Salvage Tibiotalocalcaneal Arthrodesis Augmented with Fibular Columns and Iliac Crest Autograft: A Technical Note

Category: Ankle; Ankle Arthritis Introduction/Purpose: End-stage ankle arthritis may be managed with ankle arthrodesis or total ankle replacement (TAR). Failure of these procedures results in a challenging clinical situation. Revision in these scenarios is technically demanding, and if associated with subtalar degeneration, conversion to tibiotalocalcaneal (TTC) arthrodesis may be required. Bone grafting may be necessary to maintain length and reduce disability, and fibular strut grafting in form of ‘pillars’ or ‘columns’ may be used in association with intramedullary TTC nailing. In our experience, fibular column autograft may be supplemented with tricortical and cancellous iliac crest graft and stabilised with cannulated screws and either an intramedullary nail or a lateral plate. In this technical note, we review the history of this technique and report indications, surgical approach, results and complications. Methods: A distal J-shaped lateral approach is performed over the posterior edge of the distal fibula. An oblique fibular cut is made with a saw at 8- 12 cm from the fibular tip. Careful removal of the implant, previous cement spacer or metalwork is performed then articular surfaces are prepared. After assessment of the articular gap, the autograft is prepared by removing the tip of the fibula from the fibular block, then sectioning it in to either three or four columns which are positioned into the gap and stabilised either in a press-fit fashion or using 1.6mm K-wires. Six patients (4M, 2F; mean age: 69.8 years (range, 51 to 83)) were treated between December 2018 and March 2019 (5 failed TAR and 1 was symptomatic tibiotalar non-union) at our institution. Fixation was achieved in 5 cases with a locked intramedullary nail and in 1 case with a lateral locking plate. Results: At a mean follow up of 10 months (range, 6 to 11 months), 4 patients had clinically and radiologically united and were satisfied with the outcome of surgery. Two patients remained dissatisfied having not united: one patient with a background of chronic kidney disease had raised inflammatory blood markers at 10 months and is undergoing investigation to exclude infection whilst one other patient with no obvious risk factors for non-union has started low intensity pulsed ultrasound treatment at 6 months. No other complications were observed. Conclusion: Tibiotalocalcaneal fusion augmented with fibular columns and iliac crest autograft is an option to treat combined ankle and the subtalar joint pathologies with significant talar bone loss. However larger studies with longer follow-up are required to define the rates of success and failure with future research directed to better understand which factors may predict the outcome.

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Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized controlled trial in 44 patients

Patient Safety in Surgery ◽

10.1186/s13037-019-0215-3 ◽

2019 ◽

Vol 13 (1) ◽

Cited By ~ 1

Author(s):

Carlos Augusto Finelli ◽

Fernando Baldy dos Reis ◽

Helio Alvachian Fernandes ◽

Adriana Dell’Aquila ◽

Rogério Carvalho ◽

...

Keyword(s):

Intramedullary Nail ◽

Controlled Trial ◽

Long Bone ◽

Cement Spacer ◽

Coagulase Negative Staphylococci ◽

Radiological Criteria ◽

Intramedullary Reaming ◽

Prospective Randomized Controlled Trial ◽

Retrograde Nail

Abstract Background Studies addressing the management of intramedullary infection are mainly retrospective and with a limited number of cases. Reaming can be performed using either conventional reaming or using the reamer/irrigator/aspirator (RIA) system. Until now there have been no comparative prospective studies between these two methods. We aimed to compare the efficacy of RIA with conventional reaming followed by insertion of antibiotic-loaded cement, for the treatment of intramedullary nail infection of long bones. We assessed the rate of remission between groups after two-year follow-up and identified microorganisms using tissue cultures and sonication of explanted intramedullary nail (IMN). Methods A noninferiority, randomized clinical trial was carried out between August 2013 and August 2015 involving 44 patients of whom a locked IMN implant of the femur and/or tibia was retrieved and who all met the clinical and radiological criteria for IMN-associated osteomyelitis. Patients were randomized into two groups: RIA alone versus conventional reaming followed by antibiotic-loaded cement insertion. Both groups also underwent six-weeks of antibiotic treatment according to the results of the antibiogram. Patients were evaluated after 1, 3, 6, 12 and 24 months for radiological and clinical follow-up. Results After 24 months, the rate of infection remission was similar between the two groups, 87% in the RIA group and 95.5% in the conventional reaming group (p = 0.60). Among four patients who had recurrence of infection, the time to reappearance of symptoms varied from 20 days to twenty-two months. Staphylococcus aureus and coagulase-negative Staphylococci were isolated in 23 (40.4%) and 13 (22.9%) patients, respectively. Interestingly, we identified 20% (9/45) of polymicrobial infection. Conclusion This study concludes that the RIA system alone, is noninferior to conventional reaming followed by antibiotic cement spacer in the treatment of IMN infection. However, RIA shows greater efficacy in the collection of infected medullary bone tissue, mainly in cases of infected retrograde nail of the femur. Trial registration ISRCTN82233198. Retroactively registered on July 29, 2019.

