Lower Bone Density on Preoperative Computed Tomography Predicts Periprosthetic Fracture Risk in Total Ankle Arthroplasty

2018 ◽  
Vol 40 (1) ◽  
pp. 1-8 ◽  
Author(s):  
Elizabeth A. Cody ◽  
James R. Lachman ◽  
Elizabeth B. Gausden ◽  
James A. Nunley ◽  
Mark E. Easley
Keyword(s):  
Computed Tomography ◽  
Fracture Risk ◽  
Periprosthetic Fracture ◽  
Total Ankle Arthroplasty ◽  
Periprosthetic Fractures ◽  
Additional Patient ◽  
Mineral Density ◽  
Patient Factors ◽  
Ankle Arthroplasty ◽  
Preoperative Ct

Background: The effect of bone mineral density (BMD) on outcomes from total ankle arthroplasty (TAA) has not been studied. BMD can be estimated by measuring Hounsfield units (HU) on standard computed tomography (CT), which is frequently performed prior to TAA. We aimed to identify whether tibial and talar HU measured from preoperative CT scans were associated with periprosthetic fracture or revision risk in patients undergoing TAA. Methods: A prospectively collected database was used to retrospectively screen all patients undergoing primary TAA. Only patients with a preoperative CT within 1 year of surgery were included. Primary outcomes were periprosthetic fracture and prosthetic revision. HU were measured on axial CT cuts in the distal tibia and talus. Additional patient factors analyzed included age, sex, weight, body mass index (BMI), tobacco use, presence of rheumatoid arthritis, and preoperative deformity. A total of 198 ankles were included, with a mean 2.4 years of follow-up. Results: There were 7 intraoperative and 9 postoperative periprosthetic fractures (3.5% and 4.5%, respectively). Seven patients (3.5%) underwent prosthetic removal or revision. Lower tibial and talar HU, lower weight, and lower BMI were associated with periprosthetic fractures ( P < .05). After controlling for age, sex, and weight, only tibial HU was significantly associated with periprosthetic fracture ( P = .018). All intraoperative fractures occurred in patients with tibial HU less than 200. None of the patient factors analyzed were associated with revision. Conclusions: Lower tibial HU on preoperative CT was strongly associated with periprosthetic fracture risk with TAA. In patients with tibial HU less than 200, surgeons may consider prophylactic internal fixation of the medial malleolus. Level of Evidence: Level III, retrospective cohort study.

scholarly journals The Effect of Preoperative Bone Density and Subchondral Cysts on Periprosthetic Fracture Risk in Total Ankle Arthroplasty

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0003
Author(s):  
Elizabeth Cody ◽  
James Lachman ◽  
Elizabeth Gausden ◽  
James Nunley ◽  
Mark Easley
Keyword(s):  
Bone Density ◽  
Ct Scan ◽  
Periprosthetic Fracture ◽  
Total Ankle Arthroplasty ◽  
Periprosthetic Fractures ◽  
Additional Patient ◽  
Inclusion Criteria ◽  
Mineral Density ◽  
Ankle Arthroplasty ◽  
Preoperative Ct

Category: Ankle Arthritis Introduction/Purpose: Bone density is a modifiable factor which can be addressed prior to elective surgery if necessary. However, its role pertaining to complications of total ankle arthroplasty (TAA) has not been studied. Hounsfield units (HU) can be measured on standard computed tomography (CT) imaging, and have been shown to correlate with bone mineral density measures from dual-energy X-ray absorptiometry (DEXA). There is a precedent for these measurements in the orthopedic literature: different authors have shown that patients with higher vertebral bone density on CT are at lower risk for pedicle screw loosening. We hypothesized that patients with lower bone density, as measured by HU on preoperative CT, or with large preoperative cysts, would be at greater risk for revision and periprosthetic fractures following TAA. Methods: An existing database at the authors’ institution was used to screen all patients who underwent primary TAA. Inclusion criteria included a CT scan within one year prior to surgery. Exclusion criteria included tibial or talar hardware and nonweightbearing status at the time of the CT scan. The primary outcomes were prosthetic revision and periprosthetic fracture. HU were measured on axial CT cuts at 10 mm above the tibial plafond and at 5 mm below the talar dome to approximate the location of bone cuts. HU measurements for 30 patients were made independently by two reviewers in order to establish interrater reliability. Subchondral cysts at least 5 mm in diameter were counted. Additional patient factors analyzed included age, sex, weight, body mass index (BMI), tobacco use, presence of rheumatoid arthritis, preoperative deformity =15°, and pain visual analog scale scores. Results: 198 patients with a mean 2.4 years of follow-up met the inclusion criteria. The intraclass correlation coefficients for tibial and talar HU measurements were both 0.95. Seven patients (3.5%) underwent revision, four for infection, at a mean 1.2 years postoperatively. There were seven intraoperative and nine postoperative periprosthetic fractures (3.5% and 4.5%, respectively). Neither bone density nor cysts were associated with revision (p>.05). Lower tibial and talar HU, lower weight, and lower BMI were all associated with periprosthetic fracture (Table). After controlling for age, sex, and weight, only tibial HU was significantly associated with periprosthetic fractures (p=0.018). All intraoperative fractures occurred in patients with tibial HU <200. Of patients with tibial HU <200, 10 (22%) sustained an intra- or postoperative periprosthetic fracture. Conclusion: Lower tibial and talar bone density on preoperative CT of the ankle was strongly associated with periprosthetic fracture. The low incidence of revision during the relatively short study period limited our ability to analyze effects on revision rates. In patients who have had a preoperative CT, measuring HU represents a quick, simple method of assessing bone density with excellent inter-rater reliability. In patients with tibial HU <200, surgeons may wish to consider prophylactic internal fixation of the medial malleolus.

