What’s New in Orthopaedic Trauma 2021
Every month, JBJS publishes a review of the most pertinent and impactful studies reported in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.
This month, co-author Mai P. Nguyen, MD summarizes the 5 most compelling findings from the >30 studies highlighted in the recently published “What’s New in Orthopaedic Trauma.”
Proximal Humeral Fracture
–The DelPhi (Delta prosthesis-PHILOS plate) study, a multicenter, single-blinded, randomized controlled trial (RCT), evaluated the outcomes of reverse shoulder arthroplasty vs open reduction and internal fixation for displaced proximal humeral fractures in elderly patients. The results favored reverse shoulder arthroplasty (mean 2-year Constant-Murley score of 68.0 vs. 54.6 points for the 2 groups, respectively).
Hip Fracture
–An RCT comparing hemiarthroplasty with or without cement in elderly patients with a displaced intracapsular fracture of the hip found better results for cemented hemiarthroplasty1. There was a trend toward a higher mortality rate in the uncemented group, and although pain scores and reoperations were similar between the groups, better recovery of mobility was noted for the cemented group.
Proximal Femoral Fracture
–Another recent RCT investigated the efficacy of a preoperative fascia iliaca compartment block (FICB) for patients with proximal femoral fractures (neck, intertrochanteric, or subtrochanteric regions)2. Lower morphine consumption (0.4 vs 19.4 mg; p = 0.05) and greater patient-reported satisfaction (31%; p = 0.01) were noted for the FICB cohort.
Ankle Fracture
–Among patients treated for unstable, rotational-type ankle fractures, a prospective RCT compared weight-bearing at 2 vs 6 weeks postoperatively3. Early weight-bearing at 2 weeks was associated with higher EuroQol-5 Dimension (EQ-5D) visual analog scale (VAS) scores at the 6-week follow-up. No difference, however, was seen at later follow-up time points.
Recovery After Trauma
–The impact of trauma recovery services (TRS), which provide education and psychosocial support to patients with trauma and their families, was assessed in a recent study4. A total of 294 patients with operatively treated extremity fractures were prospectively surveyed. Injury, social, and demographic characteristics were studied for a possible association with patient-satisfaction scores. Use of TRS was the greatest predictor of better overall care ratings.
References
- Parker MJ, Cawley S. Cemented or uncemented hemiarthroplasty for displaced intracapsular fractures of the hip: a randomized trial of 400 patients. Bone Joint J. 2020 Jan;102-B(1):11-6.
- Thompson J, Long M, Rogers E, Pesso R, Galos D, Dengenis RC, Ruotolo C. Fascia iliaca block decreases hip fracture postoperative opioid consumption: a prospective randomized controlled trial. J Orthop Trauma. 2020 Jan;34(1):49-54.
- Schubert J, Lambers KTA, Kimber C, Denk K, Cho M, Doornberg JN, Jaarsma RL. Effect on overall health status with weightbearing at 2 weeks vs 6 weeks after open reduction and internal fixation of ankle fractures. Foot Ankle Int. 2020 Jun;41(6):658-65. Epub 2020 Mar 6.
- Simske NM, Benedick A, Rascoe AS, Hendrickson SB, Vallier HA. Patient satisfaction is improved with exposure to Trauma Recovery Services. J Am Acad Orthop Surg. 2020 Jul 15;28(14):597-605.
Minimally Invasive Hallux Valgus Correction: Promising Outcomes of Third-Generation Technique
The field of orthopaedics continually seeks to improve our ability to help patients return to optimal function as quickly and efficiently as possible. New surgical techniques aimed at better outcomes, faster recovery, and smaller (and hopefully less painful) scars are regularly being developed and evaluated. The concept of minimally invasive surgery (MIS) has been around for some time, with newer techniques being utilized in multiple subspecialties. Foot and ankle surgery is no exception, with procedures including MIS for hallux valgus deformity correction. While early generations of such procedures were fraught with complications, newer, third-generation MIS (involving screw fixation of a distal metatarsal osteotomy site) has shown promising early results, with a documented learning curve of 20 to 50 cases.
In the July 7, 2021 issue of JBJS, Lewis et al. present their results from a consecutive series of third-generation minimally invasive chevron and Akin osteotomies (MICA) in the treatment of hallux valgus. Patient-reported outcome measures (PROMs) collected preoperatively and at a minimum of 2 years postoperatively as well as radiographic outcomes and complications were evaluated.
