Enhancing precision in osteochondral lesions of the talus measurements and improving agreement in surgical decision-making using weight-bearing computed tomography and distance mapping.

PURPOSE: Weight-bearing computed tomography (WBCT) enables the creation of a three-dimensional (3D) model that represents the ankle morphology in a standing position. Distance mapping (DM) is a complementary feature that uses color coding to represent the relative intraarticular distance and can be used to outline intraarticular defects. Consequently, DM offers a novel approach to delineating osteochondral lesions of the talus (OLT), allowing for the quantification of its surface, volume and depth. The reliability of DM for OLT measurements has yet to be thoroughly evaluated. This study primarily aims to determine the reliability of DM in measuring the surface, depth and volume of OLT. A secondary objective is to ascertain whether measurements obtained through DM, when integrated with a predefined treatment algorithm, can facilitate consensus among surgeons regarding the optimal surgical intervention. METHODS: This cohort comprised 36 patients with 40 OLTs evaluated using WBCT and DM. Two raters used DM to determine the lesion boundary (LB) and lesion fundus (LF) and calculate the lesion depth, surface and volume. The raters were asked to choose between bone marrow stimulation, autologous matrix-induced chondrogenesis and osteochondral transposition based on the measurement. Inter-rater and intra-rater agreement was measured. RESULTS: Interclass correlation of the lesion's depth surface produced an excellent inter-rater and intra-rater agreement of 0.90-0.94 p < 0.001. Cohen's κ agreement analysis of the preferable preoperative plan produced a κ = 0.834, p < 0.001, indicating a near-perfect agreement. CONCLUSION: WBCT-based 3D modules and DM can be used to measure the lesion's surface, depth and volume with excellent inter-rater and inter-rater agreement; using this measurement and a predetermined treatment algorithm, a near-perfect inter-rater agreement for the preoperative planning was reached. WBCT in conjunction with AI capabilities could help determine the type of surgery needed preoperatively, evaluate the hindfoot alignment and assess if additional surgeries are needed. LEVEL OF EVIDENCE: Level III.

Significant Clinical Improvement After Arthroscopic Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A 5-Year Follow-Up.

PURPOSE: This study aims to evaluate the clinical outcomes of arthroscopic autologous matrix-induced chondrogenesis (A-AMIC) for osteochondral lesions of the talus (OLT) at 24 months and 60 months of follow-up. The secondary aim was to assess whether age, body mass index (BMI), and lesion surface affect outcomes. DESIGN: Sixty-three patients (32 males, 31 females) with a median age of 37 years [interquartile range (IQR): 25-48] were included. Preoperative and postoperative (24 months and 60 months) clinical outcomes were evaluated using a Visual Analog Score (VAS) for pain during walking, the American Orthopaedic Foot and Ankle Society (AOFAS), Short-Form Survey (SF-12), the Halasi, and the University of California, Los Angeles (UCLA) scores. Patients were categorized according to age, BMI, and lesion surface (1-1.5 cm2 and over 1.5 cm2). The effect of each category was evaluated. RESULTS: There were significant improvements in the VAS, AOFAS, SF-12, and UCLA, comparing the preoperative scores to the 60-month follow-up scores (P < 0.001). There were no significant differences in the above-mentioned outcomes between the follow-up periods. Patients older than 33 years had lower SF-12, Halasi, and UCLA scores (P = 0.005, 0.004, and <0.001, respectively). Overweight patients had lower VAS, SF-12, Halasi, and UCLA scores (P = 0.006, 0.002, 0.024, and 0.007, respectively). Lesion size was uninfluential. CONCLUSION: A-AMIC yielded clinical improvements at a minimum follow-up of 60 months in patients with symptomatic OLTs, with clinical improvement peaking in the first 2 years, followed by a plateau period. Increased age and BMI were significantly associated with inferior outcomes.

Three-Dimensional Distance Mapping to Identify Safe Zones for Lateral Column Lengthening.

