Clinical Features Requiring Sacroiliac Joint Arthrodesis in Patients with Sacroiliac Joint Pain.

PURPOSE: This study aimed to reveal the clinical features requiring sacroiliac joint (SIJ) arthrodesis, which was performed for patients who complain of severe SIJ pain. METHODS: The differences in clinical features between a surgical treatment group (n=20) and a conservative treatment group (n=66) were investigated. All patients were definitively diagnosed with SIJ pain by the use of SIJ injections. RESULTS: Six significant features were identified in the surgical treatment group, namely, sitting tolerance (<15 minutes), walking with a cane, pain in the supine position, pain while lying on the painful side, numbness in the lower limbs, and any accident that induced SIJ pain (P<0.01). Univariate logistic regression analysis revealed that sitting tolerance <15 minutes (odds ratio : 31.73), pain in the supine position (13.07), and pain while lying on the painful side (18.30) showed a high odds ratio. CONCLUSIONS: Sitting tolerance (<15 minutes), walking with a cane, pain in the supine position, pain while lying on the painful side, numbness in the lower limbs, and a history of any accident that induced SIJ pain may be considered as indicators for surgery after >?6 months of continued substantial conservative treatment. J. Med. Invest. 70 : 123-128, February, 2023.

Arthrodesis of the Fourth and Fifth Tarsometatarsal Joints in a Sensate Patient with Post-Traumatic Arthritis: A Case Report and Surgical Technique.

Lateral column arthrodesis of the tarsometatarsal joints is a highly controversial topic in foot and ankle surgery, with minimal prospective research and reproducible findings in the current literature. Arthrodesis of the lateral fourth and fifth tarsometatarsal joints, when performed, is most often done secondary to post-traumatic osteoarthritis or Charcot's neuroarthropathy deformity. This case report focuses on arthrodesis of the lateral column in a patient with post-traumatic osteoarthritis from a previously sustained Lisfranc fracture-dislocation. The patient also experienced a cavus foot deformity that was addressed with a lateral displacement calcaneal osteotomy. Arthrodesis of the fourth and fifth tarsometatarsal joints was found to be successful on this patient, with bony union noted to occur radiographically 12 weeks postoperatively. In addition, the patient experienced significant reduction in her preoperative pain and an ability to return to activities of daily living. Regular visits during an 18-month postoperative period occurred, with the patient continuing to have satisfactory results and a significant reduction in preoperative pain levels. One postoperative complication was encountered 15 months postoperatively: painful hardware, which resulted in the removal of both calcaneal screws and one screw from the fourth tarsometatarsal arthrodesis site. This case report proposes that lateral column arthrodesis may be performed successfully in select patients where other joint-preserving procedures may not be applicable. Herein we outline a suggested surgical technique with hardware that can be used to reproduce these findings and assist surgeons who are unfamiliar with performing this procedure.

Arthroscopic Ankle Arthrodesis.

Despite the increasing popularity of total ankle replacement, ankle arthrodesis remains the gold standard for the treatment of end-stage ankle arthritis. Historically, open techniques have been utilized for ankle arthrodesis. There have been many variations and techniques described, including transfibular, anterior, medial, and miniarthrotomy. Inherent disadvantages to these open techniques include postoperative pain, delayed or nonunion, wound complications, shortening, prolonged healing times, and prolonged hospital stays. Arthroscopic ankle arthrodesis provides the foot and ankle surgeon with an alternative to the traditional open techniques. Arthroscopic ankle arthrodesis has demonstrated faster union rates, decreased complications, reduced postoperative pain, and shorter hospital stays.

Small Joint Arthroscopy of the Foot.

Recently, there have been new advances in the arthroscopic approach to small joints of the foot. This is directly related to the improvement of surgical equipment, new techniques, and publications. These improvements led to broadening indications as well as minimizing complications. Several articles recently presented the uses of arthroscopic surgery in the small joints of the foot; however, the use is still relatively limited. Arthroscopic evaluation of the small joints of the foot includes the first metatarsophalangeal, lesser metatarsophalangeal, tarsometatarsal, talonavicular, and calcaneocuboid joints as well as the interphalangeal joint to the great toe and lesser toes.

