Orthopaedic colleagues who live and practice in low-resource areas around the world have clearly voiced that they want support from better-resourced partners. But such efforts must be sustainable, a key point emphasized by Woolley et al. in their thought-provoking 2019 JBJS “What’s Important” essay regarding orthopaedic care in Haiti. In contrast to “medical missions” offering short-term assistance for a small number of patients, longer-term systemwide gains come from partnerships focused on education and training that acknowledge the central role of local orthopaedic practitioners in addressing the ongoing needs of their patients.
Along those lines, Agarwal-Harding et al. describe a 3-phase pathway for improving ankle-fracture management in sub-Saharan Malawi in their recent JBJS report. In the first 2 phases, the local knowledge base and treatment strategies were assessed. (Greater than 90% of orthopaedic trauma care in the country is provided by nonphysician “clinical officers,” and most ankle-fracture management in Malawi is nonoperative because there is only about 1 orthopaedic surgeon per 1.9 million Malawians). A team of Malawian and US faculty then designed and implemented an education course that reviewed ankle anatomy, fracture classification, and evidence-based treatment guidelines. From that arose standardized protocols to improve fracture-care quality and safety in the face of limited resources.
While these protocols were unique to the Malawian context, I am convinced that similar interventions can be adapted for other low-resource environments—as long as local clinicians are part of the process. With such a flexible and sustainable program in place, efforts can then be directed toward the advancement of surgical skills and development of cost-effective supply chains. We should all support such efforts worldwide, recognizing that the burden of musculoskeletal trauma is a public health issue warranting collaborative solutions with lasting impact.
Marc Swiontkowski, MD
Click here for a related OrthoBuzz post about trauma care in Malawi.
Background: Two main treatments for end-stage ankle arthritis are ankle arthrodesis and total ankle arthroplasty (TAA). While both procedures can be performed either by a foot and ankle orthopaedic surgeon or a podiatrist (when within a particular state’s scope of practice), studies comparing the surgical outcomes of the 2 surgeon types are lacking. Therefore, in this study, we compared outcomes by surgeon type for TAA and for ankle arthrodesis.
To our knowledge, there are no reports of the Ponseti method initiated after walking age and with >10 years of follow-up. Our goal was to report the clinical findings and patient-reported outcomes for children with a previously untreated idiopathic clubfoot who were seen when they were between 1 and 5 years old, were treated with the Ponseti method, and had a minimum follow-up of 10 years.
Multisite Evaluation of a Custom Energy-Storing Carbon Fiber Orthosis for Patients with Residual Disability After Lower-Limb Trauma
Up to 40% of patients with idiopathic clubfoot who are treated with the Ponseti method experience recurrence of deformity. https://bit.ly/2IuVOm1
Concomitant Ankle Osteoarthritis Is Related to Increased Ankle Pain and a Worse Clinical Outcome Following Total Knee Arthroplasty
Occasionally, patients experience new or increased ankle pain following total knee arthroplasty (TKA). https://bit.ly/2IkLoGD #JBJS #JBJSVideoSummaries
Ankle sprain is a common musculoskeletal injury throughout the world, affecting tens of thousands of patients daily. What treatments for lateral inversion ankle injury are most effective? When is a wait-and-see approach more beneficial than a training program, and functional interventions more appropriate than surgical treatment? What surgical interventions yield better outcomes for function and instability compared with conservative treatment, particularly when the calcaneofibular ligament is disrupted, and does one postoperative regimen produce better results than another?
On Tuesday, September 19, 2017 at 5:00 PM EDT, these intriguing and clinically applicable questions will be addressed during a complimentary* LIVE webinar, hosted jointly by The Journal of Bone & Joint Surgery (JBJS) and the Journal of Orthopaedic & Sports Physical Therapy (JOSPT).
JBJS co-authors Mark E. Easley, MD, and Manuel J. Pellegrini, MD, will discuss findings from a systematic quantification of the stabilizing effects of subtalar joint soft-tissue constraints in a novel cadaveric model.
JOSPT co-author John M. van Ochten, MD, will share the results of a systematic review of randomized controlled and controlled clinical trials on the effectiveness of treatments for ankle sprains.
Moderated by Dr. Alexej Barg, a leading authority on the foot and ankle and traumatic injuries to the lower extremity, the webinar will include additional insights from expert commentators J. Chris Coetzee, MD, and Phillip A. Gribble, PhD, ATC, FNATA. The last 15 minutes will be devoted to a live Q&A session between the audience and panelists.