Possible Implications for Bundled Payment Models of Comorbidities and Complications as Drivers of Cost in Total Ankle Arthroplasty

2018 ◽  
Vol 40 (2) ◽  
pp. 210-217 ◽  
Author(s):  
Daniel Cunningham ◽  
Vasili Karas ◽  
James K. DeOrio ◽  
James A. Nunley ◽  
Mark E. Easley ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Skilled Nursing Facility ◽  
Total Ankle Arthroplasty ◽  
Wound Complications ◽  
Patient Factors ◽  
Level Of Evidence ◽  
Ankle Arthroplasty ◽  
Bundled Payment ◽  
Significance Threshold ◽  
Ed Visits

Background: The Comprehensive Care for Joint Replacement (CJR) model provides bundled payments for in-hospital and 90-day postdischarge care of patients undergoing total ankle arthroplasty (TAA). Defining patient factors associated with increased costs during TAA could help identify modifiable preoperative patient factors that could be addressed prior to the patient entering the bundle, as well as determine targets for cost reduction in postoperative care. Methods: This study is part of an institutional review board–approved single-center observational study of patients undergoing TAA from January 1, 2012, to December 15, 2016. Patients were included if they met CJR criteria for inclusion into the bundled payment model. All Medicare payments beginning at the index procedure through 90 days postoperatively were identified. Patient, operative, and postoperative characteristics were associated with costs in adjusted, multivariable analyses. One hundred thirty-seven patients met inclusion criteria for the study. Results: Cerebrovascular disease (intracranial hemorrhages, strokes, or transient ischemic attacks) was initially associated with increased costs (mean, $5595.25; 95% CI, $1710.22-$9480.28) in adjusted analyses ( P = .005), though this variable did not meet a significance threshold adjusted for multiple comparisons. Increased length of stay, discharge to a skilled nursing facility (SNF), admissions, emergency department (ED) visits, and wound complications were significant postoperative drivers of payment. Conclusion: Common comorbidities did not reliably predict increased costs. Increased length of stay, discharge to an SNF, readmission, ED visits, and wound complications were postoperative factors that considerably increased costs. Lastly, reducing the rates of SNF placement, readmission, ED visitation, and wound complications are targets for reducing costs for patients undergoing TAA. Level of Evidence: Level II, prognostic prospective cohort study.

Radiology of Osteoporosis

2016 ◽  
Vol 67 (1) ◽  
pp. 28-40 ◽  
Author(s):  
Thomas M. Link
Keyword(s):  
Computed Tomography ◽  
Fracture Risk ◽  
New Technologies ◽  
Assessment Tool ◽  
Quantitative Computed Tomography ◽  
Osteoporotic Fractures ◽  
Fragility Fractures ◽  
Bone Architecture ◽  
Mineral Density ◽  
Fracture Risk Assessment Tool