Posterior Arthroscopic Subtalar Joint Arthrodesis (Pasta).

The arthroscopic approach provides a manageable postoperative course in terms of wound healing, pain control, and bone healing when compared with an open procedure. In particular, posterior arthroscopic subtalar joint arthrodesis (PASTA) allows a reproducible and viable alternative to standard lateral-portal subtalar joint (STJ) arthrodesis without violating sinus or canalis tarsi neurovascular structures. Additionally, those patients who have undergone previous total ankle arthroplasty, arthrodesis, or talonavicular joint arthrodesis may be better served with PASTA over open arthrodesis if STJ fusion becomes necessary. This article describes the unique PASTA surgical procedure and its helpful tips and pearls.

Proximal Interphalangeal Joint Arthrodesis of the Hand Utilising a Rigid Intramedullary Device.

The proximal interphalangeal joint (PIPJ) is critical for proper finger and hand function. Arthritis of this joint can lead to significant pain and functional impairment. The APEX IP® Extremity Medical fusion device (Extremity Medical, Parsippany, New Jersey, USA) is an interlocking intramedullary screw device that provides a reliable method of hand PIPJ arthrodesis with good patient outcomes. We describe an easily reproducible surgical technique guide for using this device. Level of Evidence: Level V (Therapeutic).

A Rare Case of Naviculo-medial Cuneiform Coalition Treated with Naviculo-medial Cuneiform Arthrodesis: A Case Report.

CASE: A 19-year-old woman developed spontaneous onset of right midfoot pain in the absence of trauma. Conservative management including orthotics and steroid injection reduced, but did not resolve, pain. Weight-bearing x-ray and CT confirmed naviculo-medial cuneiform coalition. After failure of conservative treatment, the patient elected to undergo right naviculo-medial cuneiform arthrodesis and returned to normal activity without pain postoperatively and at 4-year follow-up. CONCLUSION: Naviculo-medial cuneiform coalition is a rare source of midfoot pain, but should be considered as a differential diagnosis. This case suggests that naviculo-medial cuneiform arthrodesis can successfully resolve symptoms if conservative measures fail.

Total ankle replacement versus ankle arthrodesis for patients aged 50-85 years with end-stage ankle osteoarthritis: the TARVA RCT.

Background: We aimed to compare the clinical effectiveness, cost-effectiveness and complication rates of total ankle replacement with those of arthrodesis (i.e. ankle fusion) in the treatment of end-stage ankle osteoarthritis. Methods: This was a pragmatic, multicentre, parallel-group, non-blinded randomised controlled trial. Patients with end-stage ankle osteoarthritis who were aged 50-85 years and were suitable for both procedures were recruited from 17 UK hospitals and randomised using minimisation. The primary outcome was the change in the Manchester-Oxford Foot Questionnaire walking/standing domain scores between the preoperative baseline and 52 weeks post surgery. Results: Between March 2015 and January 2019, 303 participants were randomised using a minimisation algorithm: 152 to total ankle replacement and 151 to ankle fusion. At 52 weeks, the mean (standard deviation) Manchester-Oxford Foot Questionnaire walking/standing domain score was 31.4 (30.4) in the total ankle replacement arm (n = 136) and 36.8 (30.6) in the ankle fusion arm (n = 140); the adjusted difference in the change was -5.6 (95% confidence interval -12.5 to 1.4; p = 0.12) in the intention-to-treat analysis. By week 52, one patient in the total ankle replacement arm required revision. Rates of wound-healing issues (13.4% vs. 5.7%) and nerve injuries (4.2% vs. < 1%) were higher and the rate of thromboembolic events was lower (2.9% vs. 4.9%) in the total ankle replacement arm than in the ankle fusion arm. The bone non-union rate (based on plain radiographs) in the ankle fusion arm was 12.1%, but only 7.1% of patients had symptoms. A post hoc analysis of fixed-bearing total ankle replacement showed a statistically significant improvement over ankle fusion in Manchester-Oxford Foot Questionnaire walking/standing domain score (-11.1, 95% confidence interval -19.3 to -2.9; p = 0.008). We estimate a 69% likelihood that total ankle replacement is cost-effective compared with ankle fusion at the National Institute for Health and Care Excellence's cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained over the patient's lifetime. Limitations: This initial report contains only 52-week data, which must therefore be interpreted with caution. In addition, the pragmatic nature of the study means that there was heterogeneity between surgical implants and techniques. The trial was run across 17 NHS centres to ensure that decision-making streams reflected the standard of care in the NHS as closely as possible. Conclusions: Both total ankle replacement and ankle fusion improved patients' quality of life at 1 year, and both appear to be safe. When total ankle replacement was compared with ankle fusion overall, we were unable to show a statistically significant difference between the two arms in terms of our primary outcome measure. The total ankle replacement versus ankle arthrodesis (TARVA) trial is inconclusive in terms of superiority of total ankle replacement, as the 95% confidence interval for the adjusted treatment effect includes both a difference of zero and the minimal important difference of 12, but it can rule out the superiority of ankle fusion. A post hoc analysis comparing fixed-bearing total ankle replacement with ankle fusion showed a statistically significant improvement of total ankle replacement over ankle fusion in Manchester-Oxford Foot Questionnaire walking/standing domain score. Total ankle replacement appears to be cost-effective compared with ankle fusion at the National Institute for Health and Care Excellence's cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained over a patient's lifetime based on long-term economic modelling. Future work: We recommend long-term follow-up of this important cohort, in particular radiological and clinical progress. We also recommend studies to explore the sensitivity of clinical scores to detect clinically important differences between arms when both have already achieved a significant improvement from baseline. Trial registration: This trial is registered as ISRCTN60672307 and ClinicalTrials.gov NCT02128555. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 5. See the NIHR Journals Library website for further project information.