From the initial series of 333 feet (230 patients), PROMs data were available for 292 feet, or 87.7% (200 patients). PROMs utilized included the Manchester-Oxford Foot Questionnaire (MOXFQ), a tool specifically validated for patients undergoing hallux valgus surgery; the EuroQol-5 Dimensions-5 Level (EQ-5D-5L) Index and EuroQoL visual analogue scale (EQ-VAS), validated quality-of-life measures; and a VAS for pain.
The authors found a significant improvement (greater than the minimal clinically important difference) in each domain of the MOXFQ. They also noted a significant improvement in the VAS-pain score and the EQ-5D-5L Index.
There was an overall 21.3% complication rate, with only 7.8% of the cases requiring a return to the operating room, most frequently for screw removal (6.3%). The operating surgeon was outside the reported learning curve, having previously performed approximately 100 MICA procedures, but there were still complications that can help guide the physician-patient discussion regarding the use of the MICA.
Although radiographic follow-up did not routinely go beyond 6 weeks, the authors found significant improvement in radiographic measures. With >25% of the preoperative deformities being classified as “severe,” the findings suggest the potential utility of the procedure for patients with a range of deformity severity.
This series—which the authors note is the largest of the third-generation MICA technique— opens the door for possible head-to-head comparison with traditional hallux valgus surgery via a randomized trial to further define the role of MICA in the treatment of patients with hallux valgus.
A Video Summary of this article can be found here.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
What’s New in Foot and Ankle Surgery 2021
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.
This month, co-author Timothy R. Daniels, MD, FRCSC summarizes the 5 most compelling findings from the >80 studies highlighted in the recently published “What’s New in Foot and Ankle Surgery.”
Telemedicine
–With virtual foot and ankle examinations become more widespread during the COVID-19 pandemic, a recent paper on telehealth consultations offers guidance on preparing patients for the appointment as well as examination instructions that can be read by clinicians to patients and a checklist for medical record documentation1.
Ankle Reconstruction
–Evaluating trends in foot and ankle surgery in Germany over the past decade, 1 study found that the volume of foot and ankle operations increased 39.5%, while the population increased 0.9%2. The volume of first metatarsophalangeal joint (MTPJ) arthrodesis and ankle arthrodesis rose 77% and 31%, respectively, whereas first MTPJ arthroplasty and total ankle replacement declined 48% and 39%.
Total Ankle Replacement
– In a prospective series of total ankle replacement procedures in which a standard anterior approach or an extensile anteromedial surgical approach was used in patients at higher risk for wound complications, 17 (2.6%) of 660 patients had major and 39 (5.9%) had minor wound-healing issues3. All major wound complications occurred in the anterior-approach group.
Morton Neuroma
–A recent study assessed the utility of preoperative imaging and intraoperative histopathology in Morton neuroma4. Among 313 suspected neuromas operatively resected during the 10-year study period, Morton neuroma was confirmed in 309 (98.7%) on histopathologic examination. The postoperative treatment course was not altered for any patient on the basis of the pathology report, challenging the cost and utility of histopathologic evaluation of resected neuromas.
Patient-Reported Outcomes
–Another recent study investigated the question of whether sociodemographic factors impact PROMIS scores meeting the Patient-Acceptable Symptom State (PASS) among foot and ankle patients. The authors found that patients ≥65 years of age accepted more functional limitation than younger patients, patients in the lowest income brackets reported more severe functional limitations as satisfactory compared with patients in the highest income brackets, and patients in the lowest income bracket sought surgical care later than those in the highest income bracket5.
References
- Eble SK, Hansen OB, Ellis SJ, Drakos MC. The virtual foot and ankle physical examination. Foot Ankle Int. 2020 Aug;41(8):1017-26. Epub 2020 Jul 8.
- Milstrey A, Domnick C, Garcia P, Raschke MJ, Evers J, Ochman S. Trends in arthrodeses and total joint replacements in foot and ankle surgery in Germany during the past decade-back to the fusion? Foot Ankle Surg. 2020 May 26 [Epub ahead of print].
- Halai MM, Pinsker E, Daniels TR. Effect of novel anteromedial approach on wound complications following ankle arthroplasty. Foot Ankle Int. 2020 Oct;41(10):1198-205. Epub 2020 Jul 18.
