Outcomes of Total Ankle Replacement with Preoperative Varus Deformity.

Historically, coronal plane deformities of greater than 10° to 15° have been deemed contraindications for total ankle replacement (TAR). However, recent studies show satisfactory results in TAR with severe preoperative varus deformity. When correctly applying ancillary procedures, preoperative varus deformity can be structurally corrected, resulting in similar clinical scores to those obtained with "regular TAR." However, complications and revisions appear to increase with increasing deformity. Unfortunately, results of TAR in varus ankles consist of heterogeneous data (eg, with regards to prosthetic brands, bearing-types, duration of follow-up, and ancillary procedures) precluding strict conclusions. This could be solved by an international consensus group.

Sacral chordoma: a clinical review of 101 cases with 30-year experience in a single institution.

BACKGROUND: Local recurrence rates are high in sacral chordoma patients. Adjuvant radiotherapy may play a role in increasing local control. Patients with locally recurrent tumors continue to comprise a significant proportion of the sacral chordoma population and appear to have worse prognosis than those with primary tumors. High-quality studies comparing presentation and treatments for primary and first local recurrent sacral chordoma tumors are sparse. PURPOSE: To determine: whether there is a difference in how primary and tumors at first recurrence present; the overall survival, local relapse-free survival, and distant relapse-free survival rates and prognostic factors for patients presenting with a primary tumor; overall survival, local relapse-free survival, and distant relapse-free survival rates and prognostic factors for patients presenting with a first local relapse; if there any differences in overall survival, local relapse-free survival, and distant relapse-free survival rates between patients presenting with a primary tumor and those with a first local relapse. STUDY DESIGN: Retrospective case series. PATIENT SAMPLE: One hundred one sacral chordoma cases. OUTCOME MEASURE: Overall survival, local relapse-free survival, and distant relapse-free survival rates. METHODS: Between 1978 and 2013, 131 patients with sacral chordoma were seen. Of them, 17 patients (13%) presented with a history of more than one local recurrence. One patient (1%) presented with multiple distant metastases. Ten patients (8%) had less than 36 months of follow-up and had no event (eg, death, local recurrence, or distant metastasis). A total of 102 patients met our inclusion criteria: patients with primary or first recurrent tumors, without metastatic disease, who underwent surgery and with at least 36 months of follow-up. One patient (1%) died intraoperatively; therefore, 101 patients were included in the present analysis. Cox proportional hazards regression analysis was performed for primary and local recurrent tumor separately and to compare primary and local recurrent tumors. RESULTS: We analyzed 73 primary and 28 first time recurrent sacral chordomas. Tumor size at presentation was different for primary and recurrent tumors (primary median size: 158 cm3, interquartile range [IQR]: 46-634; recurrent median size: 39 cm3, IQR: 14-175; p=.001). Overall survival at 5 and 10years for the primary tumors was 79% and 59%, respectively. Local relapse-free survival at 5years was 86%. For primary tumors, not receiving radiation was an independent predictor for worse local relapse-free survival (hazard ratio [HR]: 0.20; 95% confidence interval [CI]: 0.0043-0.90; p=.004) and increased tumor size was an independent predictor for both worse overall survival (HR: 1.68; 95% CI: 1.38-2.42; p=.004) and worse distant relapse-free survival (HR: 2.25; 95% CI: 1.47-3.44; p<.001). For recurrent tumors, the 5- and 10-year overall survival was 65% and 40%, respectively. Local relapse-free survival at 5years was 79% for recurrent tumors. On bivariate analysis, increased tumor size was a significant predictor for worse survival (LR median: 338 mL; IQR: 218-503 mL; no LR median: 26 mL; IQR: 9-71 mL). A trend was seen toward better distant relapse survival for tumors presenting as a primary tumor (HR: 0.51; 95% CI: 0.25-1.06; p=.072). CONCLUSION: Using a combination of surgical resection and adjuvant radiotherapy allowed us to obtain a good overall survival, local relapse-free survival, and distant relapse-free survival in patients presenting with either a primary tumor or with a first time local recurrent tumor.