Each year, over 29,000 patients with ankle osteoarthritis seek a specialist opinion, of whom 4000 undergo NHS surgical treatment. The main surgical treatments for severe ankle osteoarthritis are total ankle replacement or arthrodesis (i.e. ankle fusion). Both are known to be good treatments to relieve pain, and each has its advantages. Total ankle replacement is a more popular patient choice than ankle fusion. When deciding whether to undergo ankle replacement or fusion, patients consult various sources, but the majority of them rely on the advice of their surgeon to make a final decision. To the best of our knowledge, there has never been a high-quality randomised clinical trial comparing these two treatments and there are no published guidelines on the most suitable management. In this study, 303 patients were randomised to a type of ankle surgery: 138 in the total ankle replacement arm and 144 in the ankle fusion arm received surgery. We found that both total ankle replacement and ankle fusion improved patients' walking ability, but we did not find a statistically significant difference between the treatment arms based on our primary outcome measure at 1 year. When we considered the type of total ankle replacement implant, we found that the implant most commonly used in the NHS (a fixed-bearing two-component implant) had better outcomes at 1 year than ankle fusion. Both total ankle replacement and ankle fusion appear to be safe. However, there were more wound-healing issues and nerve injuries in the total ankle replacement arm than in the ankle fusion arm. Twelve per cent of patients experienced bone non-union in the ankle fusion arm, but only 7.1% experienced symptoms. We estimate that there is a 69% chance that total ankle replacement would be cost-effective compared with ankle fusion at the National Institute for Health and Care Excellence's cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained over a patient's lifetime. This study provides the NHS with important information that could help to obtain the best possible outcome for patients with severe ankle arthritis.

Proximal row carpectomy versus four-corner arthrodesis in the treatment of SLAC and SNAC wrist: meta-analysis and literature review.