- Raouf T, Rogero R, McDonald E, Fuchs D, Shakked RJ, Winters BS, Daniel JN, Pedowitz DI, Raikin SM. Value of preoperative imaging and intraoperative histopathology in Morton’s neuroma. Foot Ankle Int. 2019 Sep;40(9):1032-6. Epub 2019 May 29.
- Bernstein DN, Mayo K, Baumhauer JF, Dasilva C, Fear K, Houck JR. Do patient sociodemographic factors impact the PROMIS scores meeting the patient-acceptable symptom state at the initial point of care in orthopaedic foot and ankle patients? Clin Orthop Relat Res. 2019 Nov;477(11):2555-65.
STAR Ankle Component Fracture: Awareness, Not Alarm
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent “safety communication” from the FDA, the following commentary comes from Ariel Palanca, MD; Adam Bitterman, DO: and Christopher Gross, MD.
During the past decade, total ankle replacement (TAR) has been challenging the gold standard of ankle fusion for treatment of end-stage ankle arthritis. Improvements in TAR component design and refined surgical techniques have led to more predictable and reproducible outcomes.
On March 15, 2021, however, the US Food and Drug Administration (FDA) released a Safety Communication about the Scandinavian Total Ankle Replacement (STAR Ankle), a product line that DJO Surgical acquired from Stryker in November 2020. The FDA’s statement cites a “higher than expected” rate of fracture of the device’s mobile-bearing polyethylene component. The communication goes on to suggest that patients younger than 55 years old and those with an active lifestyle may have a higher risk of component fracture than older, more sedentary patients.
The STAR Ankle received premarket approval from the FDA in 2009, and the FDA is compiling data from 2 post-approval trials of the device. In August 2019, Stryker issued a safety notification regarding the higher-than-expected fracture risk for STAR polyethylene implanted before August 2014. The recent FDA safety notification states there may also be a high risk of fracture for STAR polyethylene components implanted after August 2014, although the agency’s notification acknowledges that “the long-term fracture rate is not known in devices manufactured after the 2014 packaging change.”
The “packaging change” mentioned above refers to the August 2014 changeover when STAR polyethylene started to be packaged in a foil pouch, which virtually eliminates oxidation of the polyethylene and should therefore reduce fracture rates. Additionally, many peer-reviewed journal articles have reported lower STAR-component fracture rates than those found in the post-approval trials at equal or longer follow-ups.
It’s also important to note that the 8-year follow-up FDA study that revealed a 13.8% cumulative polyethylene-fracture rate only included 87 of the 606 STAR patients in the clinical trial. Patients with complications are often more likely to follow up than those with no complications, creating a potential negative bias.
Still, to err on the side of caution, the FDA suggests that surgeons who treat and follow patients with a STAR implant closely monitor them–especially younger, more active patients–for potential component fractures until more post-approval data is analyzed to further clarify any risk.
Ariel Palanca, MD is an orthopaedic foot and ankle surgeon at Arch Health Medical Group in Escondido, California. Adam Bitterman, DO (@DrAdamBitterman) is a foot and ankle specialist, an assistant professor of orthopaedic surgery at Zucker School of Medicine at Hofstra/Northwell, and a member of the JBJS Social Media Advisory Board. Christopher Gross, MD is an orthopaedic surgeon specializing in foot and ankle disorders at the Medical University of South Carolina in Charleston and a member of the JBJS Social Media Advisory Board.
Outcomes of Joint-Preserving Surgery in RA-Affected Feet
Dramatic improvements in medical treatment of rheumatoid arthritis (RA) have led to marked reductions in joint damage and deformities. Consequently, surgical methods for treating RA-related foot problems have gradually evolved from joint-sacrificing to joint-preserving procedures. In a recent issue of The Journal of Bone & Joint Surgery, Yano et al. reported on outcomes of 105 feet in RA patients treated with joint-preserving methods followed up for a mean of 6 years.
What the Researchers Did:
- Performed a proximal rotational closing-wedge osteotomy of the first metatarsal and modified shortening oblique osteotomies of the lesser metatarsals
- Recorded Self-Administered Foot Evaluation Questionnaire (SAFE-Q) scores preoperatively and at latest follow-up
- Measured hallux valgus angle (HVA), intermetatarsal angle (IMA), and medial sesamoid position before surgery, 3 months after surgery, and at the latest follow-up
- Tracked delayed wound healing, hallux valgus recurrence, nonunion, and reoperations
- Calculated Kaplan-Meier survivorship with reoperation as the endpoint
What the Researchers Found:
- Surgery was associated with significantly improved median SAFE-Q scores, relative to preoperative values.
