The purpose of this study was to evaluate non-contrast magnetic resonance imaging (MRI) findings of adhesive capsulitis and correlate them with clinical stages of adhesive capsulitis. This will hopefully define a role for shoulder MR imaging in the diagnosis of adhesive capsulitis as well as in potentially directing appropriate treatment. Forty-seven consecutive non-contrast magnetic resonance imaging examinations of 46 patients with a clinical diagnosis of adhesive capsulitis were retrospectively reviewed and correlated with clinical staging. Specific MRI criteria correlated with the clinical stage of adhesive capsulitis, including the thickness and signal intensity of the joint capsule and synovium as well as the presence and severity of scarring in the rotator interval. Routine MRI of the shoulder without intraarticular administration of gadolinium can be used to diagnose all stages of adhesive capsulitis, including stage 1, where findings may be subtle on clinical examination. We believe that future studies assessing the role of MRI in guiding the initiation of appropriate treatment should be undertaken.
While metatarsus primus elevatus (MPE) has been implicated in the development of hallux rigidus, previous studies have presented conflicting findings regarding the relationship between MPE and arthritis. This may be due to the variety of definitions for MPE and the radiographic measurement techniques that are used to assess it. Additionally, previous studies have only assessed elevation of the first metatarsal with respect to the floor or the second metatarsal, and not with respect to the proximal phalanx. The aim of this study was to examine the reliability of new radiographic measurements that consider the elevation of the first metatarsal in relation to the proximal phalanx, rather than in relation to the second metatarsal as previously described, to assess for MPE. In addition, we aimed to determine whether the elevation of the first metatarsal was significantly different in patients with hallux rigidus than in a control population.A retrospective chart review was conducted from prospectively collected registry data at the investigators' institution to identify patients with hallux rigidus (n = 65). A size-matched control cohort of patients without evidence for first metatarsophalangeal (MTP) joint arthritis was identified (n = 65). Patients with a previous history of foot surgery, rheumatoid arthritis, or hallux valgus were excluded. Five blinded raters of varying levels of training, including 2 research assistants, 1 senior orthopedic resident, 1 foot and ankle fellowship-trained orthopedic surgeon, and 1 attending musculoskeletal fellowship-trained radiologist, evaluated 7 radiographic measurements for their reliability in assessing for MPE in hallux rigidus and control groups. Four of the 7 were newly designed measurements that include the relationship of the first MTP joint. Inter- and intrarater reliability were calculated using intraclass correlation coefficients (ICCs) and categorized by Landis and Koch reliability thresholds. The measurements between the hallux rigidus and control populations were compared using an independent t test.Six of the 7 radiographic measurements were found to have substantial to almost perfect interrater reliability (ICC, 0.800-0.953) between all levels of training, except for the proximal phalanx-first metatarsal angle, which showed moderate reliability (ICC, 0.527). Substantial to almost perfect intrarater reliability (ICC, 0.710-0.982) was demonstrated by the measurements performed by research assistants. All 7 of the measurements taken by the musculoskeletal fellowship-trained radiologist demonstrated significant differences in first metatarsal elevation between the hallux rigidus and control populations, with the hallux rigidus group showing increased elevation (P < .001-.019).This study confirmed the reliability of 7 radiographic measurements used to assess for MPE, including 3 previously established and 4 newly described measurements. Observers across all levels of training were able to demonstrate reliable measurements. In addition, the measurements were used to show that patients with hallux rigidus were more likely to have MPE compared with patients without radiographic evidence for first MTP arthritis. These measurements could be used in future work to examine how the presence of MPE relates to the etiology and progression of hallux rigidus, and how it affects the results of operative treatment.Level III, retrospective comparative study.
