The procedures are performed using the Zimmer Trabecular Metal Total Ankle prosthesis (Zimmer, Warsaw, IN).

All methods described have been approved by our institutional review board and the local ethics committee and they have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
1. Preoperative Radiographic Evaluation
<ol>
	<li>Perform weight bearing radiographs of the ankle and the foot with antero-posterior, lateral, and rearfoot alignment views (Saltzman&#39;s view30).</li>
	<li>Perform a conventional computed tomography (CT) of the ankle and request any other diagnostic exams (such as magnetic resonance), if necessary, to better clarify the diagnosis.</li>
	<li>Measure the following parameters on the preoperative weight-bearing radiographs.
	<ol>
		<li>Measure the anterior distal tibial angle (ADTA, normal value 83.0 &#177; 3.6 &#176;) on the lateral ankle view: measure the angle between the anatomic axis of the tibia and the line connecting the distal points on the anterior and posterior edge of the tibial articular surface (Figure 1)30,31.</li>
		<li>Measure the lateral distal tibial angle (LDTA, normal value 89.0 &#177; 3.0 &#176;) on the anteroposterior ankle view: measure the angle subtended between the anatomic axis of the tibia and the line connecting the distal points on the medial and lateral edge of the tibial articular surface (Figure 2)32,33,34.</li>
		<li>Measure the tibio-talar ratio (TT ratio, normal value 34.8 &#177; 3.8%): measure this parameter on the lateral ankle view; it is the ratio between the posterior longitudinal talar length (the length between the posterior talar edge and the intercept of the anatomical tibial axis) and the full longitudinal talar length (Figure 1)33,35,36.</li>
		<li>Measure the tibio-talar surface angle (normal value 89.0 &#177; 2.6 &#176;) on the anteroposterior ankle view: measure the angle between the anatomic axis of the tibia and the line connecting the proximal point on the medial and lateral talar articular surface (Figure 2)37.</li>
	</ol>
	</li>
	<li>Use the CT to assess the available bone stock and to evaluate the severity of the avascular necrosis of the talus, if present.</li>
</ol>
2. Surgical Technique17
NOTE: This procedure is performed under general or regional anesthesia (spinal anesthesia).
<ol>
	<li>Place the patient in the supine position with a rigid board under the leg to sustain the alignment stand. Position a thick pad under the ipsilateral hip. Do not use a tourniquet.</li>
	<li>Make a longitudinal incision with a scalpel over the lateral malleolus that curves under its tip toward the sinus tarsi (Figure 3). Dissect the fibula and the anterior side of the tibia subperiosteally with the scalpel and the periosteal elevator to obtain a complete view of the osteophytes and the joint.</li>
	<li>Release the posterior capsule of the tibia and the fibula using a periosteal elevator.</li>
	<li>Make an oblique lateral malleolus osteotomy with a sagittal saw blade: begin from the posterior edge of the fibula, 6-7 cm proximal to the joint line; end on the anterior side of the fibula, 2 cm proximal to the joint line. Rotate the fibular malleolus distally and use a 1.6 mm K-wire to fix it to the calcaneus.</li>
	<li>Remove the anterior osteophytes with the sagittal saw blade and a rongeur until the ankle can be easily placed in a neutral position. 
	NOTE: The medial gutter release can be performed later during the tibial preparation.</li>
	<li>Measure the medial/lateral talar width with the manufacturer&#39;s sizer, choosing the largest size possible while avoiding overhang.</li>
	<li>Place the leg in the alignment stand that is assembled at the beginning of the procedure.</li>
	<li>Internally rotate the foot and use the trans-calcaneal pin to fix it to the foot plate. Use the 4.0 mm pin to fix the talus to the footplate: put the pin as distal as possible in the talar neck, thus facilitating further correction of talar tilt.</li>
	<li>Check the tibial alignment with fluoroscopy using a bar that is parallel to the mechanical tibial axis. Use fluoroscopy with the following parameters: 55 kilovolts, 3 milliampere-seconds.</li>
	<li>Insert two 5.0 mm pins on the medial border of the tibia while an assistant pushes the tibia anteriorly if an anterior sagittal talar shifting is present. To increase the rigidity of the construct, an adjunctive carbon fiber bar can be placed in a vertical position.</li>
	<li>Verify the level of the desired joint line with the pointer located through the &#39;&#39;Position&#39;&#39; hole of the cutting guide of the selected size. Check the amount of bone resection with the pointer placed in the &#39;&#39;Talus&#39;&#39; and &#39;&#39;Tibia #1&#39;&#39; hole.</li>
	<li>Use the 4.0 mm drill through the pre-cutting guide to pre-drill the talus and the tibia surfaces. Assemble the bone burr to the pneumatic handpieces and put the contralateral talar trial of the selected size between the bone burr and the cutting guide to assess the medial depth of the bone cut. Then, use the bone burr to make the definitive bone cuts through the &#39;&#39;Talus&#39;&#39; and the &#39;&#39;Tibia #1&#39;&#39; holes of the guide. Use the &#39;&#39;Tibia #2&#39;&#39; hole to reach the whole tibial cut on the medial side and to release osteophytes of the medial gutter</li>
	<li>Position the rail drill guides. Utilize antero-posterior fluoroscopy to verify they are properly placed to avoid lateral overhang. Drill the rails and position the provisional implant, then choose the insert size.</li>