The radiologist has a number of roles not only in diagnosing but also in treating osteoporosis. Radiologists diagnose fragility fractures with all imaging modalities, which includes magnetic resonance imaging (MRI) demonstrating radiologically occult insufficiency fractures, but also lateral chest radiographs showing asymptomatic vertebral fractures. In particular MRI fragility fractures may have a nonspecific appearance and the radiologists needs to be familiar with the typical locations and findings, to differentiate these fractures from neoplastic lesions. It should be noted that radiologists do not simply need to diagnose fractures related to osteoporosis but also to diagnose those fractures which are complications of osteoporosis related pharmacotherapy. In addition to using standard radiological techniques radiologists also use dual-energy x-ray absorptiometry (DXA) and quantitative computed tomography (QCT) to quantitatively assess bone mineral density for diagnosing osteoporosis or osteopenia as well as to monitor therapy. DXA measurements of the femoral neck are also used to calculate osteoporotic fracture risk based on the Fracture Risk Assessment Tool (FRAX) score, which is universally available. Some of the new technologies such as high-resolution peripheral computed tomography (HR-pQCT) and MR spectroscopy allow assessment of bone architecture and bone marrow composition to characterize fracture risk. Finally radiologists are also involved in the therapy of osteoporotic fractures by using vertebroplasty, kyphoplasty, and sacroplasty. This review article will focus on standard techniques and new concepts in diagnosing and managing osteoporosis.

scholarly journals Bone Mineral Density of the Tarsals and Metatarsals With Reloading

2008 ◽  
Vol 88 (6) ◽  
pp. 766-779 ◽  
Author(s):  
Mary Kent Hastings ◽  
Judy Gelber ◽  
Paul K Commean ◽  
Fred Prior ◽  
David R Sinacore
Keyword(s):  
Computed Tomography ◽  
Bone Mineral Density ◽  
Case Report ◽  
Fracture Risk ◽  
Bone Mineral ◽  
Weight Bearing ◽  
Quantitative Computed Tomography ◽  
Case Description ◽  
Mineral Density ◽  
Lateral Column

Background and PurposeBone mineral density (BMD) decreases rapidly with prolonged non–weight bearing. Maximizing the BMD response to reloading activities after NWB is critical to minimizing fracture risk. Methods for measuring individual tarsal and metatarsal BMD have not been available. This case report describes tarsal and metatarsal BMD with a reloading program, as revealed by quantitative computed tomography (QCT).Case DescriptionA 24-year-old woman was non–weight bearing for 6 weeks after right talocrural arthroscopy. Tarsal and metatarsal BMD were measured with QCT 9 weeks (before reloading) and 32 weeks (after reloading) after surgery. A 26-week progressive reloading program was completed. Change scores were calculated for BMD before reloading and BMD after reloading for the total foot (average of all tarsals and metatarsals), tarsals, metatarsals, bones of the medial column (calcaneus, navicular, cuneiforms 1 and 2, and metatarsal 1), and bones of the lateral column (calcaneus, cuboid, cuneiform 3, and metatarsals 2–5). The percent differences in BMD between the involved side and the uninvolved side were calculated.OutcomesBefore reloading, BMD of the involved total foot was 9% lower than that on the uninvolved side. After reloading, BMD increased 22% and 21% for the total foot, 16% and 14% for the tarsals, 29% and 30% for the metatarsals, 14% and 15% for the medial column bones, and 28% and 26% for the lateral column bones on the involved and uninvolved sides, respectively. After reloading, BMD of the involved total foot remained 8% lower than that on the uninvolved side.DiscussionThe increase in BMD with reloading was not uniform across all pedal bones; the metatarsals showed a greater increase than the tarsals, and the lateral column bones showed a greater increase than the medial column bones.

Mathematical Optimization of Mechanical Testing to Study Periprosthetic Fracture Following Femoral Trochanteric Nail Fixation

2008 ◽  
Author(s):  
Andrew T. Schenk ◽  
Kevin S. Horowitz ◽  
Paul F. Bucchi ◽  
Patrick J. Wiater ◽  
Constantine K. Demetropoulos
Keyword(s):  
Fracture Risk ◽  
Mechanical Testing ◽  
Periprosthetic Fracture ◽  
Mathematical Optimization ◽  
Aging Population ◽  
Periprosthetic Fractures ◽  
Orthopaedic Implant ◽  
Loading Conditions ◽  
Prevalence Of Osteoporosis

Understanding the biomechanics of periprosthetic fractures is especially important in today’s aging population. As the prevalence of osteoporosis continues to climb, fracture risk, especially in proximity of an orthopaedic implant, is of great concern. In a study designed to investigate the mechanism of such fractures, the authors have chosen to test human cadaveric specimens implanted with short Synthes Titanium Trochanteric Fixation Nails. However, the exact loading conditions that elicit fracture are not known.