Evidence-based indications for hindfoot endoscopy.

PURPOSE: The 2-portal hindfoot endoscopic technique with the patient in prone position, first introduced by van Dijk et al. (Arthroscopy 16:871-876, 2000), is currently the most used by foot and ankle surgeons to address endoscopically pathologies located in the hindfoot. This article aims to review the literature to provide a comprehensive description of the level of evidence available to support the use of the 2-portal hindfoot endoscopy technique for the current generally accepted indications. METHODS: A comprehensive review was performed by use of the PubMed database to isolate literature that described therapeutic studies investigating the results of different hindfoot endoscopy treatment techniques. All articles were reviewed and assigned a classification (I-V) of level of evidence. An analysis of the literature reviewed was used to assign a grade of recommendation for each current generally accepted indication for hindfoot endoscopy. A subscale was used to further describe the evidence base for indications receiving a grade of recommendation indicating poor-quality evidence. RESULTS: On the basis on the available evidence, posterior ankle impingement syndrome, subtalar arthritis and retrocalcaneal bursitis have the strongest recommendation in favour of treatment (grade Cf). CONCLUSION: Although a low level of evidence of the included studies, the review showed that adequate literature to support the use of the 2-portal endoscopic techniques for most currently accepted indications exists. Future "higher quality" evidence could strengthen current recommendations and further help surgeons in evidence-based practice. LEVEL OF EVIDENCE: Level V, Review of Level III, IV and V studies.

Histological characteristics of ligament healing after bio-enhanced repair of the transected goat ACL.

BACKGROUND: Recently, healing of a ruptured anterior cruciate ligament (ACL) is reconsidered. In a previous study, we have shown that the transected ACL can heal after treatment with the triple X locking suture alone or combined with small intestine submucosa (SIS). The first research question of this study was whether the healing ACLs in both groups show histological characteristics that are typical for ligament healing. Secondly, did the combined treatment with SIS lead to improved histological healing, in terms of the morphology of the fibrous synovial layer, the extracellular matrix (ECM), collagen fiber orientation, cellularity, ratio of myofibroblasts, and collagen type 3 staining. The hypothesis was that SIS enhances the healing by the scaffolding effect, endogenous growth factors, and chemoattractants. METHODS: In the Suture group, the left ACL was transected and sutured with the triple X locking suture repair technique. In the Suture-SIS group, the left ACL underwent the same procedure with the addition of SIS. The right ACL served as internal control. Standard histology and immunostaining of α-smooth muscle actin (SMA) and collagen type 3 were used. RESULTS: Microscopy showed that the fibrous synovial layer around the ACL was reestablished in both groups. The collagen fibers in the Suture-SIS group stained denser, were more compactly arranged, and the ECM contained fewer voids and fat vacuoles. Neovasculature running between the collagen fibers was observed in both experimental groups. Collagen type 3 stained less in the Suture-SIS group. The cellularity in the Suture group, Suture-SIS group and Control was 1265 ± 1034 per mm(2), 954 ± 378 per mm(2), 254 ± 92, respectively; 49%, 26% and 20% of the cells stain positive for α-SMA, respectively. CONCLUSION: The healing ACL in both treated groups showed histological characteristics which are comparable to the spontaneously healing medial collateral ligament and showed that the ACL has a similar intrinsic healing response. Though, no definitive conclusions on the beneficial effects of the SIS scaffold on the healing process can be made.

The ANKLE TRIAL (ankle treatment after injuries of the ankle ligaments): what is the benefit of external support devices in the functional treatment of acute ankle sprain? A randomised controlled trial.

