Multiplanar Semiautomatic Assessment of Foot and Ankle Offset in Adult Acquired Flatfoot Deformity.

BACKGROUND: Semiautomatic 3-dimensional (3D) biometric weightbearing computed tomography (WBCT) tools have been shown to adequately demonstrate the relationship between the center of the ankle joint and the tripod of the foot. The measurement of the foot and ankle offset (FAO) represents an optimized biomechanical assessment of foot alignment. The objective of this study was to evaluate the correlation between FAO and traditional adult acquired flatfoot deformity (AAFD) markers, measured in different planes. We hypothesized that the FAO would significantly correlate with other radiographic markers of pronounced AAFD. METHODS: In this retrospective comparative study, we included 113 patients with stage II AAFD, 43 men and 70 women, mean age of 53.5 (range, 20-86) years. 3D coordinates (x, y, and z planes) of the foot tripod (most plantar voxel of the first and fifth metatarsal heads, and calcaneal tuberosity) and the center of the ankle joint (most proximal and central voxel of the talar dome) were assessed by 2 blinded and independent fellowship-trained orthopedic foot and ankle surgeons. The FAO was automatically calculated using the 3D coordinates by dedicated software. Multiple WBCT parameters related to the severity of the deformity in the coronal, sagittal, and transverse planes were manually measured. RESULTS: We found overall good to excellent intra- (range, 0.75-0.99) and interobserver (range, 0.73-0.99) reliability for manual AAFD measurements. FAO semiautomatic measurements demonstrated excellent intra- (0.99) and interobserver (0.99) reliabilities. Hindfoot moment arm (HMA) (P < .00001), subtalar horizontal angle (P < .00001), talonavicular coverage angle (P = .00004), and forefoot arch angle (P = .0001) were the only variables found to significantly influence and correlate with FAO measurements, with an R2 value of 0.79. An HMA value of 19.8 mm was found to be a strong threshold predictor of increased values of FAO, with mean values of FAO of 6.5 when the HMA was lower than 19.8 mm and 14.6 when the HMA was equal to or higher than 19.8 mm. CONCLUSION: We found that 3D WBCT semiautomatic measurements of FAO significantly correlated with some traditional markers of pronounced AAFD. Measurements of FAO were also found to be slightly more reliable than the manual measurements. The FAO offers a simple and more complete biomechanical and multiplanar assessment of the AAFD, representing in a single measurement the 3D components of the deformity. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Position of the Posteromedial Ankle Structures in Patients Indicated for Total Ankle Replacement.

BACKGROUND: The posteromedial ankle structures are at risk during total ankle replacement (TAR). The purpose of our study was to investigate the distance of these structures from the posterior cortex of the tibia and talus in order to determine their anatomy at different levels of bone resection during a TAR and whether plantarflexion of the ankle reliably moved these structures posteriorly. METHODS: Ten feet in 10 patients with end-stage tibiotalar arthritis indicated for a TAR were included. Preoperative magnetic resonance images were obtained with the foot in a neutral position as well as in maximum plantarflexion to measure the distance of posteromedial ankle structures to the closest part of the posterior cortex of the tibia or talus. Wilcoxon signed-rank rests were used to investigate differences in these distances. RESULTS: The mean distance from the posterior tibial cortex to the tibial nerve at 14 and 7 mm above the tibial plafond was 8.7 mm (range 5.0-11.8 mm) and 6.7 mm (range 2.7-10.6 mm), respectively, which represented a statistically significant movement anteriorly (P = .021). The posterior tibial artery was, on average, 8.0 mm (range 3.6-13.9 mm) and 7.2 mm (range 3.1-9.4 mm) from the posterior tibial cortex at 14 and 7 mm above the tibial plafond, respectively. Distal to the tibial plafond, the posterior tibial artery and flexor digitorum longus tendons moved posteriorly by less than 1 mm in plantarflexion (all P < .05); otherwise, plantarflexion of the ankle did not affect the position of the tibial nerve, posterior tibial tendon, or flexor hallucis longus. CONCLUSION: In patients with end-stage ankle arthritis, the tibial nerve and posterior tibial artery lie, on average, between 6.5 and 10 mm from the posterior tibial and talar cortices. Plantarflexion of the ankle did not reliably move the posteromedial ankle structures posteriorly. LEVEL OF EVIDENCE: Level IV, case series, therapeutic.

