Tibiotalocalcaneal Arthrodesis with Hybrid Nail-Plate Constructs: A Novel Technique for Treatment of Unstable Ankle & Hindfoot Deformities

Category: Ankle; Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a treatment option for several pathologies of the hindfoot and ankle. Traditional fixation options include intramedullary nailing or plate-screw constructs. In certain patients, for example when bone quality or post-operative compliance are of concern, more robust fixation may be desired. Charcot neuroarthropathy (CN) patients in particular often have complex deformities, poor bone quality, and impaired sensation. New trauma literature shows hybrid nail-plate constructs (NPCs) may permit early weight bearing in osteoporotic distal femur fractures. We report early results of TTC arthrodesis using NPCs in patients with complex deformities of the ankle and hindfoot. Methods: Patients undergoing TTC arthrodesis via intramedullary nail fixation plus plating by a single surgeon from September 2020 to December 2022 were included in our study. Indications included CN, post-traumatic deformities, and advanced arthritis. Age, comorbidities, Hemoglobin A1c, presence of an ulcer, implants, bone graft used, and postoperative complications were retrospectively recorded. Results: Fifteen patients met inclusion criteria. Six patients had CN; eight patients had post-traumatic complications; and one patient had an arthritic cavovarus deformity. Average age was 55 years (range 31-72). Eleven patients were treated with a lateral TTC locking plate; three were treated with an anterior tibiotalar arthrodesis plate; and one was treated with a 3.5mm reconstruction plate. All patients were treated with a TTC arthrodesis nail. In all cases, cellular bone matrix was used; in fourteen cases, autograft was also used. Average follow-up was 35 weeks (min. 12). Three patients underwent below-knee amputation, two for infection and the other for hardware failure. Two others required postoperative debridements but subsequently cleared their infections. Twelve patients have a stable, non-infected, ulcer free foot at latest follow-up. Conclusion: TTC arthrodesis can be used for a variety of indications, and many of these patients present complex challenges. Patients with CN in particular often have severe deformities and poor bone quality. Hybrid fixation methods provide added stability in complex cases, possibly allowing for more powerful deformity correction and earlier weight-bearing. We report a 80% favorable outcome rate in our case series, with major complications confined to patients with significant medical comorbidities (poorly controlled diabetes, peripheral vascular disease). We believe that TTC arthrodesis with hybrid nail-plate constructs represents an attractive solution to complex ankle and hindfoot deformities

Cost Comparison of Operatively Treated Ankle Fractures Managed in an Inpatient versus Outpatient Setting

Category: Trauma Introduction/Purpose: Although choices physicians make profoundly impact the cost of healthcare, few surgeons know actual costs. Without valid cost information, surgeons cannot understand how their choices impact the total cost of care. We leveraged a validated value analytics framework to efficiently allocate clinical care costs to individual patient encounters in an effort to understand the sources and variation of cost of care for a putatively straightforward and common orthopaedic problem. Methods: We conducted a retrospective cost analysis on all isolated, operatively treated ankle fractures from a Level 1 trauma hospital and affiliated outpatient surgery center between 2013 and 2015. Patients were categorized based on whether they were treated on an inpatient or outpatient basis, and records were reviewed to determine the presence of confounding variables as well as readmission and emergency department (ED) visits within 90 days after surgery. Actual costs were determined using a validated episode of care costing system and analyzed using multivariate regression analysis. Results: 148 patients (61 inpatients, 87 outpatients) with isolated, operatively treated ankle fractures were included. After controlling for confounding variables, outpatient care was associated with 31.6% (95% CI: 19.8% - 41.8%) lower costs compared to inpatient care. Obese patients had 21.6% (95% CI: 5.8% - 39.8%) higher costs compared to patients who were not obese. There was no difference in reoperation, readmission or return visits to the ED for patients treated on an inpatient or outpatient basis. Conclusion: Inpatient surgical care is clearly more expensive than outpatient care primarily due to higher facility and labor costs without a clear advantage relative to lower readmission or ER visit rates. Where medically appropriate, this analysis suggests ankle fracture surgery should be provided in an outpatient surgical facility to provide the greatest value to the patient and society

Novel collaborative cardiology and maternal fetal medicine practice - experience at the heart and pregnancy program.