BACKGROUND: Evans (E-LCL) and Hintermann LCL (H-LCL) lateral column lengthening osteotomies are standard surgical solutions for flexible, progressive collapsing feet. E-LCL is performed between the anterior and middle facets and endangers specific os calcis subtalar joint (OCST) subtypes without distinct facets. H-LCL is oriented between the posterior and middle facets and should be suitable for all OCSTs. Both osteotomies are associated with increased subtalar osteoarthritis, indicating iatrogenic damage. Distance mapping (DM) enables visualization of the relative distance between 2 articular surfaces represented by color patterns. This study aims to measure the safe zones for LCL using 3-dimensional (3D) models and DM; we hypothesize that it could be measured with high reproducibility. METHODS: Two raters categorized 200 feet across 134 patients into OCSTs based on the Bruckner classification. Four angles were measured independently. The proximal and distal extents of the posterior safe zone (PSZ) angles were determined for H-LCL osteotomies; similarly, the proximal and distal extents of the anterior safe zone (ASZ) angles were identified for E-LCL osteotomies. Consequently, the surface available for safe osteotomies were calculated. An interclass correlation was used to assess the agreement between the 2 raters. Additionally, analysis of variance and Mann-Whitney U test were used to compare the safe zones between OCSTs. RESULTS: The mean proximal and distal extents of the PSZ angles were 68 ± 7 and 75 ± 5 degrees from a line parallel to the lateral border of the calcaneus, respectively, and the proximal and distal extent of the ASZ angles were 89 ± 6 and 95 ± 5 degrees, respectively. There were no statistically significant differences between the OCSTs. Two raters measured the angles with good to excellent interrater and intrarater agreement. In 18 cases, we were unable to plan for H-LCL or E-LCL osteotomies. CONCLUSION: Distance mapping could be used to measure the safe zone, tailor a preoperative plan, and potentially reduce the risk for iatrogenic damage in LCL. 3D models and DM can increase the reliability of preoperative plans in bones with complex 3D structures. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Axial rotation analysis in total ankle arthroplasty using weight-bearing computer tomography and three-dimensional modeling.

BACKGROUND: Post-operative alignment is the most critical indicator for a successful total ankle arthroplasty (TAA). Total ankle malrotation is associated with an increased risk for polyethylene wear and medial gutter pain. Currently, there is no consensus on the correct way to measure the alignment of the tibial and talar component rotations in the axial plane. In the current study, the post-operative analysis system was assessed using weight-bearing computer tomography and a three-dimensional (3D) model. The purpose of the study was to assess the inter-observer and intra-observer agreement of this system. MATERIAL AND METHOD: Four angles were measured by two raters independently in two separate readings: posterior tibial component rotation angle (PTIRA), posterior talar component rotation angle (PTARA), tibia talar component axial angle (TTAM), and tibial component to the second metatarsal angle (TMRA). Agreement analysis was quantified according to the interclass coefficient. RESULTS: Sixty TAAs across 60 patients were evaluated. A good inter-observer agreement and intra-observer agreement when measuring the PTIRA, PTARA, and TTAM angles was observed along with an excellent inter-observer agreement and intra-observer agreement when measuring the TMRA angle. CONCLUSION: In conclusion, the current 3D model-based measurement system demonstrates good to excellent inter and intra-agreement. According to these results, 3D modelling can be reliably used to measure and assess the axial rotation of TAA components. LEVEL OF EVIDENCE: Level 3 retrospective study.

Reliability of Cone Beam Weightbearing Computed Tomography Analysis of Total Ankle Arthroplasty Positioning and Comparison to Weightbearing X-Ray Measurements.