BACKGROUND: Acute lateral ankle ligament injuries are very common problems in present health care. Still there is no hard evidence about which treatment strategy is superior. Current evidence supports the view that a functional treatment strategy is preferable, but insufficient data are present to prove the benefit of external support devices in these types of treatment. The hypothesis of our study is that external ankle support devices will not result in better outcome in the treatment of acute ankle sprains, compared to a purely functional treatment strategy. Overall objective is to compare the results of three different strategies of functional treatment for acute ankle sprain, especially to determine the advantages of external support devices in addition to functional treatment strategy, based on balance and coordination exercises. METHODS/DESIGN: This study is designed as a randomised controlled multi-centre trial with one-year follow-up. Adult and healthy patients (N = 180) with acute, single sided and first inversion trauma of the lateral ankle ligaments will be included. They will all follow the same schedule of balancing exercises and will be divided into 3 treatment groups, 1. pressure bandage and tape, 2. pressure bandage and brace and 3. no external support. Primary outcome measure is the Karlsson scoring scale; secondary outcomes are FAOS (subscales), number of recurrent ankle injuries, Visual Analogue Scales of pain and satisfaction and adverse events. They will be measured after one week, 6 weeks, 6 months and 1 year. DISCUSSION: The ANKLE TRIAL is a randomized controlled trial in which a purely functional treated control group, without any external support is investigated. Results of this study could lead to other opinions about usefulness of external support devices in the treatment of acute ankle sprain. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR2151.

Incidence and risk factors for the development of radiographic arthrosis after traumatic elbow injuries.

PURPOSE: Radiographic arthrosis is a common sequela of elbow trauma. Few studies have addressed risk factors for radiographic arthrosis after elbow injury, especially in the long term. Data from multiple long-term follow-up studies of patients with surgically treated elbow fractures provided us with an opportunity to assess risk factors for long-term radiographic arthrosis after elbow injury. METHODS: During a 5-year period, we obtained radiographs during a research-specific evaluation of 139 patients (81 men and 58 women) 10 or more years (median, 19.5 y; range, 10-34 y) after surgical treatment of an elbow fracture as part of multiple retrospective studies. Radiographic arthrosis was graded according to the system of Broberg and Morrey. Bivariate and multivariable analyses evaluated risk factors for radiographic arthrosis. RESULTS: Of 139 patients, 75 had radiographic evidence of arthrosis at final evaluation and 32 had moderate or severe radiographic arthrosis. Mechanism of injury, age, gender, follow-up time, occupation, and limb dominance were not associated with radiographic arthrosis. Multiple logistic regression analysis identified the type of injury as the only independent predictor of moderate to severe radiographic arthrosis. Patients with a bicolumnar fracture of the distal humerus, a capitellum/trochlear fracture, or an elbow fracture-dislocation were 8.0, 7.3, and 5.2 times more likely (odds ratio), respectively, to develop radiographic evidence of moderate or severe radiographic arthrosis than the average patient in this cohort. CONCLUSIONS: Distal humerus fractures (both columnar and capitellum/trochlea) and elbow fracture-dislocations are more likely than fractures of the olecranon and radial head to develop moderate or severe radiographic arthrosis in the long term. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Isolated diaphyseal fractures of the radius in skeletally immature patients.

Diaphyseal radius fractures without associated ulna fracture or radioulnar dislocation (isolated fracture of the radius) are recognized in adults but are rarely described in skeletally immature patients. A search of our database (1974-2002) identified 17 pediatric patients that had an isolated fracture of the radius. Among the 13 patients with at least 1 year follow-up, ten were treated with manipulative reduction and immobilization in an above elbow cast and three had initial operative treatment with plate and screw fixation. These 13 patients were evaluated for an average of 18 months (range, 12 to 45 months) after injury using the system of Price and colleagues. The incidence of isolated diaphyseal radius fractures in skeletally immature patients was 0.56 per year in our database and represented 27% of the 63 patients with a diaphyseal forearm fracture. All 13 patients, with at least 1 year follow-up, regained full elbow flexion and extension and full forearm rotation. According to the classification system of Price, all 13 patients (100%) had an excellent result. As in adults, isolated radius fractures seem to occur in children more frequently than previously appreciated. Treatment of isolated radius fractures in skeletally immature patients has a low complication rate, and excellent functional outcomes are the rule.