Is Interposition Arthroplasty a Viable Option for Treatment of Moderate to Severe Hallux Rigidus? A Systematic Review and Meta-analysis

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus is a painful arthritis of the first metatarsophalangeal joint that causes progressive loss of mobility. Treatment options include activity modifications, analgesics, corticosteroids, and surgery. Arthrodesis of the MTP joint is considered the gold standard treatment for hallux rigidus, but it is often reserved for advanced. Interposition arthroplasty uses a spacer taken from an autograft, allograft, or synthetic material. For patients with severe arthritic diseases who would like to preserve MTP joint function, interposition arthroplasty may be a viable option. The purpose of this systematic review is to investigate patient outcomes after undergoing interposition arthroplasty of the MTP joint. The objectives are to determine if this technique is practical for patients who would prefer to avoid arthrodesis, and to systematically analyze post-operative improvement. Methods: The systematic review was performed following PRISMA (Preferred Reporting Items for Systematic Review and Meta-analyses) guidelines. Medline, pubmed, Embase, and Cohrane Database of Systematic Reviews (CDRS) were searched for publications from 2000 to 2017. Duplicates were then removed, and titles and abstracts were reviewed to confirm the relevance f the study. Studies were included if they reported results of first MTP joint interposition arthroplasty in one of the well-known scoring systems: AOFAS, FFI, or SF-36. Studies also were also required to have a 12 month follow up. Systematic review and data extraction were performed on all selected studies. Means were recorded and placed in tables for all variables including scoring results and complication rates. A linear regression model comparing the change in preoperative to postoperative AOFAS scores between the autogenous versus allogenous interposition materials was performed. Results: Database searches produced 574 articles for review. 15 of these were included in the systematic review. Mean AOFAS score was improved from 41.35 preoperatively to 83.17 postoperatively. Mean pain, function, and alignment scores improved from preoperative values of 14.9, 24.9, and 10 to postoperative values of 33.3, 35.8, and 14.5. Mean dorsiflexion increased from 21.27 degrees (5-30) to 42.03 degrees (25-71). Mean ROM improved from 21.06 to 46.43 degrees. Eighty-seven percent of patients were satisfied to highly satisfied with their surgery and would choose surgery again. Joint space increased by 0.8 mm to 2.5 mm. The most common complications included metatarsalgia (13.9%), loss of ground contact (9.7%), osteonecrosis (5.4%), great toe weakness (4.8%), hypoesthesia (4.2%), decreased push off power (4.2%), and callous formation (4.2%). Conclusion: The management of hallux rigidus remains heavily debated. This systematic review of the current literature suggests that interposition arthroplasty is a viable short and intermediate term treatment for hallux rigidus in terms of patient satisfaction, pain scores, and AOFAS scores. Further studies with greater sample sizes, more uniform methods, and longer follow-up times are needed to further support the superiority of interposition arthroplasty

A Comparative Analysis of Risk and Cost-effectiveness of Outpatient versus Inpatient Hindfoot Fusion

Category: Hindfoot Introduction/Purpose: Hindfoot fusion procedures are increasingly being performed in the outpatient setting. However, the cost-effectiveness of hindfoot fusion procedures compared with risk and benefit have not been clearly investigated. The primary objective of this study was to investigate the cost-effectiveness of outpatient versus inpatient hindfoot arthrodesis. Secondary objectives were to compare patient characteristics and short-term complications of patients in each cohort. Methods: This was a retrospective review of all patients who underwent inpatient and outpatient hindfoot fusion procedures at a single institution from 2013-2017. Data collected for each patient included demographic information, operative variables, comorbidities, complications, and any subsequent emergency department visits, readmissions or reoperations. Cost data was collected for each inpatient or outpatient encounter, as well as any subsequent encounters related to the index procedure. Results: Of 151 total hindfoot procedures performed over the study period, 37 were inpatient and 114 were performed in the outpatient setting. There were 3 more readmissions, 22 more ED visits, and 0 more reoperations after outpatient surgery vs inpatient surgery. The average total cost for an outpatient hindfoot fusion procedure was significantly lower than the average total cost for inpatient hindfoot fusion, without a significant increase in complication rate. We are currently in the process of performing the total cost analysis, and will have the completed cost and risk/benefit information within the next two weeks. Conclusion: Outpatient hindfoot fusion surgery may be more cost-effective when compared to inpatient fusion surgery without a significant increase in complications, ED visits, or readmissions