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Tibiotalocalcaneal Fusion Rate with a Novel Pseudoelastic Intramedullary Nail with NiTiNOL

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00042 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0004

Author(s):

Travis Dekker ◽

John Steele ◽

Beau Kildow ◽

James DeOrio ◽

Mark Easley ◽

...

Keyword(s):

High Risk ◽

Bone Resorption ◽

Intramedullary Nail ◽

Fusion Rate ◽

High Risk Population ◽

Risk Population ◽

Non Union ◽

Significant Difference ◽

History Of

Category: Ankle Arthritis Introduction/Purpose: Tibiotalocalcaneal (TTC) fusion is a salvage operation for patients with significant arthritis and deformity of ankle and subtalar joints. Despite overall clinic success, fusion across both joints continues to be a major challenge with nonunion rates reported up to 48% [Franceschi]. Aside from certain patient comorbidities, nonunion may result when compression across the joint is lost in the setting of bone resorption. The use of a pseudoelastic intramedullary nail has been shown to maintain compression across fusion site in response to bone resorption. The purpose of this study was to evaluate the fusion rate in a high-risk population at a tertiary care center using a psuedoelastic intramedullary nail with an internal nitinol element. Methods: After obtaining IRB approval, a retrospective review of consecutive patients that underwent procedures with TTC fusion with novel intramedullary nail system with super elastic internal nickel titanium (NiTiNOL, DynaNail, Medshape Inc, Atlanta, GA) was performed at a single academic institution. From 2014 to 2016, 58 patients were identified, 55 of which had minimum one year follow up or clinical and radiographic fusion (20 months average, range 6-41 months). The primary outcome was radiographic fusion analysis which was reviewed by three authors. Fusion was determined by consensus with criteria of 3 of 4 cortices with osseous bridging in asymptomatic patients[1, 2] or CT fusion based on Glazebrook et. al. criteria for hindfoot fusion[3, 4]. Average age of this cohort was 59 (SD= 16.3) years with BMI average 33.1 (SD= 8.87). Exclusion criteria include: follow-up less than 12 months in non-fused patients, and incomplete clinical or radiologic data. Results: The fusion rate in this high-risk population was 80.0% with the use of the NiTiNOL tibiotalocalcaneal nailing system. Univariate analysis demonstrated no significant difference (p>0.05) in fusion rates with patient comorbidities that portend to non-union: current or former history of tobacco use, diabetes mellitus, rheumatoid arthritis, nor patients with chronic kidney disease. The average BMI in the fusion group was 31.97 compared to 27.4 in the non-union group (p=0.016). There were 5 deep infections requiring reoperation with a single patient requiring a below the knee amputation. Seven patients required a second operation for removal of prominent interlocking screws. Conclusion: This preliminary data demonstrates fusion rates with this novel intramedullary device are consistent with historical data. These findings are encouraging in that this nailing system shows equal rates of fusion in patients with high risk comorbidities for non-union compared to historical controls demonstrating increased non-union rates in diabetics, patients with chronic renal failure and those with a history of smoking. This Tibiotalocalcaneal nailing system is safe and offers theoretical sustained compression with up to 6 mm of resorption or settling.

