Patient-Reported Outcomes in Total Ankle Arthroplasty: Patient Specific Versus Standard Instrumentation.

BACKGROUND: Total ankle arthroplasty (TAA) can now be performed using patient-specific instrumentation (PSI). Advantages include the ability to preoperatively plan and reduce the number of intraoperative surgical steps. The aim of this study was to compare PSI with standard instrumentation (SI) in a nonrandomized retrospective cohort study with respect to patient-reported outcome measures (PROMs). Secondary aims were to compare complications, reoperations, tourniquet time, fluoroscopy time, and postoperative alignment. METHODS: In all, 159 patients (111 men, 48 women) undergoing a total of 168 Infinity TAA (Stryker, Memphis, TN) using PSI (Prophecy, Stryker, Memphis, TN) or SI between 2014 and 2021 were included with a minimum follow-up of 12 months. The PROMs were obtained preoperatively and at 1 year, and included the Manchester-Oxford Foot Questionnaire (MOXFQ), Ankle Osteoarthritis Scale (AOS), and European Quality of Life 5 Dimension 3 Level (EQ-5D-3L). Coronal plane deformity correction was assessed using the midline tibiotalar angle (MTTA). Demographics, tourniquet time, and intraoperative fluoroscopy times were obtained from the hospital records. RESULTS: There were 61 TAAs in the PSI group and 107 TAAs in the SI group. There was no significant difference in total MOXFQ, AOS, or EQ-5D. There was a significantly reduced tourniquet time (PSI mean: 95.39 minutes, SI mean: 116.87 minutes, P < .001) and radiation exposure (PSI mean: 31 seconds, SI mean: 53 seconds, P < .001). Angular correction was more accurate in the PSI group (PSI mean: 1.29°, SI mean: 2.26°, P = .005). CONCLUSION: This study supports the use of PSI to decrease operative time, reduce intraoperative fluoroscopy, improve accuracy of implantation, and improve postoperative alignment in TAA. There was a significant difference (P = .032) in favor of PSI in the walking/standing domain of the MOXFQ at 12 months but no significant difference in overall PROMs. LEVELS OF EVIDENCE: Level III, Retrospective.

Anomalous origin of the left coronary artery from the pulmonary artery in adults: a comprehensive review of 151 adult cases and a new diagnosis in a 53-year-old woman.

BACKGROUND: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary abnormality associated with early infant mortality and adult sudden death. As it predominantly presents in the first year of life, diagnosis in living adults is extremely rare. Current management is based on limited case series or extrapolated from pediatric cases. Modern advances in noninvasive cardiac imaging have substantially increased the number of diagnoses, uncovering a large adult population that has not been reviewed. HYPOTHESIS: The availability of newer diagnostic modalities correlates with an increasing incidence in an older cohort, and true association between sudden death and ALCAPA may be lower, especially among older patients. METHODS: A comprehensive literature search was performed for all case reports of ALCAPA on MEDLINE and PubMed using the keywords ALCAPA, Bland-White-Garland, and coronary anomaly; and augmented by references from published case reports from 1908 to 2008. All adult cases, defined by age 18 years and older, were reviewed for this article. RESULTS: One hundred fifty-one adult cases of ALCAPA are described, in addition to the case of an asymptomatic 53-year-old woman. The average reported age was 41 years old with the oldest being 83. Sixty-six percent of the patients presented with symptoms of angina, dyspnea, palpitations, or fatigue; 17% presented with ventricular arrhythmia, syncope, or sudden death; and 14% were asymptomatic. Twelve percent were diagnosed at autopsy. The majority had some form of surgical correction during their clinical course. CONCLUSIONS: ALCAPA is a rare and life-threatening condition in adults. The availability of newer, less invasive diagnostic modalities has resulted in more frequent identification of this condition in an older cohort.

Underestimation of left atrial size measured with transthoracic echocardiography compared with 3D MDCT.