Health Literacy and Recall of Postoperative Instructions in Patients Undergoing the Lapidus Procedure.

BACKGROUND: Active participation in patients' own care is essential for success after Lapidus procedure. Poor health literacy, comprehension, and retention of patient instructions may be correlated with patient participation. Currently, there is no objective measure of how well patients internalize and retain instructions before and after a Lapidus procedure. We performed this study to assess how much of the information given to patients preoperatively was able to be recalled at the first postoperative visit. METHODS: All patients between ages 18 and 88 years undergoing a Lapidus procedure for hallux valgus by the senior author between June 2016 and July 2018 were considered eligible for inclusion. Patients were excluded if they had a history of previous bunion surgery or if the procedure was part of a flatfoot reconstruction. Patients were given written and verbal instructions at the preoperative visit. Demographic and comprehension surveys were administered at their first visit approximately 2 weeks postoperatively. A total of 50 patients, of which 42 (84%) were female and 43 (86%) had a bachelor's degree or higher, were enrolled. RESULTS: Mean overall score on the comprehension survey was 6.2/8 (±1.2), mean procedure subscore was 1.8/3 (±0.64), and mean postoperative protocol subscore was 4.4/5 (±0.8). The most frequently missed question asked patients to identify the joint fused in the procedure. CONCLUSION: Although comprehension and retention of instructions given preoperatively was quite high in our well-educated cohort, our findings highlight the importance of delivering clear instructions preoperatively and reinforcing these instructions often. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Smoking Is a Risk Factor for Wound Complications after Direct Anterior Hip Arthroplasty with Mesh Tape Closure.

OBJECTIVE: To determine what factors increase the risk of early wound complications in patients undergoing direct anterior total hip arthroplasty whose wounds were closed with 2-octyl cyanoacrylate with mesh. METHODS: This study was a retrospective review of 75 consecutive patients who underwent direct anterior total hip arthroplasty closed with 2-octyl cyanoacrylate with mesh. MAIN RESULTS: Of 29 patients who were smokers, five patients (17.2%) developed a wound complication, whereas out of 46 nonsmokers, only one patient (2.2%) developed a wound complication (P = .029). CONCLUSIONS: The authors recommend a closure technique that sufficiently protects the wound during healing, as well as preoperative patient optimization and smoking cessation.

Effect of the Modified Lapidus Procedure on Pronation of the First Ray in Hallux Valgus.

BACKGROUND: Hallux valgus (HV) is a triplanar deformity of the first ray including pronation of the first metatarsal with subluxation of the sesamoids. The purpose of this study was to investigate if a first tarsometatarsal fusion (modified Lapidus technique), without preoperative knowledge of pronation measured on weightbearing computed tomographic (CT) scans, changed pronation of the first metatarsal and determine if reduction of the sesamoids was correlated with changes in first metatarsal pronation. METHODS: Thirty-one feet in 31 patients with HV who underwent a modified Lapidus procedure had preoperative and at least 5-month postoperative weightbearing CT scans and radiographs. Differences in preoperative and postoperative pronation of the first metatarsal using a 3-dimensional computer-aided design, HV angle, and intermetatarsal angle (IMA) were calculated using Wilcoxon signed-rank tests. After dividing patients into groups based on sesamoid station, Kruskal-Wallis H tests were used to compare first metatarsal pronation between the groups. RESULTS: The mean preoperative and postoperative pronation of the first metatarsal was 29.0 degrees (range 15.8-51.1, SD 8.7) and 20.2 degrees (range 10.4-32.6, SD 5.4), respectively, which was a mean change in pronation of the first ray of -8.8 degrees (P < .001). There was no difference in pronation of the first ray when stratified by postoperative sesamoid position (P > .250). The average preoperative and postoperative IMA was 16.7 degrees (SD 3.2) and 8.8 degrees (SD 2.8), which demonstrated a significant change (P < .001). CONCLUSIONS: The modified Lapidus procedure was an effective tool to change pronation of the first ray. Reduction of the sesamoids was not associated with postoperative first metatarsal pronation. LEVEL OF EVIDENCE: Level IV, case series.

Outcomes of Reconstruction of the Flexible Adult-acquired Flatfoot Deformity.