- The average HVA, IMA, and grade of medial sesamoid positioning decreased significantly, compared with preoperative measurements.
- Kaplan-Meier survivorship at 7 years was 89.5%.
- Delayed wound healing was found in 20% of the feet (all wounds healed with nonoperative treatment), hallux valgus recurrence in 10.5% of the feet, and reoperation in 10.5% of the feet.
Yano et al. emphasize several advantages of joint-sparing over joint-sacrificing surgery: preserved range of motion, stability of the metatarsophalangeal joint, and improved plantar-pressure distribution. However, these advantages and the “satisfactory” long-term outcomes noted above come with substantial complications that foot-and-ankle surgeons will strive to address in the future.
Surgical Costs: Just the Half of It
Total-cost breakdown for ankle-fracture patients treated nonoperatively.
The Journal is receiving an increasing number of manuscripts related to value assessments and cost-effectiveness analyses of treatments for orthopaedic pathologies. This line of investigation is crucial to helping the larger healthcare system lower costs while improving patient outcomes. One aspect of determining the total cost of a musculoskeletal intervention is the impact of so-called indirect costs. Components of indirect costs include lost patient wages from not working, higher transportation costs, and extra dollars spent by the individual or family to manage household chores and self-care.
In the December 16, 2020 issue of The Journal, Noback et al. examine the total, direct, and indirect costs of care among 60 patients with a lateral malleolar fracture that was treated either nonsurgically or surgically. They found that in many cases, indirect costs exceeded the direct cost of delivering medical/surgical care. Not surprisingly, this was especially true in nonoperatively treated patients, where three-quarters of the total cost were indirect costs (see Figure).
I believe that our community needs to more widely appreciate and study the impact of patients’ lost wage-earning opportunities and out-of-pocket expenditures. Every treatment recommendation we make in clinical practice involves these financial implications for our patients. Noback et al. go so far as to claim that “any cost-effectiveness analysis… must assess indirect costs or it risks drastically mischaracterizing a treatment’s value.”
We therefore should continue pushing our treatment and rehabilitation strategies to more aggressively limit time lost to full weight-bearing or use of the upper limb. Also, orthopaedic research should be directed toward strategies that limit the impact of indirect costs and family burdens as we seek to continuously improve care for our patients.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
What Affects Symptoms in Kids with Flatfoot?
Pes planovalgus (flatfoot) is a common condition seen in the pediatric orthopaedic clinic. We who help manage this condition differentiate it from adult acquired flatfoot deformity, primarily in that most child and adolescent patients remain asymptomatic or minimally symptomatic and rarely require surgical intervention. However, it would be nice to have data to share with young patients and their parents regarding factors associated with flatfoot symptoms.
Min et al. provide some of that data in the September 2, 2020 issue of The Journal. The authors retrospectively evaluated factors affecting the symptoms of idiopathic pes planovalgus among 123 patients (mean age of 10.1 ± 3.2 years) using the 4-domain Oxford Ankle Foot Questionnaire (OxAFQ) administered to patients and their parents. They compared questionnaire scores to 3 radiographic measurements─anteroposterior (AP) talo-first metatarsal angle, lateral talo-first metatarsal angle, and hallux valgus angles. They also analyzed the scores in relation to patient age and sex.
Min et al. found that the physical domain score for the child-reported OxAFQ decreased by 0.74 with each 1° increase in the AP talo-first metatarsal angle. Because that angle is a surrogate for forefoot abduction, this finding portends worse patient-reported outcomes in kids with greater severity of that component of flatfoot. Female sex was also associated with lower physical domain scores, with the authors postulating that this might be attributable to culturally influenced sex differences.
In addition, age was a significant factor in 3 domains of the OxAFQ. Compared with scores from younger kids, children ≥10 years old and their parents reported statistically worse outcomes with regard to school/play, emotional well-being, and footwear. In other words, at or beyond the age of 10, flatfoot deformity seems to significantly affect the patient’s choice of footwear, interferes with the ability to participate in sports and play, and may cause personal distress, such as that which comes from being teased about foot appearance.