	<li>Insert the definitive implants using the talar and tibial inserter.</li>
	<li>Use fluoroscopy to check the positioning, and use two or three 3.5 mm lag screws to fix the fibula; alternatively, use a plate-fixation of the lateral malleolus, if the deformity requires a malleolar lengthening or shortening that does not leave sufficient contact for screw fixation.</li>
	<li>Check the stability of the syndesmosis with a bone hookapplied to the lateral malleolus. Gently pull the fibula laterally to assess any residual tibiofibular instability. If a lateral movement of the lateral malleolus is present, stabilize it with a syndesmosis screw fixation across four cortices. Test the ankle range of motion.</li>
	<li>Repair the anterior talofibular ligament with resorbable suture before routine wound-closure.</li>
</ol>
3. Postoperative Care
<ol>
	<li>Place the leg into a cast and forbid weight-bearing for four weeks. Then allow weight-bearing with a walker-boot for two weeks.</li>
	<li>Allow calf strengthening, proprioceptive training and stretching of the triceps surae six weeks after the surgery.</li>
</ol>
4. Clinical and Radiographic Follow-Up
<ol>
	<li>Radiologically and clinically evaluate patients at one, two, six, and twelve months after the procedure and, afterward, every twelve months. The follow-up protocol consists of function and pain assessment with SF-12, VAS pain score, and AOFAS ankle and hindfoot scores collected at each time-point.</li>
	<li>Perform radiographic examination: request weight-bearing radiographs of the ankle and of the foot with antero-posterior, lateral and Saltzman&#39;s view at each end-point.</li>
	<li>Measure the following parameters on the postoperative radiographs at each end-point.
	<ol>
		<li>Measure the alpha angle (&#945;-angle) on the antero-posterior ankle view: measure the angle formed laterally by the anatomical axis of the tibia and the articular surface of the tibial component (Figure 4)38.</li>
		<li>Measure the beta angle (&#946;-angle) on the lateral ankle view: measure the angle subtended anteriorly by the anatomical axis of the tibia and the articular surface of the tibial component (Figure 5)18,38.</li>
		<li>Measure the gamma angle (&#947;-angle) on the lateral ankle view: measure the angle between a line through the anterior and the posterior edge of the talar component and a line along the center of the talar neck (Figure 5)39.</li>
		<li>Measure the Tibio-talar ratio.</li>
		<li>Measure the Tibio-talar surface angle.</li>
	</ol>
	</li>
</ol>

Dr. Usuelli receives grants and personal fees from Zimmer. Dr. D'Ambrosi, Dr. Maccario, Dr. Manzi and Dr. Indino have nothing to disclose.

We reported the methods and protocol we use performing TAR with lateral transfibular approach. The absolute contraindications for TAR are talar avascular necrosis involving more than 50% of the bone-stock, acute or active infection with or without osteomyelitis, diabetic syndrome with polyneuropathy, high anesthesiologic risks, neuromuscular disorders, peripheral vascular disease, and neuroarthropathy (Charcot arthropathy of the midfoot or hindfoot)19,42. The relative contraindications are diabetic syndrome without polyneuropathy, immunosuppressive therapy and severe osteoporosis19. Patients active in sports and physically demanding activities should be informed about potential increased risk of wear and aseptic loosening43,44,45,46.
We modified the manufacturer&#39;s surgical technique with some tips derived from personal experience17. The first modification deals with the incision: the manufacturer&#39;s guidelines suggest a straight incision. The straight incision sometimes does not allow for a whole removal of the anterior osteophytes because of a problematic achievement of an appropriate view of the anterior joint line. We prefer to curve the incision toward the sinus tarsi in order to address this problem. This kind of incision permits the removal of all the osteophytes that could obstacle the achievement of the neutral dorsiflexion prior to the bone cuts: this is a key-step to achieve a satisfactory range of motion at the end of the procedure. Moreover, the manufacturer&#39;s surgical technique suggests a 1.5-cm oblique fibular osteotomy in the superolateral-inferomedial direction: that kind of osteotomy routinely requires a fixation with the plate and does not require adequate fibular shortening or lengthening for major coronal deformity. We prefer to perform a longer osteotomy beginning at the posterior border of the lateral malleolus (6-7 cm proximal to the joint line), and directing the osteotomy distally toward the anterior border of the lateral malleolus (2 cm proximal to the joint line). This kind of osteotomy facilitates addressing a great number of fibula-length issues and, consequently, a great number of coronal malalignments. Also, it permits a fixation with lag screws, decreasing the risk of hardware removal consequent to subjective discomfort or impaired wound healing. Despite these advantages, the adherences between fibular malleolus and the adjacent soft tissues could make the reflection of the lateral malleolus more complicated in case of long fibular osteotomy. Moreover, the manufacturer&#39;s surgical technique includes the use of cement to fix the implants. However, we do not cement the components because an appropriate stability is normally obtained without cementation. Furthermore, the osseointegration features of the implants&#39; material ensure a stable and durable fixation.