PURPOSE: The Heart and Pregnancy Program (HPP) was created to evaluate and manage pregnant women with cardiac conditions simultaneously by cardiology and maternal-fetal medicine (MFM). The objective of our study was to describe the experience at this multidisciplinary program. METHODS: This is a retrospective review of women managed at HPP for over 4.5 years. Subjects were compared based on indication for referral. RESULTS: One hundred and seventy-three women were seen during the time period. Referral indications included cardiac complaints without history of cardiac disease ( CONCLUSIONS: In our collaborative cardiology/MFM practice, most pregnant women had known cardiac disease. No significant adverse outcomes were noted. Our experience provides support for creating a joint model of care for pregnant women with cardiac disease

IFRD1: possibile gene modificatore della malattia polmonare in fibrosi cistica

La Fibrosi Cistica (CF) \ue8 una malattia autosomica recessiva causata da mutazioni nel gene CFTR. L\u2019espressione clinica della malattia mostra una variabilit\ue0 anche in soggetti che presentano lo stesso genotipo CFTR e/o appartenenti alla stessa famiglia. Dati di letteratura recenti suggeriscono che la variabilit\ue0 delle manifestazioni cliniche, soprattutto del fenotipo polmonare, possa essere correlata ad altri fattori genetici indipendenti dal gene CFTR. Si ipotizza,quindi,un possibile ruolo modulatore di altri geni correlati in vario modo alla malattia Recentemente i polimorfismi rs7817, rs3807213, rs6968084 del gene IFRD1(Interferon-Related Developmental Regulator 1)sono stati descritti associati ad una maggiore gravit\ue0 della malattia polmonare in CF in varie popolazioni. Scopo di questo studio \ue8 quello di confermare tale associazione anche nella popolazione del Nord Italia. Sono stati analizzati 146 soggetti CF, selezionati e valutati clinicamente presso il Centro Regionale CF di Verona. L\u2019analisi molecolare \ue8 stata condotta mediante PCR e restrizione enzimatica. L'analisi di associazione tra le SNPs analizzate e i parametri respiratori e gastrointestinali correlati alla malattia ha evidenziato un'associazione statisticamente significativa (p=0.0307) tra l'aumento dei valori di FEV1 e il genotipo eterozigote C/T della SNPs rs7817. Questi risultati confermano che variazioni genetiche in IFRD1, o mutazioni in linkage disequilibrium con le SNPs studiate, possono contribuire alla variabilit\ue0 della malattia polmonare in CF

IFRD1: a possible modifier gene for Cystic Fibrosis Lung Diesease

Aim of the study was to analyse IFRD1 gene as a possible modifier gene for Cystic Fibrosis Lung Diseas

Epidemiology and a novel procedure for large scale analysis of CFTR rearrangements in classic and atypical CF patients: A multicentric Italian study.

BACKGROUND: Mutation epidemiology in each ethnic group is a crucial step of strategies for cystic fibrosis (CF) diagnosis and counselling. To date, the scanning of the whole coding region of the cystic fibrosis transmembrane conductance regulator (CFTR) gene permits to identify about 90% of alleles from patients bearing CF and a lower percentage in patients bearing atypical CF. CFTR rearrangements in heterozygosis elude current techniques for molecular analysis, and some of them have been reported with a frequency up to 6% in various ethnic groups. METHODS: Using quantitative PCR analysis of all coding regions, we assessed the occurrence of CFTR rearrangements in 130 alleles from classic CF patients and in 198 alleles from atypical CF patients (all unrelated and from Italian descent) bearing unidentified mutations after the scanning of CFTR. RESULTS: Seven rearrangements (i.e., dele1, dele2, dele2_3, dele 14b_17b, dele17a_18, dele22_23, and dele22_24) were identified in 34/131 (26.0%) CF alleles bearing undetected mutations (which means about 2.5% of all CF alleles) and in none of the 198 alleles from atypical CF. The CFTR haplotype and the sequence analysis of the breakpoints confirmed the common origin of all the rearrangements. Thus, we set up a novel duplex PCR assay for the large-scale analysis of the seven rearrangements. The procedure was rapid (all PCR amplifications were obtained under the same conditions), costless and repeatable. CONCLUSIONS: It is useful to select the CFTR rearrangements more frequent in specific ethnic groups and to set up procedures for large-scale analysis. Their study can be performed in cases in which a high detection rate is required (i.e., partners of CF carriers/patients). On the contrary, the analysis of rearrangement is useless in atypical CF patients

The Gene-Environment Interactions in Respiratory Diseases (GEIRD) Project

The role of genetic and environmental factors, as well as their interaction, in the natural history of asthma, allergic rhinitis and chronic obstructive pulmonary disease (COPD) is largely unknown. This is mainly due to the lack of large-scale analytical epidemiological/genetic studies aimed at investigating these 3 respiratory conditions simultaneously. The GEIRD project is a collaborative initiative designed to collect information on biomarkers of inflammation and oxidative stress, individual and ecological exposures, diet, early-life factors, smoking habits, genetic traits and medication use in large and accurately defined series of asthma, allergic rhinitis and COPD phenotypes. It is a population-based multicase-control design, where cases and controls are identified through a 2-stage screening process (postal questionnaire and clinical examination) in pre-existing cohorts or new samples of subjects. It is aimed at elucidating the role that modifiable and genetic factors play in the occurrence, persistence, severity and control of inflammatory airway diseases, by way of the establishment of a historical multicentre standardized databank of phenotypes, contributed by and openly available to international epidemiologists. Researchers conducting population-based surveys with standardized methods may contribute to the public-domain case-control database, and use the resulting increased power to answer their own scientific questions