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Talar Osteo-Periostic grafting from the Iliac Crest (TOPIC): 1-year Results of a New Press-fit Surgical Treatment for Large Talar Osteochondral Defects

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00040 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0004 ◽

Cited By ~ 1

Author(s):

Gino Kerkhoffs ◽

Sjoerd Stufkens ◽

Jari Dahmen ◽

Nienke Altink

Keyword(s):

Surgical Treatment ◽

Iliac Crest ◽

Bone Ingrowth ◽

Osteochondral Defects ◽

Short Term ◽

Press Fit ◽

Sf 36 ◽

Grafting From ◽

Large Primary

Category: Ankle Introduction/Purpose: The purpose of this study was to present the surgical technique and to evaluate the short-term clinical and radiological outcomes of a new press-fit OATS technique for large primary and secondary talar osteochondral defects of the talus, Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC). Methods: Twenty-eight underwent a press-fit TOPIC procedure. Mean age was 38 years (SD 4.6). Pre- and postoperative clinical assessment at 12 months follow-up included the American Orthopaedic Foot & Ankle Society (AOFAS) score, the Short-Form 36 (SF-36) Mental Component Scale (MCS) and Physical Component Scale (PCS), the Numeric Rating Scales (NRS) of pain at rest, during walking and stairclimbing, and the Foot and Ankle Outcome Score (FAOS) including accompanying subscales. Remodeling of the contour of the talus, bone ingrowth and consolidation of the implanted graft were assessed on computed tomography (CT) one year post-operatively. Results: 28 out of 29 patients were available for follow up. The AOFAS significantly improved from 45 to 92 (p=0.001). The NRS on pain during rest improved from 3 to 0 (p=0.001), the NRS during walking improved from 5 to 1 and the NRS during stairclimbing also improved from 5 to 1 (p=0.001). Both components of the SF-36 improved. The PCS improved from 34 to 47 (p=0.001) and the MCS improved from 37 to 66 (p=0.001). Finally all FAOS subscales significantly improved. All patients were satisfied with the procedure and indicated that the level of functioning was good or very good. On the post-operative CT scans, all patients showed remodeling of the talus and all grafts showed consolidation as well as bone ingrowth. No complications occurred. Conclusion: The TOPIC procedure appears to be a very promising surgical treatment option for large primary and secondary talar OCDs. Despite these good short-term clinical and radiological outcomes, a prospective study with longer follow-up is necessary to assess the clinical outcome and the progression of osteoarthritis at the long term.

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Non-Vascularized Tri-Cortical Iliac Crest Graft–A Reliable Option in the Management of Scaphoid Waist Non-Unions

The Journal of Hand Surgery (Asian-Pacific Volume) ◽

10.1142/s2424835521500363 ◽

2021 ◽

Vol 26 (03) ◽

pp. 383-389

Author(s):

Vivek Singh ◽

Nagaraj Manju Moger ◽

Pragadeeshwaran Jaisankar ◽

Surjala Rajkumar ◽

Sunny Chaudhary ◽

...

Keyword(s):

Iliac Crest ◽

Wrist Joint ◽

Successful Outcome ◽

Iliac Crest Bone Graft ◽

Bony Union ◽

X Rays ◽

Iliac Crest Graft ◽

Non Union ◽

Functional Scores

Background: Scaphoid non-union often leads to a change in biomechanics of the wrist joint. Various types of bone grafts and different sites of harvest have been described in the literature for scaphoid reconstruction. This study was conducted to assess the clinical and radiological outcome after non-vascularised tri-cortical iliac crest bone graft for non-union of scaphoid waist fractures. Methods: 12 adult patients who underwent reconstruction of scaphoid waist non-union with tricortical iliac crest grafting and internal fixation with headless compression screws (11 cases) and k-wires (1 case) were prospectively analysed. There were 11 males and 1 female (mean age 23.9 years). The mean duration of presentation was 5.7 months following injury. Outcome following surgery were analyzed clinically by range of movements (ROM) and functional scores like DASH and modified Mayo wrist score and radiologically by X-rays and Non contrast CT of the wrist. Radiological assessment included scaphoid length, radio-lunate (RL) angle and scapho-lunate (SL) angle at latest 6 months follow up. Results: Bony union was achieved in 10 cases (union rate 83%). All the cases which achieved union had a significant improvement in radiological and clinical outcome criterias at 6-month follow-up interval. 1 patient had persistent non-union and 1 had k-wire back out with fixation failure. Conclusions: It is important to restore scaphoid length and to correct flexion deformity for a successful outcome. This can reliably be acheived by a carefully planned wedge-shaped iliac crest graft along with secure fixation with a headless compression screw.