A systematic literature review was performed on 84 articles from 2000 to 2020 on proximal row carpectomy (PRC) or four-corner arthrodesis (FCA) in patients with posttraumatic wrist osteoarthritis. Qualitative assessment was conducted on 14 articles. Pain, range of motion (ROM), grip strength and complications were analyzed using weighted average means. Meta-analysis with a random effects model was performed for the flexion-extension arc and grip strength. A total of 1,066 PRCs and 2,771 FCAs were analyzed, with a mean follow-up of 9 and 7 years respectively. Mean flexion after PRC and FCA respectively was 36.2 ° and 31.1 °, mean extension 41.4 ° and 32.4 °, and mean grip strength 26.4 kg and 27.5 kg. PRC had a larger flexion-extension arc than FCA, with a standard mean difference (SMD) of 0.41 (range, 0.02-0.81). No significant difference was found for grip strength. Osteoarthritis occurred in 42.2% of PRC cases, independently of capitate shape. Conversion to wrist arthrodesis was performed in 10.1% of failed PRCs. Revision was chosen in 4.7% of FCAs and conversion to wrist arthrodesis in 4.6%. We conclude that the functional results of both techniques are similar, but prefer PRC to FCA because of the lower complications rate.

Trends in management of adult tarsometatarsal joint injuries in a contemporary Australian context: a nationwide study of claims data over 20 years.

BACKGROUND: Traumatic tarsometatarsal joint (TMTJ) injuries are uncommon, but can cause significant morbidity due to delayed or missed diagnosis. Recent evidence highlights the importance of achieving anatomical reduction via operative management. This study aims to analyse trends in rates of open reduction internal fixation (ORIF) for Lisfranc injuries in Australia according to Nationwide claims data. METHODS: Claims according to the Medicare Benefits Schedule (MBS) on ORIF of traumatic TMTJ injuries were collated for the period from January 2000 to December 2020. Paediatric patients were excluded. Two negative binomial models were utilized to analyse the trends in TMTJ injuries over time after controlling for sex, age group and population changes. Results were absolute and per 100 000 population. RESULTS: 7840 patients underwent TMTJ ORIF over the period studied. There was a mean yearly increase of 12% (P < 0.001). Age group (P < 0.001) and year (P < 0.001) were significant predictors for TMTJ fixation, whilst sex was not (P = 0.48). Patients older than 65 years were noted to have a 53% lower rate of TMTJ ORIF per person, when compared to the reference group of 25-34 year-olds (P < 0.001). Five-year block analysis revealed increases in rate of fixation for all age groups. CONCLUSION: Rates of operative fixation for TMTJ injuries are increasing in Australia. This is likely due to improved diagnostics, understanding of optimal treatment goals, and increased orthopaedic subspecialisation. Further studies with clinical and patient reported outcomes, as well as comparing rates of operative intervention to incidence, will be useful.

Recomendaciones para la recuperación posquirúrgica optimizada en columna (REPOC) / Recommendations for enhanced post-surgical recovery in the spine (REPOC)

Introducción y objetivos: La recuperación posquirúrgica optimizada en columna (REPOC) constituye un enfoque multimodal, basado en la evidencia científica disponible, que consigue una mejora eficaz de la funcionalidad fisiológica del paciente, reduce el dolor e incluso disminuye los costes hospitalarios. El objetivo de este trabajo es proponer unos estándares para la aplicación de la REPOC a la cirugía de fusión lumbar. Métodos: Se constituyó ad hoc un grupo multidisciplinario de expertos que revisaron la evidencia disponible y plantearon recomendaciones consensuadas para la artrodesis lumbar, utilizando el sistema Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Resultados: Se seleccionaron 23 recomendaciones en las fases preoperatoria, intraoperatoria y postoperatoria de la intervención quirúrgica. También se elaboró una lista de 29 ítems para la aplicación de la REPOC en cirugía de columna. Conclusiones: Este listado de recomendaciones facilitará la implementación del enfoque REPOC como herramienta segura y eficaz para la reducción de los eventos adversos en nuestro entorno.(AU)

Introduction/objectives: Enhanced recovery after surgery (ERAS) constitutes a multimodal approach, based on available scientific evidence, that achieves better patient's functionality, reduces pain, and even lowers financial costs. The present consensus statement proposes the standards for the implementation of ERAS programs to lumbar fusion surgery, a meant benchmark we call REPOC. Methodology: A multidisciplinary group of experts was set up ad hoc to review consensus recommendations for lumbar arthrodesis, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Results: As a result, 23 recommendations were selected throughout the preoperative, intraoperative, and postoperative phases of the surgical procedure. A 29-item checklist was also drawn up to implement REPOC protocols in spinal surgeries. Conclusions: This list of recommendations will facilitate the implementation of this multimodal approach as a safe and effective tool for reducing adverse events in our environment.(AU)

