Results of more than 11,000 scans with weightbearing CT : impact on costs, radiation exposure, and procedure time

Background: Weightbearing CT (WBCT) has been proven to more precisely measure bone position than conventional weightbearing radiographic series (R) and conventional CT (CT). The purpose of this study was to assess the benefit of using WBCT instead of R and/or CT as the standard imaging modality, evaluating image acquisition time, radiation dose, and cost-effectiveness. Methods: All patients who obtained a WBCT as part of standard of care from July 1, 2013 until March 15, 2019 were included in the study. Image acquisition time (T), radiation dose (RD) per patient, and costeffectiveness were analyzed and compared between the time period using WBCT (yearly average) and the parameters from 2012, i.e. before the availability of WBCT (RCT group). Results: 11,009 WBCT scans were obtained from 4987 patients (4,987 scans (45%) before treatment; 6,022 scans (55%) at follow-up). On a yearly average, 1,957 WBCTs (bilateral scans) and an additional 10.6 CTs (bilateral feet and ankles) were obtained (WBCT group). In 2012, 1,850 Rs (bilateral feet, dorsoplantar and lateral, metatarsal head skyline view) and 254 CTs were obtained from 885 patients (RCT group). The mean yearly RD was 4.3/4.8uSv for the WBCT/RCT groups (mean difference of .5 uSv; a decrease of 10% for the WBCT group; p < .01). Yearly mean T was 114/493 h in total (3.3/16.0 min per patient) for WBCT/RCT groups (mean difference of 379 h; a 77% decrease for the WBCT group; p < .01). Yearly cost-effectiveness was a mean profit of 43,959/-723 Euros for WBCT/RCT groups. Conclusions: 11,009 WBCT scans from 4,987 patients over a period of 5.6 years at a foot and ankle department resulted in 10% decreased RD, 77% decreased T, and increased financial profit (51 Euros per patient) for the institution. (c) 2019 The Author(s). Published by Elsevier Ltd on behalf of European Foot and Ankle Society

Weight-bearing cone beam CT scans in the foot and ankle

The 3D anatomical complexity of the foot and ankle and the importance of weight-bearing in diagnosis have required the combination of conventional radiographs and medical CT. Conventional plain radiographs (XR) have demonstrated substantial limitations such as perspective, rotational and fan distortion, as well as poor reproducibility of radiographic installations. Conventional CT produces high levels of radiation exposure and does not offer weight-bearing capabilities. The literature investigating biometrics based on 2D XR has inherent limitations due to the technology itself and thereby can focus only on whether measurements are reproducible, when the real question is whether the radiographs are. Low dose weight-bearing cone beam CT (WBCT) combines 3D and weight-bearing as well as 'built in' reliability validated through industry-standardized processes during production and clinical use (quality assurance testing). Research is accumulating to validate measurements based on traditional 2D techniques, and new 3D biometrics are being described and tested. Time- and cost-efficient use in medical imaging will require the use of automatic measurements. Merging WBCT and clinical data will offer new perspectives in terms of research with the help of modern data analysis techniques

Comparison total joint replacement (Roto-Glide) with arthrodesis of the 1st metatarsophalangeal joint – clinical follow-up study including pedography