Seats are limited, so Register Now.
* This webinar is complimentary for those who attend the event live and will continue to be available at no charge for 24 hours following its conclusion.
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.
One of the most challenging diagnoses for general orthopedic surgeons as well as fracture specialists is a fracture of the talar neck. The infrequency of displaced talar fractures means that orthopaedic residents receive relatively little training in this area. A pivotal JBJS article in 1978 focused attention on these vexatious injuries. “Fractures of the Neck of the Talus” by Canale and Kelly provides clinically useful information and does two things that are very difficult to do today:
- Follows patients for a long time (an average of nearly 13 years)
- Obtains direct evidence of outcomes by physical exam, one-on-one measurement, and long-term imaging.
This remarkable duration of follow-up, so important in determining the impact of treatment in musculoskeletal injury, is very difficult today as a result of overly enthusiastic privacy protections and a costly regulatory infrastructure.
This classic JBJS article capitalizes on other classics, such as those by Blair (1943) on talar body salvage and studies by Halliburton (1958) and Mulfinger (1970) on the anatomy of talar blood supply. While Mulfinger showed the vascular supply of the talus,1 that study did not link that information to clinical care. The study by Canale and Kelly provides insight into how our care for patients with these uncommon fractures affects outcomes. In addition, the relatively primitive state of art at the time for the operative treatment of talar fractures led to fear of infection, and limited understanding of the basics of fracture healing and underdeveloped implants for fixation steered many surgeons away from rigid fixation in favor of closed reduction and cast immobilization.
The authors identified 107 fractures treated over a 33-year period; they examined and obtained radiographs on 71 of those fractures in 70 patients at an average follow-up of almost 13 years. (Fourteen of the patients were followed for more than 20 years, and 5 were followed for more than 30 years.) The preferred treatment protocol was closed reduction and casting. A reduction with less than 5 mm of displacement and 5° of misalignment was considered adequate. Open reduction with internal fixation was performed when these criteria were not met.
To assess outcomes, the authors directly measured ankle and subtalar motion, assessed whether a limp was present, and asked patients to rate their pain. Long before “patient-reported outcome measures” was a recognized term, these authors recorded them. Only 59% of patients in this series achieved good or excellent outcomes. The authors identified the high morbidity of these injuries, including avascular necrosis in more than half and 25 who needed later surgical intervention. The authors also recommended against talectomy as a salvage procedure.
While hampered by relatively low-resolution imaging and outcome measures that don’t meet current standards of reproducibility, Canale and Kelly provided a great deal of information that focused attention on the importance of quality of reduction. In addition, the paper created an enduring fracture classification that paralleled complication rates and potential outcomes.
Bruce Sangeorzan, MD
JBJS Deputy Editor
- Mulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg Br. 1970 Feb;52(1):160-7
We have entered an era where total ankle arthroplasty (TAA) is accepted as a rational approach for patients with degenerative arthritis of the ankle. TAA results have been shown to be an improvement over arthrodesis in some recent comparative trials.
That was not always the case, however. In the 1980s, the orthopaedic community attacked ankle joint replacement with gusto, and numerous prosthetic designs were introduced with great enthusiasm based on short-term cohort studies. Unfortunately, the concept of TAA was all but buried as disappointing longer-term results with those older prosthetic designs appeared in the scientific literature. It took a full decade for new designs to appear and be subjected to longer-term follow-up studies before surgeons could gain ready access to more reliable instrumentation and prostheses. The producers of these implants behaved responsibly in this regard, facilitated by an FDA approval process that had increased in rigor.
In the December 21, 2016 issue of The Journal, Hofmann et al. publish their medium-term results with one prosthetic design that was FDA-approved in 2006. Implant survival among 81 consecutive TAAs was 97.5% at a mean follow-up of 5.2 years. There were only 4 cases of aseptic loosening and no deep infections in the cohort. Total range of motion increased from 35.5° preoperatively to 39.9° postoperatively.
The fact that a high percentage (44%) of ankles underwent a concomitant procedure at the time of TAA attests to the need for careful preoperative planning for alignment of the ankle joint and the need for thorough assessment of the hindfoot. The fact that a substantial percentage (21%) of ankles underwent another procedure after the TAA attests to the need for thoughtful benefit-risk conversations with patients prior to TAA.
I think the TAA concept and procedure are here to stay, but we still have much work to do in fine-tuning prosthetic designs and instrumentation and enhancing surgeon education for more reliable outcomes.
Marc Swiontkowski, MD