A Comparative Analysis of Short Term Postoperative Complications in Outpatient vs. Inpatient Total Ankle Arthroplasty

Category: Ankle Introduction/Purpose: Ankle arthritis is a potentially debilitating disease with approximately 50,000 cases diagnosed annually. Once conservative management fails, surgical options for these patients include total ankle arthroplasty (TAA) and ankle arthrodesis. Younger, more active patients may prefer TAA as it may allow better ankle mobility compared to ankle arthrodesis. TAA has historically been performed in the inpatient setting with a one- to two-night postoperative hospital stay. Outpatient surgeries are gaining popularity due to their cost effectiveness, decreased length of hospital stay, and convenience. Therefore, it is important to evaluate the safety of specific procedures in the outpatient setting compared to the inpatient setting. This study evaluates the complication rates in inpatient vs. outpatient TAA. Methods: Our team conducted a retrospective analysis of data from 591 patients receiving inpatient and outpatient TAA from the NSQIP database. This database contains de-identified patient data and allows retrospective analyses to be performed based on data they have extracted from over 400 hospitals. Demographic information was recorded including age, sex, weight, height, and race. Thirty-day postoperative complication rates were compared between 66 outpatients and 535 inpatients. Frequencies of the following complications were analyzed: wound complications, pneumonia, hematologic complications (pulmonary embolism and deep vein thrombosis), renal failure, stroke, and return to the operating room within 30 days. The inpatient and outpatient groups were compared using chi-squared tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Results: 591 total patients were identified that underwent TAA. 66 patients (11.1%) were treated as outpatients and 525 (88.8%) as inpatients. Inpatient TAA had a significantly higher mean operation time (161 min vs 148 min) and a significant difference in length of total hospital stay (2.3 days vs 1.1 days). Inpatients had higher rates of superficial incisional surgical site infection (SSI) (0.57% vs 0%), deep SSI (0.19 % vs 0%), organ/space SSI (0.19% vs 0%), pneumonia (0.38% vs 0%), and return to the operating room (0.76% to 0%). However, no significant differences were found in complication rates between inpatient and outpatient groups. There were no occurrences of acute renal failure, wound disruption, pulmonary embolism, stroke, or DVT/thrombophlebitis for inpatients or outpatients. Conclusion: We found no significant difference between inpatient vs. outpatient TAA. Incidental differences we found were that inpatients were significantly more likely to be older in age, diagnosed with diabetes, and inpatients had longer operative times. Our results suggest that inpatients are more likely, but not significantly, to have a higher occurrence of complications and return to the OR. Therefore, this study suggests that outpatient TAA is safe and may be a superior option for the correct patient population. Further investigation is warranted to verify these conclusions

A collaborative study of the etiology of breast cancer subtypes in African American women: the AMBER consortium

PURPOSE: Breast cancer is a heterogeneous disease, with at least five intrinsic subtypes defined by molecular characteristics. Tumors that express the estrogen receptor (ER+) have better outcomes than ER− tumors, due in part to the success of hormonal therapies that target ER+ tumors. The incidence of ER− breast cancer, and the subset of ER− cancers that are basal-like, is about twice as high among African American (AA) women as among U.S. women of European descent (EA). This disparity appears to explain, in part, the disproportionately high mortality from breast cancer that occurs in AA women. Epidemiologic research on breast cancer in AA women lags behind research in EA women. Here, we review differences in the etiology of breast cancer subtypes among AA women and describe a new consortium of ongoing studies of breast cancer in AA women. METHODS: We combined samples and data from four large epidemiologic studies of breast cancer in AA women, two cohort and two case-control, creating the AMBER consortium. Tumor tissue is obtained and stored in tissue microarrays, with assays of molecular markers carried out at a pathology core. Genotyping, carried out centrally, includes a whole exome SNP array and over 180,000 custom SNPs for fine-mapping of GWAS loci and candidate pathways. RESULTS: To date, questionnaire data from 5,739 breast cancer cases and 14,273 controls have been harmonized. Genotyping of the first 3,200 cases and 3,700 controls is underway, with a total of 6,000 each expected by the end of the study period. CONCLUSIONS: The new consortium will likely have sufficient statistical power to assess potential risk factors, both genetic and non-genetic in relation to specific subtypes of breast cancer in AA women