Orthopaedists can help manage most cases of pediatric flatfoot with sound footwear recommendations and reassurance. But it appears that in the setting of increased forefoot abduction, female sex, and symptoms that persist past the age of 10 years, further investigation may be warranted. Although this study has weaknesses, it shows that there may be detriments─both physical and emotional─associated with pes planovalgus in pediatric patients that should not be ignored.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
What’s New in Orthopaedic Trauma 2020
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, co-author Niloofar Dehghan, MD, selected the 5 most clinically compelling findings from the >20 studies summarized in the July 1, 2020 “What’s New in Orthopaedic Trauma.”
Hip Fracture
—An international randomized controlled trial (RCT) of hip fracture patients ≥45 years of age1 compared outcomes among 1,487 who underwent an “accelerated” surgical procedure (within 6 hours of diagnosis) and 1,483 who received “standard care” (surgery within 24 hours of diagnosis). Mortality and major complication percentages were similar in both groups, but it is important to note that even the standard-care group had a relatively rapid median time-to-surgery of 24 hours.
—An RCT of nearly 1,500 patients who were ≥50 years of age and followed for 2 years2 compared total hip arthroplasty (THA) with hemiarthroplasty for the treatment of displaced femoral neck fractures. There was no between-group difference in the need for secondary surgical procedures, but hip instability or dislocation occurred in 4.7% of the THA group versus 2.4% of the hemiarthroplasty group. Functional outcomes measured with the WOMAC index were slightly better (statistically, but not clinically) in the THA group. Serious adverse events were high in both groups (41.8% in the THA group and 36.7% in the hemiarthroplasty group). Although the authors conclude that the advantages of THA may not be as compelling as has been purported, THA’s benefits may become more pronounced with follow-up >2 years.
—A preplanned secondary analysis of data from the FAITH RCT examined the effect of posterior tilt on the need for subsequent arthroplasty among older patients with a Garden I or II femoral neck fracture who were treated with either a sliding hip screw or cannulated screws. Patients with a posterior tilt of ≥20° had a significantly higher risk of subsequent arthroplasty (22.4%) compared with those with a posterior tilt of <20° (11.9%). In light of these findings, instead of internal fixation, primary arthroplasty may be an appropriate treatment for older patients who have Garden I and II femoral neck fractures with posterior tilt of >20°.
Ankle Syndesmotic Injury
—An RCT that compared ankle syndesmosis fixation using a suture button with fixation using two 3.5-mm screws3 found a higher rate of malreduction at 3 months postoperatively with screw fixation (39%) than with suture button repair (15%). With the rate of reoperation also higher in the screw group due to implant removal, these findings add to the preponderance of recent evidence that the suture button technique is preferred.
Wound Management
—A 460-patient RCT examining the cost-effectiveness of negative-pressure wound therapy4 for initial wound management in severe open fractures of the lower extremity found the technique to be associated with higher costs and only marginal improvement in quality-adjusted life-years for patients.
References
- HIP ATTACK Investigators. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet.2020 Feb 29;395(10225):698-708. Epub 2020 Feb 9.
- Bhandari M, Einhorn TA, Guyatt G, Schemitsch EH, Zura RD, Sprague S, Frihagen F, Guerra-Farfán E, Kleinlugtenbelt YV, Poolman RW, Rangan A, Bzovsky S, Heels-Ansdell D, Thabane L, Walter SD, Devereaux PJ; HEALTH Investigators. Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med.2019 Dec 5;381(23):2199-208. Epub 2019 Sep 26.
- Sanders D, Schneider P, Taylor M, Tieszer C, Lawendy AR; Canadian Orthopaedic Trauma Society. Improved reduction of the tibiofibular syndesmosis with TightRope compared with screw fixation: results of a randomized controlled study. J Orthop Trauma.2019 Nov;33(11):531-7.
- Petrou S, Parker B, Masters J, Achten J, Bruce J, Lamb SE, Parsons N, Costa ML; WOLLF Trial Collaborators. Cost-effectiveness of negative-pressure wound therapy in adults with severe open fractures of the lower limb: evidence from the WOLLF randomized controlled trial. Bone Joint J.2019 Nov;101-B(11):1392-401.
What’s New in Foot and Ankle Surgery 2020
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the 5 most clinically compelling findings from the >60 studies summarized in the May 20, 2020 “What’s New in Foot and Ankle Surgery.”
Total Ankle Replacement
—An analysis of a consecutive series of 278 total ankle replacemments1 found that the overall incidence of postoperative complications was 41.7%. However, the clinical outcome was affected in only 7.6% of these cases, as most complications were minor.