Category: Ankle, Arthroscopy, Sports Introduction/Purpose: Historically, microfracture has been the standard surgical treatment for talar osteochondral lesions (OLTs); however, it is associated with unsatisfactory long-term results due to the formation of biomechanically inferior reparative fibrocartilage as opposed to normal hyaline-like cartilage. Thus, the optimal treatment for OLTs remains contested. Application of micronized allogenic cartilage extracellular matrix (ECM) as an adjuvant therapy during the treatment of OLTs offers a promising option that could be administered arthroscopically to improve the quality of reparative tissue. The purpose of this study is to provide a case-control series comparing radiographic and functional outcomes following treatment of OLTs with an adjuvant mixture of micronized allogenic cartilage ECM and bone marrow aspirate concentrate (BMAC) to those achieved following standard microfracture with or without BMAC. Methods: 194 patients (average age 37) with a minimum 1-year follow-up who were treated for an OLT by a fellowship-trained foot and ankle surgeon were screened for inclusion. 107 patients who received mixed micronized cartilage ECM and BMAC (Group I), 40 who were treated by microfracture augmented with BMAC (Group II), and 47 patients who were treated with traditional microfracture alone (Group III) were identified. Preoperative lesion size, lesion location, and concurrent injuries were recorded retrospectively. Foot and Ankle Outcome Scores (FAOS) were completed preoperatively and postoperatively through the prospective Registry database at the authors’ institution. Outcomes were assessed radiographically at a minimum of 6 months postoperatively by a trained radiologist using the MOCART scoring system. Linear regression modeling was used to assess differences in MOCART scores, post-operative FAOS scores, pre-to-postoperative change in FAOS, and the rate of revision surgery between groups I, II, and III. Results: The average MOCART score for Group I was 62.39, (average follow-up 16.13 months; n = 46), 58.8 (26.82 months; n =25) for Group II and, 55.36 (43.12 months; n=14) for Group III patients (p=0.57). The rate of revision surgery for OLTs treated using adjuvant micronized cartilage ECM was 5% and was significantly lower when compared to a 22.7% rate of revision surgery following microfracture with or without BMAC (p<0.001). Finally, when controlling for lesion size, changes in pre-to-postoperative FAOS Pain and Sports Activities were significantly different amongst the 3 treatment groups (p=0.05). Group I had the greatest improvement in Pain. Conclusion: Micronized allogenic cartilage extracellular matrix serves as an adjunctive therapy that may help improve patients’ radiographic and functional outcomes following treatment of OLTs when compared to outcomes following traditional microfracture. Specifically, use of adjunctive ECM appears to have better postop FAOS Pain scores when controlled for lesion size when compared to microfracture. There is a lower rate of revision surgery with the use of allogenic cartilage ECM in the short to intermediate term when compared with microfracture.
Category: Ankle Arthritis Introduction/Purpose: n important principle of joint replacement is to restore the joint line to its native level. Previous studies have demonstrated a correlation between clinical outcomes and our ability to restore the joint in total knee arthroplasty. To date, there has been no study to assess restoration of joint height in total ankle replacement (TAR). In addition, there is no accepted method for assess joint line height in patients who undergo TAR. The objective of this study is to develop a reliable radiographic ankle joint line level measurement. Additionally, the measure will be used to evaluate and compare ankle joint line levels seen on pre-TAR, post-TAR, and non-arthritic contralateral ankle radiographs. Methods: One hundred and twelve primary TAR patients with weightbearing preoperative (pre-TAR) and 1-year postoperative (post-TAR) anteroposterior (AP) ankle radiographs were retrospectively reviewed. Patients with bilateral disease, concomitant malleolar osteotomy, and component subsidence were excluded. Two raters measured the vertical intermalleolar distance (VIMD, Figure 1) and the vertical joint line distance (VJLD, Figure 1) for all radiographs (pre-TAR, post-TAR, and contralateral normal ankle) on two separate occasions. The measurement ”joint line height ratio” was calculated as the ratio of the VJLD to the VIMD (Figure 1). Reliability was assessed using intraclass correlation coefficients (ICCs). Pearson correlation test was used to assess the level of correlation between the VJLD and the VIMD. The comparisons of pre-TAR, non-arthritic contralateral ankle, and post- TAR “joint line height ratio” were performed using paired t-tests and considered significantly different if p < 0.05. Results: Inter/intra-rater reliabilities of all measurements were excellent (r>0.9). Pearson correlation test demonstrated strong positive correlations of VIMD and VJLD with r 0.809 for pre-TAR and r 0.756 for post-TAR, p<0.001. Mean(SD) VIMDs for pre- TAR, non-arthritis contralateral ankle, and post-TAR were 17.91(4.79), 18.96(4.67) and 17.37(4.76) mm. Mean(SD) VJLDs for pre- TAR, non-arthritis contralateral ankle, and post-TAR were 26.49(4.64), 25.47(4.12) and 26.70(5.31) mm. Additionally, mean(SD) ”joint line height ratio” for pre-TAR, non-arthritic contralateral, and post-TAR ankle radiographs were 1.54(0.31), 1.39(0.26) and 1.62(0.49). The “joint line height ratio” of pre- and post-TAR was significantly higher compared to non-arthritic contralateral ankle (p 0.0001 and < 0.0001), respectively. No significant difference in ”joint line height ratio” was found between pre- and post-TAR(p = 0.15). Conclusion: The “joint line height ratio” was a reliable tool for assessing the ankle joint line pre and post-TAR. End-stage ankle arthritis leads to an elevated joint line compared to non-arthritic ankle. The joint line level after TAR was preserved to that measured before TAR, but not restored compared to the non-arthritic contralateral ankle. When performing TAR, joint line level restoration should be evaluated compared to the contralateral non-arthritic ankle radiograph. The amount of tibial cut should be minimized as much as possible to prevent further bone loss and ankle joint line elevation.
