Secondary Subtalar Joint Osteoarthritis Following Total Ankle Replacement.

BACKGROUND: An advantage of total ankle replacement (TAR) compared to ankle fusion is that by maintaining motion, the occurrence of hypermobility of adjacent joints may be prevented. This could affect the development of symptomatic subtalar joint osteoarthritis (OA). The aim of the study was to determine the incidence of subtalar joint fusion and the progression of subtalar joint OA following TAR. METHODS: Secondary subtalar joint fusion rate was determined from a cohort of 941 patients receiving primary TAR between 2000 and 2016. The indication for fusion, the time interval from primary TAR to fusion, and the union rate were evaluated. To assess the progression of subtalar joint OA, degenerative changes of the subtalar joint were classified in 671 patients using the Kellgren-Lawrence score (KLS) prior to TAR and at latest follow-up. RESULTS: In 4% (37) of the patients, a secondary subtalar joint fusion was necessary. The indication for fusion was symptomatic OA in 51% (19), hindfoot instability in 27% (10), osteonecrosis of the talus in 19% (7), and cystic changes of the talus in 3% (1) of the patients. Time from primary TAR to subtalar joint fusion due to progressive OA was 5.0 (range, 0.3-10) years and for other reasons 1.6 (range, 0.2-11.6) years (P = .3). In 68% (456) of the patients, no progression of subtalar joint OA was observed. CONCLUSION: The incidence of secondary subtalar joint fusion was low. The most common reason for subtalar joint fusion following TAR was symptomatic OA. LEVEL OF EVIDENCE: Level IV, case series.

Vascularized Bone Autograft for the Treatment of Chondroblastoma of the Talus at Imminent Risk of Joint Breakdown: Three Case Reports.

Surgical treatment options in a chondroblastoma of the talus breaching the subchondral layer with imminent risk of talar collapse in the weightbearing area are limited. A joint-preserving surgery should be advocated. Because current treatment options such as curettage, cryosurgery, or radiofrequency ablation may not be able to prevent a talar dome breakdown in large defects, nonvascularized bone grafting has been advocated to fill the void. To overcome the lack of vitality, a vascularized bone autograft might be an attractive alternative. We present 3 cases where a large talar defect owing to a chondroblastoma was treated with a vascularized bone autograft. In 1 of the cases, a free microvascular iliac crest bone graft was used, whereas in the other 2 cases, a vascularized graft was harvested from the medial femoral condyle. Computed tomographic scans demonstrated a stable incorporation of the graft in all cases. All patients were highly satisfied with the obtained results and showed a clinical functional outcome similar to the contralateral foot after 36, 60, and 72 months. At the latest radiographic follow-up, no evidence of recurrence was observed. In conclusion, a free vascularized bone autograft can be used to treat a large talar defect owing to chondroblastoma in young patients.

Combined Subtalar and Naviculocuneiform Fusion for Treating Adult Acquired Flatfoot Deformity With Medial Arch Collapse at the Level of the Naviculocuneiform Joint.

BACKGROUND:: A challenge in treating acquired flatfoot deformities is the collapse of the medial arch at the level of the naviculocuneiform (NC) joint. Triple fusions, being a treatment option, may lead to problems such as increased foot stiffness. We thus established a method that combines subtalar (ST) fusion with NC fusion while preserving the Chopart joint. We analyzed the radiographic correction, fusion rate, and patient satisfaction with this procedure. METHODS:: 34 feet in 31 patients (female, 23; male, 8; age 67 [45-81] years) were treated with a ST and NC joint fusion. In 15 cases, a medial sliding-osteotomy was additionally necessary to fully correct hindfoot valgus. The following radiographic parameters were measured on weightbearing radiographs preoperatively and at 2 years: talo-first metatarsal angle, talocalcaneal angle, calcaneal pitch, talonavicular coverage angle and calcaneal offset. Fusion was radiologically confirmed. RESULTS:: All parameters, except the calcaneal pitch, showed a significant improvement. Fusion was observed after 1 year in all but 2 cases (94.1%). One nonunion each occurred at the ST and NC joint without needing any subsequent treatment. One patient developed avascular necrosis of the lateral talus with need for total ankle replacement after 1 year. All patients were satisfied with the obtained results. CONCLUSION:: Our data suggest that a combined fusion of the ST and NC joint was effective and safe when treating adult acquired flatfoot with collapse of the medial arch at the level of the NC joint. Although the talonavicular joint was not fused, its subluxation was significantly reduced. LEVEL OF EVIDENCE:: Level IV, case series.

