total of 9 radiolucent lines with a radiographically stable implant, and no patients had cystic changes. CONCLUSION: This is one of the first articles to report clinical and radiographic outcome data for the fixed bearing version of this prosthesis. We observed significant improvements in subjective outcome measures and range of motion with a 98% component survivorship at short to midterm follow-up. Longer follow-up will be necessary to determine the durability of this implant. LEVEL OF EVIDENCE: Level IV, case series.

Donor site morbidity with reamer-irrigator-aspirator (RIA) use for autogenous bone graft harvesting in a single centre 204 case series.

Donor site morbidity and complication rate using the reamer-irrigator-aspirator (RIA) system for intramedullary, non-structural autogenous bone graft harvesting were investigated in a retrospective chart and radiographic review at a University affiliated Level-1 Trauma Centre. 204 RIA procedures in 184 patients were performed between 1/1/2007 and 12/31/2010. RIA-indication was bone graft harvesting in 201 (98.5%), and intramedullary irrigation and debridement in 3 (1.5%) cases. Donor sites were: femur - antegrade 175, retrograde 4, tibia - antegrade 7, retrograde 18. Sixteen patients had undergone two RIA procedures, two had undergone three procedures, all using different donor sites. In 4 cases, same bone harvesting was done twice. Mean volume of bone graft harvested was 47 ± 22ml (20-85 ml). The complication rate was 1.96% (N=4). Operative revisions included 2 retrograde femoral nails for supracondylar femur fractures 6 and 41 days postoperatively (antegrade femoral RIA), 1 trochanteric entry femoral nail (subtrochanteric fracture) 17 days postoperatively (retrograde femoral RIA) and 1 prophylactic stabilization with a trochanteric entry femoral nail for intraoperative posterior femoral cortex penetration without fracture. In our centre, the RIA technique has a low donor site morbidity and has been successfully implemented for harvesting large volumes of nonstructural autogenous bone graft.