scholarly journals The Effect of Quantitative Computed Tomography Acquisition Protocols on Bone Mineral Density Estimation

2015 ◽  
Vol 137 (11) ◽  
Author(s):  
Hugo Giambini ◽  
Dan Dragomir-Daescu ◽  
Paul M. Huddleston ◽  
Jon J. Camp ◽  
Kai-Nan An ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Bone Mineral Density ◽  
Fracture Risk ◽  
Risk Prediction ◽  
Material Property ◽  
Bone Mineral ◽  
Quantitative Computed Tomography ◽  
Patient Specific ◽  
Mineral Density ◽  
Fracture Risk Prediction

Osteoporosis is characterized by bony material loss and decreased bone strength leading to a significant increase in fracture risk. Patient-specific quantitative computed tomography (QCT) finite element (FE) models may be used to predict fracture under physiological loading. Material properties for the FE models used to predict fracture are obtained by converting grayscale values from the CT into volumetric bone mineral density (vBMD) using calibration phantoms. If there are any variations arising from the CT acquisition protocol, vBMD estimation and material property assignment could be affected, thus, affecting fracture risk prediction. We hypothesized that material property assignments may be dependent on scanning and postprocessing settings including voltage, current, and reconstruction kernel, thus potentially having an effect in fracture risk prediction. A rabbit femur and a standard calibration phantom were imaged by QCT using different protocols. Cortical and cancellous regions were segmented, their average Hounsfield unit (HU) values obtained and converted to vBMD. Estimated vBMD for the cortical and cancellous regions were affected by voltage and kernel but not by current. Our study demonstrated that there exists a significant variation in the estimated vBMD values obtained with different scanning acquisitions. In addition, the large noise differences observed utilizing different scanning parameters could have an important negative effect on small subregions containing fewer voxels.

Complications Following Total Ankle Arthroplasty Versus Ankle Arthrodesis for Primary Ankle Osteoarthritis

2021 ◽  
pp. 193864002098774
Author(s):  
Bailey J. Ross ◽  
Ian Savage-Elliott ◽  
Victor J. Wu ◽  
Ramon F. Rodriguez
Keyword(s):  
Joint Infection ◽  
Operative Management ◽  
Ankle Arthrodesis ◽  
Total Ankle Arthroplasty ◽  
Hardware Removal ◽  
Periprosthetic Fractures ◽  
Ankle Arthroplasty ◽  
Large Patient ◽  
Prosthetic Joint ◽  
Patient Database

Introduction There are minimal data comparing complications between ankle arthrodesis (AA) versus total ankle arthroplasty (TAR) for operative management of primary osteoarthritis (OA). This study aimed to compare outcomes following AA versus TAR for primary ankle OA using a large patient database. Methods Patients who received AA or TAR for primary ankle OA from 2010 to 2019 were queried from PearlDiver. Rates of common joint complications were compared at 90 days, 1 year, and 2 years postoperatively using multivariable logistic regression. Results A total of 1136 (67%) patients received AA and 584 (33%) patients underwent TAR. Patients that received AA exhibited significantly higher rates of at least one common joint complication at 90 days (19.3% vs 12.6%; odds ratio [OR] 1.69), 1 year (25.6% vs 15.0%; OR 2.00), and 2 years (26.9% vs 16.2%; OR 1.91) postoperatively. This included higher rates of adjacent fusion or osteotomy procedures, periprosthetic fractures, and hardware removal at each postoperative follow-up (all P < .05). Rates of prosthetic joint infection were comparable at 2 years postoperatively (4.3% vs 4.2%; OR 0.91). Conclusion The AA cohort exhibited higher rates of postoperative joint complications in the short and medium-term, namely, subsequent fusions or osteotomies, periprosthetic fractures, and hardware removal. Levels of Evidence Level III

scholarly journals Investigation on the contour and bone mineral density of the distal tibial cutting surface used for total ankle arthroplasty

2021 ◽  
Vol 29 (2) ◽  
pp. 230949902110280
Author(s):  
Dahang Zhao ◽  
Gonghao Zhang ◽  
Dichao Huang ◽  
Jian Yu ◽  
Kan Wang ◽  
...  
Keyword(s):  
Bone Mineral Density ◽  
Cortical Bone ◽  
Bone Mineral ◽  
Ct Images ◽  
Total Ankle Arthroplasty ◽  
Tibial Tubercle ◽  
Mineral Density ◽  
Ankle Arthroplasty ◽  
Cutting Surface ◽  
Value Measurement