OBJECTIVE: High-resolution 64-MDCT images of the beating heart can be used for measurement of left atrial volume with 3D chamber reconstruction. The purpose of this study was to correlate measurements of left atrial volume obtained with clinical transthoracic echocardiography (TTE) and measurements obtained with 64-MDCT 3D reconstructions of the left atrium. MATERIALS AND METHODS: Patients who underwent TTE and MDCT within 3 days were identified. TTE images were graded as excellent, good, or suboptimal. Two independent observers calculated estimates of left atrial volume from TTE and 64-MDCT images using 3D chamber reconstructions and conventional geometric assumptions on MDCT echocardiographic views. RESULTS: MDCT estimates of phantom volume on 3D chamber reconstructions agreed with actual volumes within 1.5%. The TTE images of 37 of the 52 patients were judged to be of good or excellent quality and were included in the analysis. Mean left atrial volume measured on 3D chamber reconstructions was 61 +/- 14 mL/m(2). Estimates of left atrial volume obtained with TTE were significantly lower (28 +/- 12 mL/m(2)) than similar estimates obtained with MDCT echocardiographic views (53 +/- 15 mL/m(2)) (p < 0.001). TTE left atrial volume and 3D chamber reconstruction left atrial volume exhibited moderate correlation (r = 0.60-0.70), but the correlation improved when analysis was limited to the 26 studies with excellent-quality TTE images (r = 0.71). MDCT echocardiographic estimates of left atrial volume with the area-length method had excellent correlation (r = 0.89) with and were closest to estimates made on 3D chamber reconstructions. CONCLUSION: Left atrial volume is significantly underestimated on TTE images, and TTE estimates have moderate correlation with left atrial volume measured with MDCT. Measured and estimated left atrial volumes at MDCT can provide important additive prognostic information in the care of patients undergoing MDCT for other reasons. Future studies are needed to obtain normative MDCT measurements of left atrial volume.

Impact of perioperative myocardial infarction on angiographic and clinical outcomes following coronary artery bypass grafting (from PRoject of Ex-vivo Vein graft ENgineering via Transfection [PREVENT] IV).

Myocardial infarction (MI) after coronary artery bypass grafting (CABG) is associated with significant morbidity and mortality. Frequency, management, mechanisms, and angiographic and clinical outcomes associated with perioperative MI remain poorly understood. PREVENT IV was a multicenter, randomized, placebo-controlled trial of edifoligide in 3,014 patients undergoing CABG. Angiographic and 2-year clinical follow-up were complete for 1,920 and 2,956 patients, respectively. Perioperative MI was defined as creatinine kinase-MB increase >or=10 times the upper limit of normal or >or=5 times the upper limit of normal with new 30-ms Q waves within 24 hours of surgery. Baseline characteristics, in-hospital management, and angiographic and clinical outcomes of patients with and without perioperative MI were compared. Perioperative MI occurred in 294 patients (9.8%). Patients with perioperative MI had longer surgery (250 vs 230 minutes; p <0.001), more on-pump surgery (83% vs 78%; p = 0.048), and worse target-artery quality (p <0.001). Patients with perioperative MI more frequently underwent angiography within 30 days of enrollment (1.7% vs 0.6%; p = 0.021). One-year angiographic vein graft failure occurred in 62.4% of patients with and 43.8% of patients without perioperative MI (p <0.001). Two-year composite clinical outcome (death, MI, or revascularization) was worse in patients with perioperative MI before (19.4% vs 15.2%; p = 0.039) and after (hazard ratio 1.33, 95% confidence interval 1.00 to 1.76, p = 0.046) adjusting for differences in significant predictors. In conclusion, perioperative MI was relatively common, was associated with worse outcomes, and mechanisms other than vein graft failure accounted for a substantial proportion of these MIs. Further research is needed into the prevention and treatment of perioperative MI in patients undergoing CABG.

An efficient synthesis of an alphavbeta3 antagonist.

A practical preparation of an alpha(v)beta(3) antagonist is reported. The antagonist consists of three key components, a tetrahydronaphthyridine moiety, a beta-alanine moiety, and a central imidazolidone moiety. The tetrahydronaphthyridine component was prepared using two different methods, both of which relied on variations of the Friedländer reaction to establish the desired regiochemistry. The beta-alanine component was prepared using Davies' asymmetric 1,4-addition methodology as the key stereo-defining step. The central imidazolidone portion was created from these two components using an effective three-step cyclization protocol. Thus, a highly convergent process for the drug candidate was defined.