Does the Subtalar Joint Compensate for Ankle Malalignment in End-stage Ankle Arthritis?

BackgroundPatients with ankle arthritis often present with concomitant hindfoot deformity, which may involve the tibiotalar and subtalar joints. However, the possible compensatory mechanisms of these two mechanically linked joints are not well known.Questions/purposesIn this study we sought to (1) compare ankle and hindfoot alignment of our study cohort with end-stage ankle arthritis with that of a control group; (2) explore the frequency of compensated malalignment between the tibiotalar and subtalar joints in our study cohort; and (3) assess the intraobserver and interobserver reliability of classification methods of hindfoot alignment used in this study.MethodsBetween March 2006 and September 2013, we performed 419 ankle arthrodesis and ankle replacements (380 patients). In this study, we evaluated radiographs for 233 (56%) ankles (226 patients) which met the following inclusion criteria: (1) no prior subtalar arthrodesis; (2) no previously failed total ankle replacement or ankle arthrodesis; (3) with complete conventional radiographs (all three ankle views were required: mortise, lateral, and hindfoot alignment view). Ankle and hindfoot alignment was assessed by measurement of the medial distal tibial angle, tibial talar surface angle, talar tilting angle, tibiocalcaneal axis angle, and moment arm of calcaneus. The obtained values were compared with those observed in the control group of 60 ankles from 60 people. Only those without obvious degenerative changes of the tibiotalar and subtalar joints and without previous surgeries of the ankle or hindfoot were included in the control group. Demographic data for the patients with arthritis and the control group were comparable (sex, p = 0.321; age, p = 0.087). The frequency of compensated malalignment between the tibiotalar and subtalar joints, defined as tibiocalcaneal angle or moment arm of the calcaneus being greater or smaller than the same 95% CI statistical cutoffs from the control group, was tallied. All ankle radiographs were independently measured by two observers to determine the interobserver reliability. One of the observers evaluated all images twice to determine the intraobserver reliability.ResultsThere were differences in medial distal tibial surface angle (86.6° ± 7.3° [95% CI, 66.3°–123.7°) versus 89.1° ± 2.9° [95% CI, 83.0°–96.3°], p < 0.001), tibiotalar surface angle (84.9° ± 14.4° [95% CI, 45.3°–122.7°] versus 89.1° ± 2.9° [95% CI, 83.0°–96.3°], p < 0.001), talar tilting angle (−1.7° ± 12.5° [95% CI, −41.3°–30.3°) versus 0.0° ± 0.0° [95% CI, 0.0°–0.0°], p = 0.003), and tibiocalcaneal axis angle (−7.2° ± 13.1° [95% CI, −57°–33°) versus −2.7° ± 5.2° [95% CI, −13.3°–9.0°], p < 0.001) between patients with ankle arthritis and the control group. Using the classification system based on the tibiocalcaneal angle, there were 62 (53%) and 22 (39%) compensated ankles in the varus and valgus groups, respectively. Using the classification system based on the moment arm of the calcaneus, there were 68 (58%) and 20 (35%) compensated ankles in the varus and valgus groups, respectively. For all conditions or methods of measurement, patients with no or mild degenerative change of the subtalar joint have a greater likelihood of compensating coronal plane deformity of the ankle with arthritis (p < 0.001–p = 0.032). The interobserver and intraobserver reliability for all radiographic measurements was good to excellent (the correlation coefficients range from 0.820 to 0.943).ConclusionsSubstantial ankle malalignment, mostly varus deformity, is common in ankles with end-stage osteoarthritis. The subtalar joint often compensates for the malaligned ankle in static weightbearing.

Level of Evidence

Level III, diagnostic study.     

Does Total Ankle Arthroplasty Belong in the Comprehensive Care for Joint Replacement?

The Comprehensive Care for Joint Replacement (CJR) model seeks to lower costs and improve quality for primary lower extremity joint replacements. This includes total ankle arthroplasty (TAA), which is performed far less frequently than total hip (THA) and knee (TKA) arthroplasty. We used the SPARCS database to identify 537 TAA and 239,053 elective primary THA or TKA procedures from 2009 to 2014, excluding hip fractures. Compared with THA and TKA, TAA had a shorter mean length of stay (2.2 versus 3.2 days), greater mean cost ($20,817 versus $17,613), lower rate of disposition to nursing and rehabilitation facilities (17% versus 52%), and lower rate of 90-day readmission (4.9% versus 5.8%). In multivariable-adjusted regression models of TAA versus THA and TKA, length of stay was 30% shorter (p?<?.001), costs were 14% greater (p?<?.001), and risk of disposition to nursing and rehabilitation facilities was 86% lower (p?<?.001), with no significant difference in 90-day readmission (p?=?.957). Patients undergoing TAA had different patterns of short-term resource usage compared with patients undergoing THA and TKA, most notably higher short-term costs. The economic viability of TAA is threatened by alternative payment models that reimburse hospitals for TAA at the same rate as THA and TKA.     

