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 (pâ€‰<â€‰.001), costs were 14% greater (pâ€‰<â€‰.001), and risk of disposition to nursing and rehabilitation facilities was 86% lower (pâ€‰<â€‰.001), with no significant difference in 90-day readmission (pâ€‰=â€‰.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.
Acute and Chronic Lateral Ankle Instability Diagnosis, Management, and New Concepts
Lateral ankle instability is a common entity that can result in degenerative arthritis if left untreated. Acute ligament injuries should primarily be treated nonoperatively with a course of physical therapy and functional bracing. Chronic ankle instability is defined as mechanical or functional and can be diagnosed using a combination of history, physical examination, stress radiographs, and magnetic resonance imaging. After failure of nonoperative treatment, surgical treatment with anatomic ligament repair and inferior extensor retinaculum augmentation has the best clinical outcomes. Patients with high athletic demands, ligamentous instability, and failure of initial surgical treatment may do better with an anatomic ligament reconstruction or combined ligament repair with peroneus brevis transfer. Those patients with underlying foot deformity benefit from deformity correction in addition to ligament repair or reconstruction. Ankle arthroscopy is an important component of ankle instability to treat the commonly associated intraarticular lesions; however, all-arthroscopic ligament repair is associated with a high complication rate, and techniques may not be perfected as of yet.
Total ankle replacement--evolution of the technology and future applications
Total ankle arthroplasty was developed to reduce pain and retain motion of the ankle joint in patients with osteoarthritis much like its total hip and knee counterparts. Orthopaedic surgeons are well equipped to evaluate and treat patients with end-stage hip or knee arthritis; however, the management of patients with ankle arthritis represents a challenge to both general orthopaedic surgeons and to the foot and ankle surgeons to whom these patients are often referred. Although techniques for both hip and knee arthroplasty have evolved to provide long-term pain relief and functional improvement, neither ankle arthrodesis nor arthroplasty has demonstrated comparably favorable outcomes in long-term follow-up studies. Early ankle arthroplasty designs with highly constrained cemented components were abandoned due to unacceptably high failure rates and complications. While arthrodesis is still considered the "gold standard" for treatment of end-stage ankle arthritis, progression of adjacent joint arthrosis and diminished gait efficiency has led to a resurgence of interest in ankle arthroplasty. Long-term outcome studies for total ankle replacement found excellent or good results in 82% of patients who received a newer generation ankle device compared with 72% if undergoing ankle fusion. Continued long-term follow-up studies are necessary, but total ankle arthroplasty has become a viable option for surgical treatment of ankle arthritis.
Combined ankle and talus fractures--a case report [Case Report]
A 50-year-old male patient sustained a supination-adduction type ankle fracture with an associated sagittal split fracture of the talus. The patient was treated initially in a short leg splint, and upon presentation to an orthopaedic surgeon, an external fixator was applied. After the soft tissue swelling improved enough to permit open reduction and internal fixation, the patient was brought back to the operating room for definitive treatment with removal of the external fixator and open reduction and placement of internal fixation. The patient's postoperative course was uncomplicated. At the 6-week follow-up visit, he was noted to have a radiographic Hawkin's sign in the dome of the talus. At 3 months postoperatively, he was weightbearing as tolerated with radiographic evidence of fracture healing, and his ankle range of motion was from 30 degrees of plantar flexion to 15 degrees of dorsiflexion. At 6 months postoperatively, the patient had no complaints and was ambulating in a regular shoe. His plantar flexion was 35 degrees and his dorsiflexion was 15 degrees . His subtalar motion was from 5 degrees of eversion to 10 degrees of inversion. He returned for his one-year follow-up doing well without complaints, and he had returned to his previous activities.
Fractures of the proximal fifth metatarsal - keeping up with the joneses
Fractures of the proximal fifth metatarsal are among the most common fractures of the foot. History, physical examination, and subsequent radiographic work-up can help with the diagnosis of such a fracture. Many fractures of the proximal fifth metatarsal can have an associated prodrome, thereby establishing a level of chronicity to the problem. Identification of the location of the fracture plane within the proximal fifth metatarsal can have prognostic implications in regards to fracture union rate and guide treatment options, due to the particular vascular anatomy of the region. Additional findings on physical exam, such as heel varus, can also impact prognosis and treatment options. Treatments can range from nonoperative to operative modalities, and time to weightbearing can vary. Within the realm of operative treatment, identification of certain parameters can aid in successful reduction and fixation of the fracture and thus impact healing. Careful consideration of the patient's particular constellation of social and professional needs, clinical and radiographic parameters, and acceptance of different options can help guide treatment recommendations in the individual patient.
Foot and shoe size mismatch in three different new york city populations
Proper shoe size is an important element of foot health, especially in the elderly and diabetic populations. An improper fit can lead to pain, functional limitations, and falls. The aim of the present study was to determine the proportion of adults who are unaware of their own shoe size in 3 different New York City populations: a foot specialist private practice, an academic diabetic foot and ankle clinic, and a charity care center, the Bowery clinic, serving the homeless. A shoe size mismatch was defined as a difference of at least 0.5 in size between the measured foot and the shoe size. Demographic data were collected during the examination and retrospectively by chart review. A total of 235 volunteers participated in our study. A significant difference in the prevalence of the measured foot and shoe size mismatch was found between the cohort from the private practice compared with both the diabetic foot and ankle clinic and the Bowery clinic (P < .01 and P < .01, respectively). A significant difference was also detected (P < .05) between the private practice and the Bowery mission cohort when a difference of at least 1.5 sizes was present between the measured foot and the shoe size. Of those with a foot to shoe size mismatch, 60% had a difference of more than 0.5 in the shoe size between their right and left foot. In conclusion, our findings suggest that proper footwear sizing is lacking among a large proportion of our patients and that an adequate shoe size can be achieved with proper counseling
Technical Tip: Use of the Kerrison Rongeur Through a Single-Incision Exposure for Resection of Haglund's Deformity
Charcot neuroarthropathy in the era of HAART [Case Report]
MRI of medial malleolar bursa
OBJECTIVE: This study was designed to assess the MR appearance of the medial perimalleolar fat in an asymptomatic population and describe the MRI appearance of the medial malleolar bursa. CONCLUSION: The MRI findings of medial perimalleolar fat in asymptomatic individuals and in patients with suspected medial malleolar bursa include normal fat, minimal or extensive subcutaneous edema, and a fluid-filled sac. The latter pattern is consistent with the MR appearance of the medial malleolar bursa.
MRI features of chronic injuries of the superior peroneal retinaculum
OBJECTIVE: The aims of this study were to assess, grade, and surgically correlate previously unreported MRI features of superior peroneal retinacular injuries in nine surgically proven cases and to record all soft-tissue and bony abnormalities associated with these injuries. CONCLUSION: MRI was found to be a useful tool for detecting and grading superior peroneal retinacular injuries and providing information, important for presurgical planning, regarding common concomitant soft-tissue and osseous abnormalities of the lateral collateral ligaments, peroneal tendons, and fibular groove. Superior peroneal retinacular injuries are frequently associated with MRI evidence of peroneal tendon dislocations and tears. Conversely, routine MRI studies may not depict dislocated peroneal tendon injuries, despite clinical history to that effect