BACKGROUND: The current reference standard for postoperative evaluation of total ankle arthroplasty (TAA) positioning, weightbearing radiography (WBXR), is subject to technical bias. Weightbearing cone beam computed tomography (WBCT) enables visualization of the foot's complex 3-dimensional (3D) structure under standing load. To date, no WBCT-based system for TAA positioning has been validated. The purpose of this study was to (1) assess TAA positioning using WBCT 3D models and (2) evaluate the agreement levels between 2 raters and thus evaluate the intermethod reliability with respect to WBXR. METHODS: Fifty-five consecutive patients were retrospectively reviewed. Two raters independently created a 3D WBCT model using dedicated software and recorded the following measurements: α angle, tibiotalar surface angle (TSA), hindfoot angle (HFA), tibiotalar ratio (TTR), ß angle, γ angle, and Φ angle. Measurements were repeated 2 months apart in similar, independent fashion and compared to WBXR. Interobserver, intraobserver, and intermethod agreements were calculated. RESULTS: All 7 measurements showed good to excellent intraobserver and interobserver reliability (ICC 0.85-0.95). The intermethod (WBCT vs WBXR) agreement showed good agreement for the γ angle (ICC 0.79); moderate agreement levels for the α angle, TSA angle, ß angle, and TTR (ICC 0.68, 0.69, 0.70, and 0.69, respectively); poor agreement for the HFA (ICC 0.25); and negative agreement for the φ angle (ICC -0.2). CONCLUSION: Position analysis of TAA using WBCT demonstrated good to excellent interobserver and intraobserver agreement and can be reliably used. Additionally, a negative to moderate agreement between standard WBCT and standard WBXR was found. LEVEL OF EVIDENCE: Level III, retrospective study.

Classification of the Os Calcis Subtalar Morphology in Symptomatic Flexible Pediatric Pes Planus Deformity Using Weightbearing CT and Distance Mapping.

BACKGROUND: The etiology of symptomatic pediatric pes planus (PP) deformity is unclear. Reduced os calcis subtalar joint (OCST) anterior facet morphology has been suggested to result in less support to the talar head and a higher propensity to develop PP deformity. Weightbearing computed tomography (WBCT) and distance mapping (DM) offer new opportunities to investigate PP deformity in general and the OCST specifically. The purpose of this study is to investigate the OCST morphology using DM and to classify PP subtalar subtypes with DM using Bruckner's A-D classification system. METHODS: Forty feet in 25 patients in a national referral center were evaluated for symptomatic PP deformity that failed nonoperative treatment. A WBCT scan was performed as part of the preoperative evaluation. Visualization of the distance distribution between the articulating surfaces of the subtalar joint was based on a DM technique. Intra- and interobserver agreement of the subtalar morphology was assessed using Bruckner's classification system. RESULTS: The mean age was 10.7 ± 1.4 years. The following mean ± SD and median ± ranges were semiautomatically measured for this group: Meary angle -21 ± 8, calcaneal inclination 15 ± 4 degrees, talar coverage angle 39 (range 32.6-49) degrees, and hindfoot moment-arm 16 ± 5 mm. Classifying subtalar morphology using DM yielded an excellent intra- and interobserver agreement. The individual percentages of each individual subtype were calculated: type A 5%, type B 48%, type C 4%, and type D in 44%. CONCLUSION: This study demonstrated excellent intraobserver and interobserver agreement in classifying the OCST using DM. A higher prevalence of types B and D was observed compared to types A and C in this PP cohort. LEVEL OF EVIDENCE: Level III, retrospective study.

Luxofracturas radiocarpianas: evaluación retrospectiva de una serie de casos / Radiocarpal fracture-dislocation. Retrospective evaluation of a case series

Introducción: Las luxofracturas radiocarpianas consisten en la pérdida total de contacto entre las superficies articulares de la primera fila del carpo y del radio. Se producen por traumatismos de alta energía. El objetivo de este estudio fue evaluar retrospectivamente una serie de casos para comparar la incidencia de estas lesiones, el manejo terapéutico y los resultados funcionales con la bibliografía publicada por centros de referencia en esta enfermedad. Materiales y métodos: Entre febrero de 2018 y junio de 2020, se evaluó, en forma retrospectiva, a pacientes con luxofractura radiocarpiana, clasificada en tipos I y II según Dumontier. Criterios de inclusión: hombres y mujeres >18 años con luxofractura radiocarpiana cerrada o abierta y un seguimiento mínimo de 3 meses. Se llevó a cabo un seguimiento clínico/por imágenes mediante radiografías, el cuestionario DASH, la escala de muñeca modificada de la Clínica Mayo, la escala analógica visual para dolor y el PSQ-18. Resultados: Se evaluó a 8 pacientes con 9 lesiones, y un seguimiento promedio de 8 meses. Las luxaciones eran 4 tipo I y 5 tipo II. Todos fueron operados. Según valores finales, hubo 2 resultados excelentes, 6 buenos/aceptables y uno pobre. Conclusión: El mejor método para el tratamiento definitivo es quirúrgico. La correcta clasificación y el estudio de la enfermedad tienen un rol fundamental en la toma de decisiones terapéuticas. Nivel de Evidencia: IV