[Translated article] Recommendations for enhanced post-surgical recovery in the spine (REPOC) / Recomendaciones para la recuperación posquirúrgica optimizada en columna (REPOC)

Introducción y objetivos: La recuperación posquirúrgica optimizada en columna (REPOC) constituye un enfoque multimodal, basado en la evidencia científica disponible, que consigue una mejora eficaz de la funcionalidad fisiológica del paciente, reduce el dolor e incluso disminuye los costes hospitalarios. El objetivo de este trabajo es proponer unos estándares para la aplicación de la REPOC a la cirugía de fusión lumbar. Métodos: Se constituyó ad hoc un grupo multidisciplinario de expertos que revisaron la evidencia disponible y plantearon recomendaciones consensuadas para la artrodesis lumbar, utilizando el sistema Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Resultados: Se seleccionaron 23 recomendaciones en las fases preoperatoria, intraoperatoria y postoperatoria de la intervención quirúrgica. También se elaboró una lista de 29 ítems para la aplicación de la REPOC en cirugía de columna. Conclusiones: Este listado de recomendaciones facilitará la implementación del enfoque REPOC como herramienta segura y eficaz para la reducción de los eventos adversos en nuestro entorno.(AU)

Introduction/objectives: Enhanced recovery after surgery (ERAS) constitutes a multimodal approach, based on available scientific evidence, that achieves better patient's functionality, reduces pain, and even lowers financial costs. The present consensus statement proposes the standards for the implementation of ERAS programs to lumbar fusion surgery, a meant benchmark we call REPOC. Methodology: A multidisciplinary group of experts was set up ad hoc to review consensus recommendations for lumbar arthrodesis, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Results: As a result, 23 recommendations were selected throughout the preoperative, intraoperative, and postoperative phases of the surgical procedure. A 29-item checklist was also drawn up to implement REPOC protocols in spinal surgeries. Conclusions: This list of recommendations will facilitate the implementation of this multimodal approach as a safe and effective tool for reducing adverse events in our environment.(AU)

Acute limb shortening and modified pantarsal arthrodesis for the treatment of a highly comminuted distal tibial articular fracture in a dog.

A three-year-old female spayed Lurcher was referred for the treatment of a highly comminuted distal tibial articular fracture. Resection of the area of comminution with a transverse osteotomy of the tibial diaphysis and talar ridges was performed, followed by modified pantarsal arthrodesis and a calcaneotibial screw. The treatment resulted in 7 cm of tibial shortening, equating to a 28% reduction in the total tibial length. Radiographic union of the arthrodesis was successful. Fair use of the pelvic limb was documented long-term. Combined acute limb shortening and modified pantarsal arthrodesis resulted in an acceptable outcome and could be considered in cases of highly comminuted distal tibial fractures.

Outcomes of Arthroscopic Scaphoid Excision and Lunocapitate Fusion for Advanced Traumatic Arthritis of the Wrist.