Introduction: Implant positioning is critical in total ankle replacement (TAR). However, the effect of sagittal tibiotalar alignment on functional outcomes in fixed-bearing TAR remains unclear. Furthermore, no studies comparing different fixed-bearing implants with respect to the anteroposterior position of the talar component have been performed to date. Methods: A retrospective analysis of 71 primary TARs in a single center was performed. Prostheses included were the INBONE II® (Wright Medical, Memphis, TN) and the Salto Talaris (Integra LifeSciences, Plainsboro, NJ). Radiographic measurements of the tibial-axis-to-talus ratio (T-T ratio) and the anteroposterior offset ratio (AP offset ratio) were performed preoperatively and postoperatively, respectively. Foot and Ankle Outcome Scores (FAOS) and SF-12 MCS and PCS scales were evaluated preoperatively and 2 years postoperatively. Results: Postoperative sagittal tibiotalar alignment was neutral in 39 ankles and anterior in 32 ankles. No significant differences were observed between groups with respect to clinical outcome scores. Patients with a Salto Talaris prosthesis had a greater AP offset ratio (0.12 ± 0.05) than patients with an INBONE II® implant (0.05 ± 0.04) (P < .01); however, this increased translation did not correlate with the outcome scores. Conclusion: At the 2-year follow-up, the INBONE II® TAA showed a more neutral sagittal alignment compared with the Salto Talaris prosthesis. However, no correlation between the postoperative AP offset ratio and functional outcome scores was observed with the use of the two fixed-bearing TAR. Further studies with longer follow-ups are needed to determine if the difference in sagittal alignment may have an effect on functional outcomes in the long-term.
Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Lateral bony impingement, one of the main causes of lateral foot pain in progressive collapsing foot deformity (PCFD), reflects disease severity and may affect surgical planning. Weightbearing computed tomography (WBCT) is known to provide better sensitivity in detecting impingement over simple radiographs, however, many Orthopaedic centers have not yet acquired WBCT imaging. This study aimed to (1) investigate the correlation of common radiographic parameters measured on standard weightbearing radiographs with talocalcaneal and calcaneofibular distance assessed with WBCT and (2) establish cut-off values for radiographic measurements on standard radiographs to detect lateral bony impingement as identified on WBCT. Methods: Ninety-one adult patients (mean age and standard deviation, 54.1 +- 17.2 years) treated for PCFD with standard preoperative radiographs and WBCT within 6 months of each other were retrospectively identified. Patients with previous ipsilateral foot and ankle surgery or asymmetric ankle arthritis (talar tilt > 2 degrees) were excluded. The talocalcaneal distance at the sinus tarsi and subfibular calcaneofibular distance were measured in multiplanar reconstructed WBCT images. Bony impingement was defined as direct contact between the structures. The relationships between WBCT measurements and four common parameters (Talonavicular coverage angle [TNC], Talo-1st metatarsal angle, Calcaneal pitch, and hindfoot moment arm [HMA]) in standard radiographs were assessed with Pearson correlations. Receiver operating characteristic (ROC) curve analysis was performed to determine the ability of radiographic parameter thresholds to predict sinus tarsi or calcaneofibular bony impingement, and the area under curve (AUC), sensitivity, specificity, negative and positive predictive value were calculated. Results: Talocalcaneal distance narrowing at the sinus tarsi on WBCT was strongly correlated with TNC (r = 0.64, p < 0.001), and the calcaneofibular distance narrowing on WBCT correlated with the HMA moderately yet best among the parameters (r=0.55, p<0.001). Interrater and intrarater reliability of WBCT measurements was excellent. TNC (AUC=0.837, 95% confidence interval [CI], 0.745-0.906) and HMA (AUC=0.959, 95%CI, 0.895-0.989) provided the best predictive ability for sinus tarsi and calcaneofibular bony impingement, respectively (Figure 1). The cut-off value for TNC for predicting sinus tarsi bony impingement was 25.4 degrees, with a sensitivity of 80.4% and a specificity of 72.5%. The cut-off value for HMA for predicting calcaneofibular bony impingement was 25.4mm, with a sensitivity of 100% and a specificity of 81.2% (Table 1). Conclusion: This study provides evidence that common radiographic parameters in standard radiographs can be potentially used to detect lateral bony impingement in PCFD. Narrowing of talocalcaneal distance at the sinus tarsi was best correlated with abduction deformity of the foot, and the narrowing of calcaneofibular distance was best correlated with valgus hindfoot deformity. TNC and HMA on standard radiographs may be used for detecting sinus tarsi and calcaneofibular bony impingement, respectively.