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Atypical Femoral Fractures due to long-term bisphosphonates therapy

Romanian Journal of Orthopaedic Surgery and Traumatology ◽

10.2478/rojost-2019-0005 ◽

2019 ◽

Vol 2 (1) ◽

pp. 23-27

Author(s):

Ioan Mihai Japie ◽

Radu Rădulescu ◽

Adrian Bădilă ◽

Ecaterina-Maria Japie ◽

Alexandru Papuc ◽

...

Keyword(s):

Intramedullary Nail ◽

Femoral Fractures ◽

Gamma Nail ◽

Atypical Femoral Fractures ◽

Non Union ◽

Female Patients ◽

Number Of Patients ◽

Long Term Treatment

AbstractIntroduction. Bisphosphonates (BPs) represent the main therapy in patients with osteoporosis, although a long-term treatment can lead to atypical fractures.Material and methods. We conducted a retrospective study between 2008 and 2017 and included 23 female patients with atypical femoral fractures (AFFs). The mean period of BPs therapy administration was 5.2 years. We included 7 subtrochanteric fractures and 18 femoral shaft fractures. Two of the total patients presented bilateral femoral fractures. 18 patients presented prodromal symptoms from 2 to 18 months before the diagnosis of fractures, all of them following low energy trauma. All the patients included in our study underwent surgery with intramedullary nail or gamma nail. The postoperative mean follow-up was 2 years. Results. Of all 23 female patients with a total of 25 fractures – 10 underwent osteosynthesis with gamma nail and 15 underwent osteosynthesis with intramedullary nail. From the total number of patients: 13 patients achieved complete union, 6 presented delayed union and 3 non-union (2 intramedullary nail and one gamma nail), whereas in one patient treated previously with gamma nail we observed implant failure.Conclusion. The treatment of AFFs after BPs therapy administration represents a challenge for orthopaedic surgeons regarding both surgical technique and postoperative follow-up.

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A Pilot Study of Mobile Telephone Message Interventions with Suicide Attempters in China

Crisis ◽

10.1027/0227-5910/a000017 ◽

2010 ◽

Vol 31 (2) ◽

pp. 109-112 ◽

Cited By ~ 35

Author(s):

Hui Chen ◽

Brian L. Mishara ◽

Xiao Xian Liu

Keyword(s):

Pilot Study ◽

Effective Means ◽

Text Message ◽

Text Messages ◽

Mobile Telephone ◽

Future Research ◽

Quick Method ◽

Suicide Attempters ◽

To Receive

Background: In China, where follow-up with hospitalized attempters is generally lacking, there is a great need for inexpensive and effective means of maintaining contact and decreasing recidivism. Aims: Our objective was to test whether mobile telephone message contacts after discharge would be feasible and acceptable to suicide attempters in China. Methods: Fifteen participants were recruited from suicide attempters seen in the Emergency Department in Wuhan, China, to participate in a pilot study to receive mobile telephone messages after discharge. All participants have access to a mobile telephone, and there is no charge for the user to receive text messages. Results: Most participants (12) considered the text message contacts an acceptable and useful form of help and would like to continue to receive them for a longer period of time. Conclusions: This suggests that, as a low-cost and quick method of intervention in areas where more intensive follow-up is not practical or available, telephone messages contacts are accessible, feasible, and acceptable to suicide attempters. We hope that this will inspire future research on regular and long-term message interventions to prevent recidivism in suicide attempters.