Background: Arthroscopic lunocapitate (LC) fusion can be an alternative surgical treatment for scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC) of the wrist. We retrospectively reviewed patients who had arthroscopic LC fusion to estimate clinical and radiological outcomes. Methods: From January 2013 to February 2017, all patients with SLAC (stage II or III) or SNAC (stage II or III) wrists, who underwent arthroscopic LC fusion with scaphoidectomy and were followed up for a minimum of 2 years, were enrolled in this retrospective study. Clinical outcomes included visual analog scale (VAS) pain, grip strength, active range of wrist motion, Mayo wrist score (MWS), and the Disabilities of Arm, Shoulder and Hand (DASH) score. Radiologic outcomes included bony union, carpal height ratio, joint space height ratio, and loosening of screws. We also performed group analysis between patients with 1 and 2 headless compression screws to fix the LC interval. Results: Eleven patients were assessed for 32.6 ± 8.0 months. Union was achieved in 10 patients (union rate, 90.9%). There was improvmenet in mean VAS pain score (from 7.9 ± 1.0 to 1.6 ± 0.7, p = 0.003) and grip strength (from 67.5% ± 11.4% to 81.8% ± 8.0%, p = 0.003) postoperatively. The mean MWS and DASH score were 40.9 ± 13.8 and 38.3 ± 8.2, respectively, preoperatively and improved to 75.5 ± 8.2 and 11.3 ± 4.1, respectively, postoperatively (p < 0.001 for all). Radiolucent screw loosening occurred in 3 patients (27.3%), including 1 nonunion patient and 1 patient who underwent screw removal due to the screw migration encroaching the lunate fossa of radius. In group analysis, only the frequency of radiolucent loosening was higher in 1 screw (3 of 4) than 2 screw fixation (0 of 7) (p = 0.024). Conclusions: Arthroscopic scaphoid excision and LC fusion for patients with advanced SLAC or SNAC of the wrist was effective and safe only in cases fixed with 2 headless compression screws. We recommend arthroscopic LC fusion using 2 screws rather than 1 to decrease radiolucent loosening, which might affect complications such as nonunion, delayed union, or screw migration.

Complex Ankle Fusion With Circular Frames: Factors Influencing Outcomes, Complications, and Patient Satisfaction.

BACKGROUND: Circular frames for ankle fusion are reserved for complex clinical scenarios. The literature is heterogenous and conflicting. We aim to present the indications and outcomes of this procedure. METHODS: A retrospective cohort study based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow-up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiologic and clinical outcomes, and adverse events. Factors influencing radiologic and clinical outcomes were analyzed. RESULTS: 47 patients were included, with a median follow-up of 30 months (interquartile range [IQR] 20-40). The median age at time of surgery was 63.5 years (IQR 58-71). Patients had a median of 2 previous surgeries (IQR 1-3). The median LOS was 8.5 days, and median EFT was 237 days (IQR 166-280). Simultaneous limb lengthening (median 3.3 cm, IQR 1.9-3.5) was performed in 11 patients, increasing the EFT by a mean of 4 months. Primary and final union rates were 91.5% and 95.7%, respectively. At last follow-up, ASAMI bone scores were excellent or good in 87.2%. ASAMI functional scores were good in 79.1%. Patient satisfaction was 83.7%. In addition, 97.7% of patients experienced adverse events, most commonly pin-site related, with major complications in 30.2% and reoperations in 60.5%. There were 3 amputations. Adverse events were associated with increased age, poor soft tissue condition, severe deformities, subtalar fusions, peripheral neuropathy, peripheral vascular disease, and prolonged EFT. CONCLUSION: Complex ankle fusion using circular frames can achieve good outcomes, however time in frame may be prolonged with a high rate of adverse events. Identified risk factors for poorer outcomes should be considered in patient counselling and prognostication. LEVEL OF EVIDENCE: Level III, prognostic.

Outcomes of Salvage Procedures for Failed Total Ankle Arthroplasty.

BACKGROUND: The number of total ankle arthroplasty (TAA) procedures increased rapidly in the last years and so have its complications. The main pillars in treating failed TAA are revision total ankle arthroplasty (RTAA), revision total ankle arthrodesis (RAA), or revision tibiotalocalcaneal fusion (RTTC). To evaluate these options, we compared clinical, radiologic, and patient-reported outcomes. METHODS: A single-center, retrospective review of 111 cases of revision procedures of failed TAA from 2006 to 2020 was performed. Patients undergoing polyethylene exchange and revision of one metallic component were excluded. Demographic data, failure, and survival rates were analyzed. The European Foot and Ankle Society (EFAS) score and radiographic changes in the subtalar joint were evaluated. The average follow-up was 67.89 ± 40.51 months. RESULTS: One hundred eleven patients underwent removal of TAA. The procedures included 40 revisions of both metallic components, 46 revision total ankle arthrodesis and 25 revision tibiotalocalcaneal fusion. The overall failure rate in the cohort was 5.41% (6/111). The failure rate after RAA was 4.35 times higher than that of RTAA, whereas RTTC did not show failures. RTAA and RTTC lead to a 1-year and 5-year survival rate of 100%. RAA resulted in a 1-year survival rate of 90% and a 5-year survival rate of 85%. The mean EFAS score in the cohort was 12.02 ± 5.83. Analysis of the EFAS score showed that RTTC provided the most reliable pain reduction, and RTAA achieved the best gait pattern. RAA resulted in poorer clinical results. Subtalar joint degeneration occurred significantly less in the RTAA group (P = .01). CONCLUSION: This retrospective study suggests lower failure rates, increased short-term survival and a better clinical outcomes of revision arthroplasty and tibiotalocalcaneal fusion than ankle arthrodesis. Revision arthroplasty is a promising solution in treating failed total ankle arthroplasty considering lower rate of subsequent adjacent joint degeneration. LEVEL OF EVIDENCE: Level III, non-randomized observational study.