Intraoperative Findings of Lateral Ligament Avulsion Fractures and Outcome After Refixation to the Fibula.

BACKGROUND: An acute ankle sprain can result in a bony avulsion of the lateral ankle ligaments. The extent of concomitant lesions and subsequent instability patterns are not clearly understood. The high incidence of old avulsion fractures found in symptomatic chronic ankle instability may indicate the need for primary fixation. METHODS: Ten patients (5 male, 5 female; mean age, 34 years; range, 15-64 years) with bony avulsion fractures of the fibula after acute ankle sprains were included. All patients were treated after a mean of 7.7 days (range, 2-17 days) with screw fixation of the fragment to the fibula. Clinical and radiographic assessments were performed, and the extent of ligament injury was documented. RESULTS: The anterior talofibular ligament and calcaneofibular ligament were found to be attached to the avulsion fragment. The average size was 6.3 mm (range, 4-9 mm) in width from anterior to posterior and 5.2 mm (range, 4-7 mm) in length from superior to inferior. The displacement of the fragment increased under varus stress. Two patients had cartilage lesions in the lateral talus. After a mean follow-up period of 2.4 years (range, 2-4 years), all were clinically and radiographically stable, and patients were satisfied. CONCLUSIONS: It was observed arthroscopically that the anterior talofibular ligament and calcaneofibular ligament were attached to the fragment. This is critical because motion between the fragment and the fibula may prevent spontaneous healing. Primary fixation of the fragment prevented rotational instability and was efficient to restore function and stability. LEVEL OF EVIDENCE: Level IV, retrospective case series.

The utility of the ankle SPECT/CT scan to predict functional and clinical outcomes in supramalleolar osteotomy patients.

Combined single-photon emission computed tomography and conventional computed tomography (SPECT/CT) is a hybrid imaging modality that shows a combination of metabolic and structural information about the ankle, including arthritis. We hypothesize that uptake in specific locations within the ankle joint can be associated with both clinical outcomes and may help predict which patients will have a successful SMO. Eighty-five pre-operative SMO patients with varus (37), valgus (41), or neutral (7) alignment of the hindfoot were assessed using SPECT/CT. The level of activation on SPECT/CT scans was measured. Pre and Post-operative functional scores were recorded. Patients with medial gutter activation had significantly worse (p < 0.05) AOFAS alignment (AOFAS-A) scores pre-operatively. Patients with varus or valgus alignment did not have any difference in VAS pain scores, but those in valgus did have worse AOFAS-P (pain) scores. Those with cystic lesions had a worse FAOS score pre-operatively. Ten patients (12.5%) had a treatment failure. Pre or post-operative alignment did not correlate to a treatment failure. The only statistically significant (p = 0.036) poor prognostic indicator was a bipolar lesion. Pre-operative SPECT/CT evaluation of an ankle before a SMO can be used to clinically correlate patient-specific factors such as pain and function in the pre and post-operative period. We caution against performing a SMO in patients with bipolar activation on a pre-operative SPECT-CT scan. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2015-2021, 2018.

The Use of Supramalleolar Osteotomies in Posttraumatic Deformity and Arthritis of the Ankle.