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Post Discharge Clinically Overt Venous Thromboembolism in Orthopaedic Surgery Patients with Negative Venography -an Overview Analysis

Thrombosis and Haemostasis ◽

10.1055/s-0038-1650681 ◽

1996 ◽

Vol 76 (06) ◽

pp. 0887-0892 ◽

Cited By ~ 32

Author(s):

Serena Ricotta ◽

Alfonso lorio ◽

Pasquale Parise ◽

Giuseppe G Nenci ◽

Giancarlo Agnelli

Keyword(s):

Venous Thromboembolism ◽

Orthopaedic Surgery ◽

Diagnostic Methods ◽

Future Research ◽

Post Discharge ◽

Pharmacological Prophylaxis ◽

Vein Thrombosis ◽

Overview Analysis ◽

Major Orthopaedic Surgery

SummaryA high incidence of post-discharge venous thromboembolism in orthopaedic surgery patients has been recently reported drawing further attention to the unresolved issue of the optimal duration of the pharmacological prophylaxis. We performed an overview analysis in order to evaluate the incidence of late occurring clinically overt venous thromboembolism in major orthopaedic surgery patients discharged from the hospital with a negative venography and without further pharmacological prophylaxis. We selected the studies published from January 1974 to December 1995 on the prophylaxis of venous thromboembolism after major orthopaedic surgery fulfilling the following criteria: 1) adoption of pharmacological prophylaxis, 2) performing of a bilateral venography before discharge, 3) interruption of pharmacological prophylaxis at discharge in patients with negative venography, and 4) post-discharge follow-up of the patients for at least four weeks. Out of 31 identified studies, 13 fulfilled the overview criteria. The total number of evaluated patients was 4120. An adequate venography was obtained in 3469 patients (84.1%). In the 2361 patients with negative venography (68.1%), 30 episodes of symptomatic venous thromboembolism after hospital discharge were reported with a resulting cumulative incidence of 1.27% (95% C.I. 0.82-1.72) and a weighted mean incidence of 1.52% (95% C.I. 1.05-1.95). Six cases of pulmonary embolism were reported. Our overview showed a low incidence of clinically overt venous thromboembolism at follow-up in major orthopaedic surgery patients discharged with negative venography. Extending pharmacological prophylaxis in these patients does not appear to be justified. Venous thrombi leading to hospital re-admission are likely to be present but asymptomatic at the time of discharge. Future research should be directed toward improving the accuracy of non invasive diagnostic methods in order to replace venography in the screening of asymptomatic post-operative deep vein thrombosis.

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Congenital Syphilis Simulating Bone Neoplasm in 2-Month Old Infant – Case Report

Medical & Clinical Research ◽

10.33140/mcr.02.01.04 ◽

2017 ◽

Vol 2 (1) ◽

Keyword(s):

Case Report ◽

Congenital Syphilis ◽

Eosinophilic Granuloma ◽

Osteolytic Lesion ◽

Lower Limbs ◽

Upper Body ◽

Elective Cesarean Section ◽

Distal Fibula ◽

X Ray

Introduction: Congenital Syphilis (CS) occurs through the transplacental transmission of Treponema pallidum in inadequately treated or non-treated pregnant women, and is capable of severe consequences such as miscarriage, preterm birth, congenital disease and/or neonatal death. CS has been showing an increasing incidence worldwide, with an increase of 208% from 2009 to 2015 in Brazil. Case report: 2-month old infant receives care in emergency service due to edema of right lower limb with pain in mobilization. X-ray with osteolytic lesion in distal fibula. Infant was sent to the Pediatrics Oncology clinic. Perinatal data: 7 prenatal appointments, negative serology at 10 and 30 weeks of gestation. End of pregnancy tests were not examined and tests for mother’s hospital admission were not requested. Mother undergone elective cesarean section at 38 weeks without complications. During the pediatric oncologist appointment, patient showed erythematous-squamous lesions in neck and other scar-like lesions in upper body. A new X-ray of lower limbs showed lesions in right fibula with periosteal reaction associated with aggressive osteolytic lesion compromising distal diaphysis, with cortical bone rupture and signs of pathological fracture, suggestive of eosinophilic granuloma. She was hospitalized for a lesion biopsy. Laboratory tests: hematocrit: 23.1 / hemoglobin 7.7 / leukocytes 10,130 (without left deviation) / platelets 638,000 / Negative Cytomegalovirus IgG and IgM and Toxoplasmosis IgG and IgM / VDRL 1:128. Congenital syphilis diagnosis with skin lesions, bone alterations and anemia. Lumbar puncture: glucose 55 / total proteins 26 / VDRL non reagent / 13 leukocytes (8% neutrophils; 84% monomorphonuclear; 8% macrophages) and 160 erythrocytes / negative VDRL and culture. X-ray of other long bones, ophthalmological evaluation and abdominal ultrasound without alterations. Patient was hospitalized for 14 days for treatment with Ceftriaxone 100mg/kg/day, due to the lack of Crystalline Penicillin in the hospital. She is now under outpatient follow-up. Discussion: CS is responsible for high rates of morbidity and mortality. The ongoing increase of cases of this pathology reflects a severe health issue and indicates failures in policies for the prevention of sexually transmitted diseases, with inadequate follow-up of prenatal and maternity protocols.