The Importance of Pragmatic Study Design to the Scholarly Influence of Surgical Hip Fracture Randomized Controlled Trials.

BACKGROUND: Surgical randomized controlled trials (RCTs) have potential drawbacks, leading some to question their role in filling the information gap in orthopaedic surgery. Pragmatism in study design was introduced to increase the clinical applicability of study results. The purpose of this study was to examine how pragmatism affects the scholarly influence of surgical RCTs. METHODS: A search for surgical hip fracture-related RCTs published between 1995 and 2015 was done. Journal impact factor, citation number, research question, significance and type of outcome, number of centers involved, and the Pragmatic-Explanatory Continuum Indicator Summary-2 level of pragmatism score were recorded for each study. Scholarly influence was estimated by a study's inclusion into orthopaedic literature or guidelines or through the study's average yearly citation rate. RESULTS: One hundred sixty RCTs were included in the final analysis. A multivariate logistic regression identified large study sample size as the only predictor of an RCT being used in clinical guidance texts. Large sample size and multicenter RCTs were predictors of high yearly citation rates. The level of pragmatism in study design did not predict scholarly influence. CONCLUSIONS: Pragmatic design is not independently associated with increased scholarly influence; however, large study sample size was the most important study characteristic affecting scholarly influence.

Mid-to long-term postoperative outcomes of ankle joint fusion in patients with haemophilia: A systematic review.

INTRODUCTION AND AIM: The ankle joint is the most common site for haemophilic arthropathy. The aim of this study was to review the outcomes of ankle joint fusion in patients with haemophilia A or B. The primary outcome measures were union rates, time to union, perioperative blood loss/transfusion, postoperative complications and length of hospital stay (LOS). Secondary outcome measures were hind foot functional outcome scores and the visual analogue pain scale (VAS). MATERIALS AND METHODS: A search of PubMed, Medline, Embase, Journals@Ovid and the Cochrane register was performed conforming to the PRISMA guidelines. Only human studies with a minimum follow-up of 1-year were included. The MINORS and ROBINS-1 tools were used for quality appraisal. RESULTS: A total of 952 articles were identified and only 17 studies met the eligibility criteria after the screening. The mean age of the patients was 37.6 (SD 10.2). A total of 271 ankle fusions were performed with the open crossed-screw fixation being the most common technique. Union rates were 71.5%-100% at 2-6 months. The pooled postoperative complication and revision rates were 13.7% and 6.5%, respectively. The range of LOS was 1.8-10.6 days. The mean preoperative American orthopedic foot and ankle society (AOFAS) ankle-hindfoot score was 35 (SD 13.1) whereas the mean postoperative AOFAS score was 79.4 (SD 5.3). The mean preoperative VAS was 6.3 (SD 1.6) while the mean postoperative VAS score was .9 (SD .4) across 38 ankle fusions. CONCLUSION: Ankle arthrodesis offers improved pain and function in haemophilic ankle arthropathy with lower revision and complication rates than that reported in the literature for total ankle replacement.

A comparative study of modern total ankle replacement and ankle arthrodesis for ankle osteoarthritis at different follow-up times: a systematic review and meta-analysis.