Category: Midfoot/Forefoot Introduction/Purpose: Total joint replacement (TJR) and arthrodesis (A) are treatment options for severe osteoarthritis of the 1st metatarsophalangeal joint (MTP1). The aim of this study was to compare outcome (clinical and pedographic) of JTR (Roto-Glide, Implants International, Thornaby-On-Tees, UK) and A of MTP1. Methods: All patients that completed follow-up of at least 24 months after TJR and A of MTP1 before November 5, 2017 were included in the study. The data was extracted from a prospectively acquired database starting November 1, 2011 including all operatively treated patient at the authors´ institution. Exclusion criteria were bilateral treatment (n=24), additional procedures at other toes (n=34), A for revision of TJR (n=12), TJR exchange (n=5), and not completed minimum-24-month-follow-up (n=20). Preoperatively and at follow-up, radiographs and/or weight-bearing computed tomographies were obtained. Degenerative changes were classified in four degrees. Standard dynamic pedography was performed (percentage force at 1st metatarsal/1st toe from force of entire foot). Visual-Analogue-Scale Foot and Ankle (VAS FA) and MTP1 range of motion for dorsi-/plantarflexion (ROM) were registered. All parameters were compared between TJR and A and between preoperatively and follow-up. Results: From November 24, 2011 until October 31, 2015, 19 TJR and 38 A were performed. Parameters (average values if not stated otherwise) for TJR/A were preoperatively: mean age 59/60 years; 5(26%)/10(26%) male; height 167/166 cm; weight 73/74 kg; degree degenerative changes 3.3/3.1; ROM 10.3/0/18.8°//10.8/0/19.2°; percentage force 1st metatarsal/1st toe 7.8/14.5//8.4/15.2; VAS FA 45.5/44.9. Follow-up time on average 37.4/32.6 and range 25.3-71.3/24.1-67.1 months. VAS FA at follow-up was 71.7/69.4; percentage force 1st metatarsal/1st toe 15.6/5.5//16.5/10.5; ROM 35.4/0/20.5°//10.2/0/0. Parameters did not differ between TJR and A (each p>.05) except higher force percentage 1st toe and lower ROM for A at follow-up (each p<.05). VAS FA and pedography parameters improved for TJR and A between preoperatively and follow-up, ROM increased for TJR and decreased for A (each p<.05). Conclusion: TJR and A were performed in similar patient cohorts regarding demographic parameter, degree of degenerative changes, ROM, pathological pedographic pattern, and validated clinical scores (VAS FA). Both improved pathological pedographic pattern and VAS FA at minimum follow-up of 24 months. TJR additionally improved ROM and showed better pedographic pattern (and not different to physiological pattern) than A. TJR was similar to A except better ROM and better pedographic pattern. Survival rate of TJR was 100% up to 6 years. In this study, TJR was a valuable alternative to A for treatment of severe MTP1 osteoarthritis

Comparison Total Joint Replacement (STAR) with Arthrodesis of the Ankle

Category: Ankle Arthritis Introduction/Purpose: Total joint replacement (TJR) and arthrodesis (A) are treatment options for severe osteoarthritis of the ankle. The aim of this study was to compare outcome (clinical and pedographic) of JTR (STAR, Stryker, Airview Boulevard, MN, USA) and A of the ankle. Methods: All patients that completed follow-up of at least 24 months after TJR and A of the ankle before November 5, 2017 were included in the study. The data was extracted from a prospectively acquired database starting November 1, 2011 including all operatively treated patient at the authors´ institution. Exclusion criteria were bilateral treatment (n=14), extensive additional procedures such as arthrodesis at other joints (n=54), A for revision of TJR (n=8), TJR exchange (n=10), and not completed minimum-24-month-follow-up (n=26). Preoperatively and at follow-up, radiographs and/or weight-bearing computed tomographies were obtained. Degenerative changes were classified in four degrees. Standard dynamic pedography was performed (percentage force at hindfoot and forefoot from force of entire foot). Visual-Analogue-Scale Foot and Ankle (VAS FA) and ankle range of motion for dorsi-/plantarflexion (ROM) were registered. All parameters were compared between TJR and A and between preoperatively and follow-up. Results: From October 11, 2011 until October 31, 2015, 36 TJR and 28 A were performed. Parameters (average values if not stated otherwise) for TJR/A were preoperatively age 61/52 years; 20(56%)/14(50%) male; height 171/175 cm; weight 83/87 kg; degree degenerative changes 3.5/3.6; ROM 5.6/0/22.8°//4.8/0/22.1°; percentage force hindfoot/forefoot 45.5/38.3//48.4/34.5; VAS FA 43.8/40.3. Follow-up time on average 35.8/33.1 and range 25.4-66.4/24.1-71.3 months. VAS FA at follow-up was 68.6/61.3; percentage force hindfoot/forefoot 64.3/22.3//53.5/28.5; ROM 15.4/0/33.6°//0/0/0. Parameters did not differ between TJR and A (each p>.05) except lower age for A, higher VAS FA, hindfoot force percentage and ROM for TJR at follow-up (each p<.05). VAS FA and pedography parameters improved for TJR and A between preoperatively and follow-up, ROM increased for TJR and decreased for A (each p<.05). Conclusion: TJR and A were performed in similar patient cohorts regarding demographic parameter (except lower age for A), degree of degenerative changes, ROM, pathological pedographic pattern, and validated clinical scores (VAS FA). Both improved pathological pedographic pattern and VAS FA at minimum follow-up of 24 months. TJR additionally improved ROM and showed better pedographic pattern (and not different than physiological pattern) and VAS FA than A. TJR resulted in better clinical outcome including ROM and pedographic pattern. Survival rate of TJR was 100% up to 5.5 years. In this study, TJR outperformed A for treatment of severe ankle osteoarthritis