Does Route of Hysterectomy Affect Outcome in Obese and Nonobese Women?

Objective:

Our objective was to compare the surgical outcomes of obese women having hysterectomy according to the route (abdominal, vaginal, or laparoscopic) of the procedure.

Methods:

A chart review of 293 hysterectomy procedures was performed. Data were collected including operative and anesthesia time, estimated blood loss, change in hematocrit, hospital stay, complications, conversion to laparotomy, transfusion, and body mass index. An analysis of variance and a Newman-Keuls Multiple Comparison test were performed.

Results:

Obese women experienced a significant decrease in hospital days (2.5 versus 4.2) and reported blood loss (204 mL versus 455 mL) in the laparoscopic hysterectomy and vaginal hysterectomy groups compared with the abdominal hysterectomy group. No significant difference was found in obese women between laparoscopic and abdominal hysterectomy for time spent in surgery and under anesthesia. For obese and normal weight women, vaginal hysterectomy offered the shortest surgery, anesthesia times, and hospital stays.

Conclusions:

For normal and obese women, vaginal hysterectomy offered the shortest hospital stay and surgery time. In obese patients for whom vaginal hysterectomy is not possible, laparoscopic hysterectomy should be considered before abdominal hysterectomy, because the laparoscopic route reduced hospital time and blood loss.     

Outcome of Arthroscopic Débridement is Worse for Patients With Glenohumeral Arthritis of Both Sides of the Joint

Glenohumeral arthritis in the young patient presents a difficult problem with potentially devastating sequelae. Reports in the literature suggest a role for arthroscopic treatment in patients with symptomatic degenerative joint disease of the shoulder. However, no published study directly compares patients with unipolar versus bipolar cartilage lesions. We retrospectively reviewed 19 patients (20 shoulders) younger than 55 years with Outerbridge Grade 2-4 articular cartilage changes who underwent arthroscopic glenohumeral débridements. We obtained WOOS, SF-12, SANE and the American Shoulder and Elbow Society scores at last followup. The minimum follow up time was 12 months (average, 20 months; range, 12-33 months). Three patients progressed to shoulder arthroplasty. All but three patients reported their shoulder function at 60% or better based on the SANE score. The grade of the lesion did not influence outcome scores, but patients with unipolar lesions had higher outcome scores than patients with bipolar lesions. We believe arthroscopic glenohumeral débridement in young patients with shoulder arthritis can be an effective tool in managing symptoms and delaying the need for invasive resurfacing or prosthetic replacement.     

Does Anatomic Versus Nonanatomic Resection Affect Recurrence and Survival in Patients Undergoing Surgery for Colorectal Liver Metastasis?

Anatomic resection of colorectal liver metastases may offer a survival advantage because (1) it removes the hepatic functional unit as a whole and (2) nonanatomic resection has been reported to have a higher incidence of positive margins. A retrospective review was performed of patients undergoing hepatic resection for colorectal liver metastases. 183 patients met inclusion criteria of undergoing either anatomic or nonanatomic resection with the aim of removing all gross disease. Mean age was 61 years (range 31–90 years), 57% were male. 89 patients (49%) underwent nonanatomic resection, the remaining 94 (51%) had anatomic resection. Average duration of inflow occlusion was 10 min. Average length of stay was 7.4 days. There were three deaths, yielding a 1.6% 30-day mortality rate. There was no difference in the incidence of positive margins between types of resection. Recurrence was 27%, 55%, and 59% at 1, 3, and 5 years respectively. Overall survival was 89%, 67%, and 55% at 1, 3, and 5 years, respectively. Type of resection was not associated with significant differences in recurrence or survival even when adjusted for differences in preoperative risk. We conclude that hepatic resection for colorectal metastases can be performed safely and offers select patients with stage IV disease prolonged survival. Resection type should be based on the number and location of tumors, rather than on segmental anatomy. An emphasis on the preservation of hepatic parenchyma may be of increasing importance in the setting of chemotherapy-associated steatohepatitis, and the growing number of patients undergoing repeated metastasectomy.     

Subtalar Coalitions: Does the Morphology of the Subtalar Joint Involvement Influence Outcomes After Coalition Excision?