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Clinical Evaluation of the Variables associated with Treatment Acceptability and Their Relation to Compliance

Behavioral Disorders ◽

10.1177/019874299201800108 ◽

1992 ◽

Vol 18 (1) ◽

pp. 67-76 ◽

Cited By ~ 36

Author(s):

Thomas M. Reimers ◽

David P. Wacker ◽

Linda J. Cooper ◽

Agnes O. Deraad

Keyword(s):

Behavior Problem ◽

Behavior Management ◽

Positive Reinforcement ◽

Treatment Acceptability ◽

Clinic Visit ◽

Future Research ◽

Parental Ratings ◽

Problem Severity ◽

The Relationship

The authors examined the acceptability ratings of positive reinforcement procedures recommended to parents seen in a pediatric behavior management outpatient clinic. Parental ratings of acceptability were obtained in the clinic and 1, 3, and 6 months following their initial clinic visit. Acceptability variables were examined by group (parents who rated the acceptability of treatments as high vs. low) and by severity (parents who rated their children's behavior problem as severe vs. mild). The relationship between these variables and reported compliance was also examined. Results show that the acceptability variables were useful in differentiating between parents who rated treatments to be more acceptable and parents who rated treatments to be less acceptable. Differences were also observed as a function of behavior problem severity. Significant correlations occurred between acceptability variables and compliance at each of the follow-up points. Results are discussed in relation to the clinical significance of these findings and the impetus they might serve for future research.

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Cohort profile of Acutelines: a large data/biobank of acute and emergency medicine

BMJ Open ◽

10.1136/bmjopen-2020-047349 ◽

2021 ◽

Vol 11 (7) ◽

pp. e047349

Author(s):

Ewoud ter Avest ◽

Barbara C van Munster ◽

Raymond J van Wijk ◽

Sanne Tent ◽

Sanne Ter Horst ◽

...

Keyword(s):

Acute Care ◽

De Novo ◽

Medical Center ◽

Large Data ◽

Future Research ◽

Imaging Data ◽

Novel Studies ◽

Long Term Follow Up ◽

Registration Number

PurposeResearch in acute care faces many challenges, including enrolment challenges, legal limitations in data sharing, limited funding and lack of singular ownership of the domain of acute care. To overcome these challenges, the Center of Acute Care of the University Medical Center Groningen in the Netherlands, has established a de novo data, image and biobank named ‘Acutelines’.ParticipantsClinical data, imaging data and biomaterials (ie, blood, urine, faeces, hair) are collected from patients presenting to the emergency department (ED) with a broad range of acute disease presentations. A deferred consent procedure (by proxy) is in place to allow collecting data and biomaterials prior to obtaining written consent. The digital infrastructure used ensures automated capturing of all bed-side monitoring data (ie, vital parameters, electrophysiological waveforms) and securely importing data from other sources, such as the electronic health records of the hospital, ambulance and general practitioner, municipal registration and pharmacy. Data are collected from all included participants during the first 72 hours of their hospitalisation, while follow-up data are collected at 3 months, 1 year, 2 years and 5 years after their ED visit.Findings to dateEnrolment of the first participant occurred on 1 September 2020. During the first month, 653 participants were screened for eligibility, of which 180 were approached as potential participants. In total, 151 (84%) provided consent for participation of which 89 participants fulfilled criteria for collection of biomaterials.Future plansThe main aim of Acutelines is to facilitate research in acute medicine by providing the framework for novel studies and issuing data, images and biomaterials for future research. The protocol will be extended by connecting with central registries to obtain long-term follow-up data, for which we already request permission from the participant.Trial registration numberNCT04615065.

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