Purpose: This study was designed to investigate (1) the contour of the distal tibial cutting surface, and (2) the bone mineral density (BMD) of the distal tibial cutting surface used during total ankle arthroplasty (TAA). Methods: Eight-four distal tibial models were created using foot and ankle computerized tomographic (CT) images taken from normal people. The distal tibial cutting surface for TAA was determined to be 10 mm proximal to the tibial plafond. The bony contour and BMD values were determined from the CT image at that level. A bounding box was made on the contour and the width and length of the contour was measured. Regional BMD was evaluated by Hounsfield units (HU) value measurement, with 7 regions of interest (ROI) on 8 different directions for all the 84 CT images. Two different observers made independent measurements and mean HU values for all the 56 ROIs were calculated. Results: Great variations were found among the contours of the cutting surface especially in term of the shape of the anterior and posterior tibial tubercle, and the fibular notch. These variations could be grouped into six categories. For the BMD of the cutting surface, the medial border of the cutting surface did not included cortical bone. The HU value of seven ROIs, which included cortical bone, were significantly greater than all the other ROIs. Few statistical differences were found by multiple comparisons among HU value of all the 49 ROIs without cortex. Conclusions: Great variability existed in the shape and the BMD of the distal tibial cutting surface.

scholarly journals Total Ankle Arthroplasty (TAR) vs. Ankle Arthrodesis (AA) for Primary Ankle Osteoarthritis: A Nationwide Analysis

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0041
Author(s):  
Bailey J. Ross ◽  
Ian Savage-Elliott ◽  
Victor Wu ◽  
Ramon F. Rodriguez
Keyword(s):  
Periprosthetic Fracture ◽  
Operative Management ◽  
Ankle Arthrodesis ◽  
Total Ankle Arthroplasty ◽  
Hardware Removal ◽  
Post Discharge ◽  
Ankle Osteoarthritis ◽  
Systemic Complications ◽  
Ankle Arthroplasty ◽  
Subtalar Fusion

Category: Ankle Arthritis; Ankle Introduction/Purpose: Ankle arthrodesis (AA) has historically been the gold standard for operative management of end-stage ankle osteoarthritis (OA). Recent increases in utilization of total ankle arthroplasty (TAR) have been observed secondary to new implant designs, improved surgical technique, and favorable functional outcomes. However, there is minimal data comparing clinical complications between the two procedures. The purpose of this study was to compare incidences of postoperative joint and systemic complications for patients that received primary AA vs. TAR for primary ankle osteoarthritis between 2007-2017 using a comprehensive Medicare database. Methods: A retrospective review of patients that received primary AA or TAR was performed using the PearlDiver database (Fort Wayne, IN). All patients and associated complications were identified using ICD-9/ICD-10 and CPT codes. Patients with a history of ankle fracture, prior AA/TAR, or active ankle infection during the index procedure were excluded. Demographic data and overall joint complication rates were compared at 90-days, 1-year, and 2-years postoperatively using a Chi-Square test. Postoperative rates of subtalar fusion, prosthetic joint infection, hardware removal, periprosthetic fracture, and systemic complications were compared using logistic regression. Statistical significance was set at p < 0.05. Results: A total of 1,580 patients received operative management of primary ankle OA: 1,100 (70%) patients received AA and 480 (30%) patients received TAR. The overall joint complication rate was higher in the AA group at 90-days (30% vs. 17%, p < 0.001), 1-year (36% vs. 21%, p < 0.001), and 2-years (38% vs. 22%, p < 0.001) post-discharge. AA patients were more likely to have a subsequent subtalar fusion at 90-days (OR 4.49), 1-year (OR 5.10), and 2-years (OR 5.36) post-discharge, as well as periprosthetic fracture at 1-year (OR 1.69) and 2-years (OR 1.77). Hardware removal was less likely for AA patients at 90-days (OR 0.43), 1-year (OR 0.41), and 2-years (OR 0.43). Neither group was more likely to develop systemic complications postoperatively. Conclusion: The present study found that AA patients have higher incidences of major joint complications in both the short- term and mid-term. Patients that received AA were more likely to have a subsequent subtalar fusion and sustain a periprosthetic fracture. Relative to TAR patients, a greater proportion of these patients were under the age of 65, obese, had diabetes, and used tobacco. TAR patients were more likely to have hardware removal post-discharge. Further study is warranted to better quantify patient selection for AA vs. TAR and trend the long-term complications of these procedures.

Sign in / Sign up

Export Citation Format

Share Document