PURPOSE: Total ankle replacement (TAR) or ankle arthrodesis (AA) is the main surgical treatment for end-stage ankle osteoarthritis. However, the therapeutic effect of the two surgical procedures at different follow-up times remains controversial. The purpose of this meta-analysis is to compare the short-term, medium-term, and long-term safety and efficiency of the two modern surgical treatments. METHODS: We conducted a comprehensive search in PubMed, EMBASE, Cochrane library databases, Web of Science, and Scopus. The main results were the patient's reported outcome measure (PROM) score, satisfaction, complications, reoperation, and surgery success rate. Different follow-up times and implant designs were used to evaluate the source of heterogeneity. We used a fixed effects model for meta-analysis and I2 statistic for evaluating heterogeneity. RESULTS: Thirty-seven comparative studies were included. In the short term, TAR significantly improved clinical scores (AOFAS score: WMD = 7.07, 95% Cl: 0.41-13.74, I2 = 0.0%; SF-36 PCS score: WMD = 2.40, 95% Cl: 2.22-2.58, I2 = 0.0%; SF-36 MCS score: WMD = 0.40, 95% Cl: 0.22-0.57, I2 = 0.0%; VAS for pain: WMD = - 0.50, 95% Cl: - 0.56-0.44, I2 = 44.3%) and had the lower incidence of revision (RR = 0.43, 95% CI: 0.23-0.81, I2 = 0.0%) and complications (RR = 0.67, 95% Cl: 0.50-0.90, I2 = 0.0%). In the medium term, there were still higher improvements in both the clinical scores (SF-36 PCS score: WMD = 1.57, 95% Cl: 1.36-1.78, I2 = 20.9%; SF-36 MCS score: WMD = 0.81, 95% Cl: 0.63-0.99, I2 = 48.8%) and the patient satisfaction (RR = 1.24, 95% Cl: 1.08-1.41, I2 = 12.1%) in the TAR group, but its total complications rate (RR = 1.84, 95% Cl: 1.26-2.68, I2 = 14.9%) and revision rate (RR = 1.58, 95% CI: 1.17-2.14, I2 = 84.6%) were significantly higher than that of the AA group. In the long term, there was no significant difference in clinical score and satisfaction, and a higher incidence of revision (RR = 2.32, 95% Cl: 1.70-3.16, I2 = 0.0%) and complications (RR = 3.18, 95% Cl: 1.69-5.99, I2 = 0.0%) was observed in TAR than in AA. The result of the third-generation design subgroup was consistent with that of the above pooled results. CONCLUSION: TAR had advantages over AA in the short term due to better performance in terms of PROMs, complications, and reoperation rates, but its complications become a disadvantage in the medium term. In the long term, AA seems to be favored because of lower complications and revision rates, although there is no difference in clinical scores.

Anatomic Description of the Calcaneocuboid Joint: Implications for Staple Fixation.

Understanding the anatomy of the calcaneocuboid (CCJ) remains essential when selecting staple fixation to optimize osseous purchase during rearfoot procedures. This anatomic study quantitatively describes the CCJ in relation to staple fixation sites. The calcaneus and cuboid from 10 cadavers were dissected. Widths at 5 mm and 10 mm increments away from the joint were measured in dorsal, midline, and plantar thirds of each bone. The widths between each position's 5 mm and 10 mm increments were compared using the Student's t test. The widths among the positions at both distances were compared using an ANOVA then post hoc testing. Statistical significance was set at p ≤ 0.05. The middle (23 ± 3 mm) and plantar third (18 ± 3 mm) of the calcaneus at the 10 mm interval was greater than the 5 mm interval (p = .04). At 5 mm distal to the CCJ, the dorsal third of the cuboid maintained a statistically significant greater width than the plantar third (p = .02). The 5 mm (p = .001) and 10 mm (p = .005) dorsal calcaneus widths as well as the 5 mm (p = .003) and 10 mm (p = .007) middle calcaneus widths were significantly greater than the plantar widths. This investigation supports the use of 20 mm staple 10 mm away from the CCJ in dorsal and midline orientations. Care should be taken when placing a plantar staple within 10 mm proximal to the CCJ as the legs may extend beyond the medial cortex compared to dorsal and midline placements.