Reconstruction of the flexible adult-acquired flatfoot deformity (AAFD) is controversial, and numerous procedures are frequently used in combination, including flexor digitorum longus transfer, medializing calcaneal osteotomy (MCO), heel cord lengthening/gastrocnemius recession, lateral column lengthening (LCL), Cotton osteotomy or first tarsometatarsal fusion, and spring ligament reconstruction. This article summarizes recent studies demonstrating that patients have significant improvements after operative treatment of flexible AAFD. It reviews current literature on clinical and radiographic outcomes of the MCO, LCL, and Cotton osteotomies. The authors describe how this information can be used in surgical decision making in order to tailor operative treatment to an individual patient's deformity.

Patient perceptions of antibiotic prophylaxis for dental procedures after total joint arthroplasty.

OBJECTIVE: Investigating patients' perceptions regarding need for antibiotic prophylaxis during dental procedures after undergoing joint arthroplasty. METHODS: Questionnaire was administered to patients presenting at: 1)an orthopaedic office; 2)a dental office; regarding perceptions of antibiotic prophylaxis. RESULTS: 36 orthopaedic patients responded "Yes" to always taking prophylaxis; 36 patients responded "No" (36/72, 50.0% compliance). Five dental patients responded "Yes" to always taking prophylaxis; 19 patients responded "No" (5/24, 20.8% compliance) (p = 0.017). 67/135 orthopaedic patients (49.6%) endorsed some form of dental prophylaxis, versus 34/58 dental patients (58.6%) (p = 0.27). CONCLUSION: Patient perceptions of the need for dental prophylaxis vary within orthopaedic and dental practices.

Imaging of Bone Perfusion and Metabolism in Subjects Undergoing Total Ankle Arthroplasty Using 18F-Fluoride Positron Emission Tomography.

BACKGROUND: Total ankle arthroplasty (TAA) continues to exhibit a relatively high incidence of complications and need for revision surgery compared to knee and hip arthroplasty. One common mode of failure in TAA is talar component subsidence. This may be caused by disruption in the talar blood supply related to the operative technique. The purpose of this study was to quantify changes in talar bone perfusion and turnover before and after TAA with the INBONE II system using 18F-fluoride positron emission tomography / computed tomography (PET/CT). METHODS: Nine subjects (5 M/4 F) aged 68.9 ± 8.2 years were enrolled for 18F-fluoride PET/CT imaging before and 3 months after TAA. Regions of interest (ROI) were placed on the postoperative CT images in the body of the talus beneath the talar component and overlaid on the fused static PET images. Standard uptake values (SUVs) along with dynamic K1 (bone blood flow) and ki (bone metabolism or osteoblastic turnover) were calculated. RESULTS: The SUV underneath the talar component compared to that measured at baseline before surgery was 1.93 ± 0.29 preoperatively vs 2.47 ± 0.37 postoperatively (P > .05). K1 was 0.84 ± 0.16 mL/min/mL preoperatively vs 1.51 ± 0.23 mL/min/mL postoperatively (P = .026). ki was constant at 0.09 ± 0.03 mL/min/mL preoperatively vs 0.12 ± 0.03 mL/min/mL postoperatively (P > .05). CONCLUSION: Our study was the first to link 18F-fluoride PET/CT with pre-post evaluation of total ankle replacements. The study quantified perfusion within the talus beneath the TAA implant supporting the hypothesis that perfusion of the talus remained intact after surgery. LEVEL OF EVIDENCE: Level II, prospective cohort study with development of diagnostic criteria.

Radiographic Calibration With a Prosthetic Femoral Head Allows Accurate Preoperative Templating for Total Hip Arthroplasty.

Templating for total hip arthroplasty requires proper radiographic calibration. One option for radiograph calibration is using a cobalt-chrome femoral head ball. The authors reviewed radiographs and clinical data for patients undergoing primary total hip arthroplasty. Radiographs were calibrated using a 28-mm cobalt-chrome femoral head ball. Agreements between templated and actual implant size were calculated. The templated acetabulum matched within one size of the actual acetabulum in 76.7% to 80.0% of cases. The templated femur matched within one size of the actual femur in 83.3% to 93.3% of cases. This technique is an attractive option when a standardized calibration marker is unavailable. [Orthopedics. 2019; 42(3):e346-e349.].

Perioperative factors associated with increased length of stay after revision of metal-on-metal total hip arthroplasty.