Posteromedial subtalar (PMST) coalitions are a recently described anatomic subtype of tarsal coalitions. We compared with clinical patient-based outcomes of patients with PMST and standard middle facet (MF) coalitions who had undergone surgical excision of their coalition. The included patients had undergone surgical excision of a subtalar tarsal coalition, preoperative computed tomography (CT), and patient-based outcomes measures after surgery (including the American Orthopaedic Foot and Ankle Society [AOFAS] scale and University of California, Los Angeles [UCLA], activity score). Blinded analysis of the preoperative CT scan findings determined the presence of a standard MF versus a PMST coalition. The perioperative factors and postoperative outcomes between the MF and PMST coalitions were compared. A total of 51 feet (36 patients) were included. The mean follow-up duration was 2.6 years after surgery. Of the 51 feet, 15 (29.4%) had a PMST coalition and 36 (70.6%) had an MF coalition. No difference was found in the UCLA activity score; however, the mean AOFAS scale score was higher for patients with PMST (95.7) than for those with MF (86.5; p = .018). Of the patients with a PMST, none had foot pain limiting their activities at the final clinical follow-up visit. However, in the group with an MF subtalar coalition, 10 (27.8%) had ongoing foot pain limiting activity at the final follow-up visit (p = .024). Compared with MF subtalar tarsal coalitions, patients with PMST coalitions showed significantly improved clinical outcomes after excision. Preoperative identification of the facet morphology can improve patient counseling and expectations after surgery.     

Does the Number of Trauma Lists Provided Affect Care and Outcome of Patients with Fractured Neck of Femur?

INTRODUCTION

Delay in surgery for fractured neck of femur is associated with increased mortality; it is recommended that patients with fractured neck of femur are operated within 48 h. North West hospitals provide dedicated trauma lists, as recommended by the British Orthopaedic Association, to allow rapid access to surgery. We investigated trauma list provision by each trust and its effects on the time taken to get neck of femur patients to surgery and patient survival.

PATIENTS AND METHODS

The number of trauma lists provided by 13 acute trusts was determined by telephone interview with the theatre manager. Data on operating delays, reasons for delay and 30-day mortality were obtained from the Greater Manchester and Wirral fractured neck of femur audit.

RESULTS

A total of 883 patients were included in the audit (35–126 per hospital). Overall, 5–15 trauma lists were provided each week, and 80% of lists were consultant-led. Of patients, 31.8% were operated on within 24 h and 36.9% were delayed more than 48 h; 37.7% of delays were for non-medical reasons. The 30-day mortality rates varied between 5–19% (mean, 11.8%). There were no significant relationships between the number of trauma lists and these variables. When divided into hospitals with > 10 lists per week (n = 6) and those with < 10 lists per week (n = 7) there were no significant differences in 48-h delay, non-medical delay or mortality. However, 24-h delay showed a trend to be lower in those with > 10 lists (34.6% of patients versus 28.9%; P = 0.09).

CONCLUSIONS

Most trusts provided at least one dedicated daily list. This study shows that extra lists may enable trusts to cope better with fractured neck of femur but do not change mortality.     

Is Neuraxial Anesthesia Safe in Patients Undergoing Surgery for Treatment of Periprosthetic Joint Infection?

BackgroundThere is concern that neuraxial anesthesia in patients undergoing surgery for treatment of a periprosthetic joint infection (PJI) may increase the risk of having a central nervous system infection develop. However, the available data on this topic are limited and contradictory.Questions/purposesWe wished to determine whether neuraxial anesthesia (1) is associated with central nervous system infections in patients undergoing surgery for a PJI, and (2) increases the likelihood of systemic infection in these patients.MethodsAll 539 patients who received neuraxial or general anesthesia during 1499 surgeries for PJI from October 2000 to May 2013 were included in this study; of these, 51% (n = 764) of the surgeries were performed in 134 patients receiving neuraxial anesthesia and 49% were performed in 143 patients receiving general anesthesia. Two hundred sixty-two patients received general and neuraxial anesthesia during different surgeries. We used the International Classification of Diseases, 9^th Revision codes and the medical records to identify patients who had an intraspinal abscess or meningitis develop after surgery for a PJI. Multivariate analysis was used to assess the effect of type of anesthesia (neuraxial versus general) on postoperative complications.ResultsThere were no cases of meningitis, but one epidural abscess developed in a patient after neuraxial anesthesia. This patient underwent six revision surgeries during a 42-day period. Patients who received neuraxial anesthesia had lower odds of systemic infections (4% versus 12%; odds ratio, 0.35; 95% CI, 023–054; p < 0.001).ConclusionsCentral nervous system infections after neuraxial anesthesia in patients with a PJI appear to be exceedingly rare. Based on the findings of this study, it may be time for the anesthesiology community to reevaluate the risk of sepsis as a relative contraindication to the use of neuraxial anesthesia.

Level of Evidence

Level III, therapeutic study.