Osteoarthritis of the ankle is a debilitating musculoskeletal disease that affects approximately 1% of adults worldwide. The most common etiology of ankle osteoarthritis is trauma. In general, patients with ankle osteoarthritis are 12 to 15 years younger than patients with hip or knee osteoarthritis. More than 50% of all patients with ankle osteoarthritis exhibit a substantial concomitant hindfoot deformity on the supramalleolar and/or inframalleolar level. Different treatment options for ankle osteoarthritis, including joint-preserving and non-joint-preserving surgical procedures, have been described in the current literature. Supramalleolar osteotomy is a joint-preserving option that can be considered in patients who have asymmetric ankle osteoarthritis, a partially preserved ankle joint, and a concomitant supramalleolar deformity. The primary goal of the supramalleolar osteotomy is to realign the hindfoot and, specifically, the spatial relationship between the talus and the tibia in order to restore normal ankle biomechanics and normalize load distribution within the ankle joint. Different surgical techniques of supramalleolar osteotomy that are based on the underlying deformity, e.g., varus versus valgus, are described. The major steps of the procedure, which are demonstrated in this video article, include (1) exposure of the distal end of the tibia, (2) determination of the osteotomy site, (3) performance of the supramalleolar osteotomy, (4) mobilization of the osteotomized distal end of the tibia, (5) internal fixation of the osteotomy site, (6) additional balancing, and (7) step-by-step wound closure. In some instances, additional procedures are required to balance the ankle joint, e.g., inframalleolar osteotomies, arthrodeses, ligament reconstructions, and tendon transfers. The postoperative rehabilitation requires non-weight-bearing activity for 6 to 8 weeks postoperatively. Intraoperative, perioperative, and postoperative complications can occur and are discussed in this article.

B-cell multicentric lymphoma as a probable cause of abortion in a Quarter horse broodmare.

A 5-year-old Quarter horse broodmare was evaluated for inappetence, depression, and diarrhea 13 days after aborting a 9-month gestation fetus. Clinical and laboratory examination ruled out uterine rupture and peritonitis. Ultrasonography of the uterus combined with cytological analysis of peritoneal fluid suggested the existence of diffuse lymphoma. A multicentric B-cell lymphoma involving the uterus and ovary was confirmed at necropsy and histopathological examination.

Lymhome multicentrique à cellules B comme cause possible d'avortement chez une jument poulinière Quarter Horse. Une jument Quarter horse de 5 ans a été présentée pour anorexie, baisse d'état général et diarrhée, trente jours après un avortement à 9 mois de gestation. Lors de l'examen clinique initial, rupture utérine et péritonite ont pu être éliminées. L'analyse cytologique des liquides péritonéaux et pleuraux aspirés suggéra un lymphome diffus confirmé en nécropsie lors de l'examen histopathologique.(Traduit par les auteurs).

Preovulatory progestagen treatment in mares fails to delay ovulation.

The major objective of this study was to determine whether short-term preovulatory progestagen treatment of mares could effectively delay ovulation. Secondary objectives were to determine the effect such supplementation had on signs of estrus, follicular growth, postovulatory luteal function and pregnancy rate. Thirteen cyclic mares of different breeds were used in this study during the natural breeding season. Once mares were confirmed in estrus with a follicle of 35 mm in diameter, they were assigned in random order to receive no treatment (control), placement of a progesterone-impregnated controlled intravaginal drug releasing device (CIDR) for 2 days, or oral altrenogest treatment (0.044 mg/kg/d) for 2 days. Transrectal ultrasonography and teasing with a vigorous stallion were performed daily. Mares were inseminated every 48 h after the end of experimental treatment (progestagen groups) or beginning when the follicular diameter was 35 mm (control group) with fresh extended semen of a single fertile stallion. Each mare was followed for 3-5 cycles, allowing each treatment to be applied one or two times. Neither CIDR nor altrenogest treatment delayed ovulation. Treatment had no effect on follicular growth rate or the size of the ovulatory follicle immediately preceding ovulation. Both forms of progestagen treatment effectively abolished estrous behavior within 24h. Estrous response to the stallion returned to the control level after cessation of treatment. Similarly, a reduction in endometrial edema was detected during progestagen treatment, which returned to normal after cessation of treatment. Altrenogest treatment tended to reduce the chance of pregnancy (P=0.09) compared to the control group. The use of progestagens to delay ovulation in mares lacks efficacy and may threaten successful establishment of pregnancy.