Introduction: Radiocarpal fracture-dislocations consist of the total loss of contact between the articular surfaces of the first row of the carpus and the radius. They are caused by high-energy trauma. The purpose of the work is to retrospectively evaluate a series of cases to compare the incidence of these lesions, their therapeutic management and functional outcomes with the literature published by reference centers in this pathology. Materials and methods: Between February 2018 and June 2020 we retrospectively evaluated patients with radiocarpal fracture-dislocations, which were classified into groups I and II according to Dumontier. Inclusion criteria: males and females over 18 years of age with closed or open radiocarpal fracture-dislocations with a minimum follow-up of 3 months. A clinical/imaging follow-up was carried out using radiographs, the DASH questionnaire (Disabilities of the Arm, Shoulder and Hand), Modified Mayo Wrist Score, visual analog scale (VAS) and Patient Satisfaction Questionnaire Short Form (PSQ-18). Results: Eight patients with nine lesions with an average follow-up of 8 months were evaluated. Lesions were grouped into type I (4) and type II (5). All were surgically operated. According to the final values, outcomes were excellent in two cases, good/acceptable in six, and poor in one. Conclusion: We believe that the best method for definitive treatment is surgical. The correct classification and study of the pathology will play a fundamental role in making therapeutic decisions. Level of Evidence: IV

Evaluación de la estabilización de fracturas expuestas de pierna grados I y II de Gustillo en la etapa aguda / Analysis of the stabilization of Gustillo grade I and II open tibia fractures in the acute stage

Introducción: La fijación interna de las fracturas de pierna expuestas en la etapa aguda, es decir, dentro de las 24 h del trauma es un tema controvertido. El objetivo de este estudio fue evaluar las infecciones asociadas a la colocación de clavos endomedulares en la etapa aguda y a la colocación diferida, en la fijación de fracturas expuestas de pierna grados I y II de Gustilo. materiales y métodos: Se realizó un estudio de cohorte retrospectivo sobre el tratamiento en la etapa aguda de los pacientes que ingresaron en el hospital con fracturas expuestas de pierna entre 2015 y 2018. Se analizó la tasa de infecciones durante los primeros 6 meses después de la cirugía y se comparó la fijación en la etapa aguda con la fijación diferida. Resultados: La fijación interna con clavos endomedulares en la etapa aguda, en pacientes con fracturas expuestas de pierna no aumentó, sino que disminuyó la tasa de infecciones en el control posoperatorio. Conclusión: El estudio avala la colocación de clavos endomedulares en la etapa aguda, en pacientes con fractura de tibia expuestas. Nivel de Evidencia: II

Introduction: The internal fixation of leg fractures exposed in acute, that is, within 24 hours of trauma is quite controversial. The objective of this work is to assess infections associated with acute intramedullary nailing fixation ­versus deferred fixation­ of Gustilo type I and II open fractures. Patients and Methods: A retrospective cohort study was conducted of the acute treatment of patients with open leg fractures admitted to the hospital between 2015 and 2018. The infection rate was analyzed during the first 6 postoperative months after intramedullary nailing, and acute fixation patients were compared against deferred fixation patients. Results: Acute internal fixation with intramedullary nail in patients with open leg fractures does not increase, but decreases, the infection rate in the postoperative control. Conclusion: The study supports acute intramedullary nailing in patients with open tibial fractures. Level of Evidence: II