Matrix-associated Stem Cell Transplantation (MAST) in Chondral Lesions at the Ankle as Part of a Complex Surgical Approach

Category: Ankle Introduction/Purpose: The aim of the study was to assess the 5-year-follow-up after matrix-associated stem cell transplantation (MAST) in chondral lesions at the ankle as part of a complex surgical approach. Methods: In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral defect that were treated with MAST from April1 2009 to September 30, 2011 were analyzed. Size and location of the chondral defects and the Visual-Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Stem cell-rich blood was harvested during the procedure from the ipsilateral pelvic bone marrow with a Jamshidi needle (10 x 3 mm, Cardinal, Dublin, OH, USA) and a special syringe (Arthrex-ACP, Arthrex, Naples, FL, USA) through a stab incision. The syringe was centrifuged (10 minutes, 1,500 rotations per minute). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Gide, Geistlich, Wollhusen, Switzerland) that was cut to the size of the cartilage defect roughly before and definitely after. The matrix with stem cells was fixed into the chondral defect with fibrin glue (Tissucoll, Deerfield, IL, USA). Results: Sixty-six patients with 69 chondral defects were included in the study. The age of the patients was 35 years on average (range, 12-64 years). VAS FA before surgery was 48.9 on average (range, 16.5-75.9). The defects were located as follows, medial talar shoulder, n=28; lateral talar shoulder, n=28 (medial and lateral talar shoulder, n=3), tibia, n=3. The defect size was 1.4 cm 2 on average (range, .6 - 6 cm 2 ). 60 patients (91%) completed 5-year-follow-up. No patient was converted to fusion or total ankle replacement. The VAS FA improved to an average of 78.2 (range, 60.8-100; p=.01). Conclusion: MAST as part of a complex surgical approach led to improved and high validated outcome scores in the mid-term-follow-up. No method related complications were registered. Even though a control group is missing, we conclude that MAST as part of a complex surgical approach is an effective method for the treatment of chondral lesions of the ankle for at least five years

Minimal Important Change for the Visual Analogue Scale Foot and Ankle (VAS-FA)

Background Visual analogue scale foot and ankle (VAS-FA) is a patient-reported outcome measure for foot and ankle disorders. The VAS-FA is validated into several languages and well adopted into use. Nonetheless, minimal important change (MIC) for the VAS-FA has not been estimated thus far. Methods The VAS-FA score was obtained from 106 patients undergoing surgery for various foot and ankle complaints. MIC was estimated using an anchor-based predictive method. Results The adjusted MIC was 6.8 for total VAS-FA score, and 9.3 for the Pain, 5.8 for the Function, and 5.7 for the Other complaints subscales. The VAS-FA score was found to separate improvement and deterioration in patients’ foot and ankle condition. Conclusions MIC was successfully defined for the VAS-FA in the current study. The VAS-FA can be used to evaluate foot and ankle patients’ clinical foot and ankle status and its change. Further research on estimating disease-specific MICs is recommended.Peer reviewe