Syndesmotic Injuries
—A meta-analysis (total n = 397) found that functional outcomes and complications were similar after suture-button fixation and screw fixation for syndesmotic injuries.2 Time to full weight-bearing, however, was faster among patients receiving suture-button fixation.
Osteochondral Lesions of the Talus
—A prospective cohort study3 examined 101 patients with osteochondral talar lesions of <1.5 cm2. After a minimum follow-up of 36 months, patients treated with microfracture alone (n = 52) and patients treated with microfracture + autologous iliac crest bone marrow aspirate concentrate (BMAC) (n = 49) both reported significant improvement in pain, sport, and activities of daily living. The revision rate was significantly lower in the microfracture + BMAC cohort.
Plantar Fasciitis
—A randomized controlled trial4 compared stretching alone (n = 20) with stretching + proximal medial gastrocnemius recession (n = 20) in patients with >12 months of plantar heel pain. The operative group had significantly greater improvements in functional and pain scores and in forefoot plantar pressure at 12 months of follow-up. Achilles function and calf weakness were similar in both groups.
Clubfoot
—A retrospective case series reviewed 220 feet among 145 Nepalese children who had been treated for idiopathic clubfoot with the Ponseti method. At a minimum of 10 years of follow-up, 95% of the 220 feet achieved a plantigrade foot. Surgical treatment, typically a percutaneous Achilles tendon release, was required in 96% of the feet.
References
- Clough TM, Alvi F, Majeed H. Total ankle arthroplasty: what are the risks?: a guide to surgical consent and a review of the literature. Bone Joint J.2018 Oct;100-B(10):1352-8.
- Chen B, Chen C, Yang Z, Huang P, Dong H, Zeng Z. To compare the efficacy between fixation with tightrope and screw in the treatment of syndesmotic injuries: a meta-analysis. Foot Ankle Surg.2019 Feb;25(1):63-70. Epub 2017 Aug 18.
- Murphy EP, McGoldrick NP, Curtin M, Kearns SR. A prospective evaluation of bone marrow aspirate concentrate and microfracture in the treatment of osteochondral lesions of the talus. Foot Ankle Surg.2019 Aug;25(4):441-8. Epub 2018 Feb 22.
- Molund M, Husebye EE, Hellesnes J, Nilsen F, Hvaal K. Proximal medial gastrocnemius recession and stretching versus stretching as treatment of chronic plantar heel pain. Foot Ankle Int.2018 Dec;39(12):1423-31. Epub 2018 Aug 22.
Weight-Bearing CT: An Incremental Step in Addressing Posttraumatic Ankle Arthritis
Orthopaedic surgeons recognize that an intra-articular fracture of the distal tibia (pilon fracture) is the worst actor when it comes to the sequela of posttraumatic ankle osteoarthritis. Despite decades of focusing on surgical techniques that yield the best-looking postoperative radiographs, we have come to realize that, to reduce the risk of subsequent arthritis, limiting the extent of the surgical approach may be as important as achieving the “perfect” articular reduction. Slowly we have come to understand that articular cartilage damage from the injury (and in some instances exacerbated by overaggressive surgical dissection) is as big a factor as the bone injury in terms of postoperative joint-space narrowing and its associated ankle stiffness and pain.
Thankfully, the orthopaedic trauma community is making strides toward new biologic, mechanical, and rehabilitative interventions that have the potential to limit this articular narrowing. But to meaningfully evaluate the effectiveness of these strategies, we need not only validated patient-oriented functional outcome measures, but also more reliable and reproducible ways to assess the joint-space narrowing.
In the May 6, 2020 issue of The Journal, Willey et al. report on a standardized technique using weight-bearing computed tomography (WBCT), which yields a 3D assessment of the postoperative joint space with the ankle in a loaded, functional position (see Figure above). When this technique was applied to 20 patients (mean age of 44 years) with a partial or complete articular pilon fracture 6 months after surgical treatment, the authors found significantly less tibiotalar joint space in the injured ankle compared with the uninjured ankle. Interrater correlation and test-retest data indicated that this method has good measurement reliability and reproducibility.
Any safe, reliable, and reproducible measure of early joint-space narrowing after pilon fracture surgery is an important incremental step in designing clinical trials that will assess new interventions designed to preserve postoperative joint space—and hopefully reduce the incidence of posttraumatic ankle arthritis. Willey et al. have demonstrated the usefulness of WBCT as such a modality.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
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