OBJECTIVE: To investigate patient factors influencing length-of-stay (LOS) after revision metal-on-metal (MoM) total hip arthroplasty (THA). METHODS: We reviewed 23 hips undergoing revision of a MoM THA with minimum 2-year follow-up. A multiple linear regression was calculated to predict LOS using multiple variables. RESULTS: Average length of stay (LOS) was 2.1 days. Multiple linear regression analysis identified a significant correlation between presence of an abductor injury (beta = 0.8886; p < 0.0001), patient age (beta = -0.4452, p = 0.0083), and pre-revision head size (beta = 0.4082; p = 0.0172) with LOS (R2 = 0.6351, p = 0.0002). CONCLUSION: Patients with abductor injury, larger femoral heads, and younger age are at risk for longer LOS.

Postoperative Medial Cuneiform Position Correlation With Patient-Reported Outcomes Following Cotton Osteotomy for Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity.

BACKGROUND: Residual supination of the midfoot during reconstruction of the stage II adult-acquired flatfoot deformity (AAFD) is often addressed with a medial cuneiform (Cotton) osteotomy after adequate correction of the hindfoot valgus deformity. The purpose of this study was to determine if there was a correlation between postoperative alignment of the medial cuneiform and patient-reported outcomes. METHODS: Sixty-three feet in 61 patients with stage II AAFD who underwent a Cotton osteotomy as part of a flatfoot reconstruction were included in the study. Radiographic angles were measured on weightbearing lateral radiographs at a minimum of 40 weeks postoperatively. Pearson's correlation analysis was used to determine if there was an association between postoperative radiographic angles and Foot and Ankle Outcome Score (FAOS) at a minimum of 24 months postoperatively. Patients were also divided into mild plantarflexion (cuneiform articular angle [CAA] ≥-2 degrees) and moderate plantarflexion (CAA <-2 degrees) groups to evaluate for differences in clinical outcomes. RESULTS: Postoperative CAA was significantly positively correlated with the postoperative FAOS symptoms ( r = .27, P = .03), daily activities ( r = .29, P = .02), sports activities ( r = .26, P = .048), and quality of life ( r = .28, P = .02) subscales. Patients in the mild plantarflexion group had statistically and clinically better outcomes compared with the moderate plantarflexion group in the FAOS symptoms ( P = .04), daily activities ( P = .04), and sports activities ( P = .01) subscales. CONCLUSIONS: Our study suggests that the surgeon should avoid excessive plantarflexion of the medial cuneiform and use the Cotton osteotomy judiciously as part of a flatfoot reconstruction for stage II AAFD. LEVEL OF EVIDENCE: Level III, comparative series.

Increased Incidence of Bleeding and Wound Complications With Factor-Xa Inhibitors After Total Joint Arthroplasty.

BACKGROUND: Factor-Xa inhibitors have been introduced for prevention of venous thromboembolism (VTE) after joint arthroplasty. However, these agents could also be associated with bleeding or wound complications after surgery. METHODS: We retrospectively reviewed a consecutive series of 59 patients (31 knees, 28 hips) undergoing joint arthroplasty at a high-volume joint arthroplasty referral center, both before and after implementation of a new VTE risk-stratification tool at our institution. Patients with a history of VTE, bilateral procedures, or medical conditions already requiring VTE chemoprophylaxis were excluded. We reviewed the medical records to determine (1) type of VTE prophylaxis used, (2) incidence of bleeding/wound complications in the postoperative period, (3) incidence of VTE in the postoperative period, and (4) change in serum hemoglobin. RESULTS: Twenty-seven patients (46%) were given aspirin for VTE prophylaxis, while 32 patients (54%) received a factor-Xa inhibitor. There were no new VTE complications in either group. And 6 of 32 patients (18.7%) in the Xa inhibitor group had a postoperative bleeding/wound complication (4 delayed healing/blistering, 1 hematoma/excessive ecchymosis, and 1 readmission for cellulitis). There were no (0%) bleeding/wound complications in the aspirin group (P = .03). The change in hemoglobin level was -2.76 g/dL in patients receiving aspirin vs -2.84 g/dL in patients receiving a Xa inhibitor (P = .73). CONCLUSION: In our study of total joint patients, factor-Xa inhibitors were associated with a higher incidence of bleeding/wound complications. The choice of VTE prophylaxis should be based on the perceived risks of bleeding and wound complications compared to the risks of VTE in each patient.