Additionally, the manufacturer&#39;s guidelines consider the exposure of the medial gutter as part of the surgical technique, while we reserve it only in those cases in which osteophytes are present after the &#39;&#39;Tibia #2&#39;&#39; cut. In fact, the bone cutting through the &#39;&#39;Tibia #2&#39;&#39; hole of the resection guide usually offers a sufficient cleaning of the medial gutter avoiding a medial impingement.
The main limitation of this technique is that the lateral transfibular approach required systematically a fibular malleolus osteotomy that is not routinely necessary in TAR performed through an anterior approach47. The disadvantages are: a lengthening of the operative time (also in consideration of the need for fibular fixation at the end of the procedure) and the risk of subsequent hardware removal in case of patient discomfort. Despite these disadvantages, the fibular osteotomy allows the management of the coronal malalignments consequent to fibula-length issues. Moreover, the osteotomy technique presented in our protocol usually allows for a stable fixation with screws alone, thus dramatically decreasing the need for further hardware removal due to plate discomfort, even if it makes the fibular reflection more complicated. Another limitation is that, though some studies regarding the results of TAR with lateral transfibular approach have already been published, the encouraging results of this technique must be confirmed by long-term follow-up studies12,16,17,18.
A critical step of this protocol is a correct preoperative evaluation in order to properly plan the surgical procedure. The preoperative clinical and radiographic evaluation aims to identify any foot and ankle malalignment that should be addressed in order to achieve a well-balanced implant. Restoring the appropriate position of the tibial and talar components and the correct foot and ankle alignment are essential for the long-term success of the implant35,48,49. 
Another critical step is represented by the postoperative care: postoperative steps must be carefully followed in order to protect the healing of fibular osteotomy and to avoid early postoperative complications.
In conclusion, in consideration of the early results of this prosthesis reported in previous studies16,17, and of the functional and postoperative pain scores reported in this article, the treatment of ankle osteoarthritis with TAR via lateral transfibular approach can provide reliable pain relief and improvements in range of motion and functional outcomes.

The most frequent etiology of ankle osteoarthritis is the post-traumatic origin. In fact, it is often secondary to traumatic injuries that typically affect young patients1,2. Ankle osteoarthritis influences patients&#39; quality of life to the same degree as hip osteoarthritis and even more than knee osteoarthritis3. Ankle fusion has been considered the gold-standard for the treatment of ankle osteoarthritis, but some studies show that it confers augmented stress and increased risk of osteoarthritis of the adjacent joints4,5,6,7; furthermore, there still exist a number of complications associated with ankle fusion, such as equinus or talipes deformity and painful non-union8,9. With the evolution of surgical techniques and implant designs, total ankle replacement (TAR) has become an excellent alternative to ankle fusion for a surgeon with a proper learning-curve10,11,12.
TAR allows the preservation of ankle range of motion and protects from adjacent joint degeneration13. The anterior approach permits an optimal visualization of the coronal alignment; at the same time, this approach is inclined to wound-healing complications14,15. Recently, a novel TAR implant was designed to be performed via the lateral transfibular approach that results in an ideal visualization of the center of rotation and curved resections that allow for sparing bone cuts16; moreover, this approach permits the implantation of components perpendicular to the bone trabeculae, thus limiting the shear forces at the level of the bone-implant interface16. This prosthesis consists of a fixed-bearing implant; an alignment coordinate system guides the bone resections and facilitates addressing both coronal and sagittal deformities17. The early results of ankle arthroplasty using this TAR implant have been published 12,16,17,18. The aim of the present paper is to present our preoperative, operative, and postoperative protocols for the treatment of the osteoarthritis of the ankle with TAR via the lateral approach.
Patient selection starts with a careful clinical examination and history. A medical history of inflammatory or vascular disease, neuropathy or neurologic disease and complicated diabetes may modify the indication. Poor soft tissue envelope of the ankle should be carefully evaluated because it may compromise the wound healing: skin and subcutaneous soft-tissue may already have been compromised from injury or previous surgery. The use of drugs that may influence healing must be considered. Muscle and tendon function, ankle and hindfoot alignment, and ankle range of motion should be evaluated: a detailed examination can indicate whether accessory procedures are needed at the time of surgery19.
We suggest always discussing the expectations of the patient concerning the outcomes of the procedure and the need for compliance with post-operative care. TAR is indicated for patients with an ankle joint disease due to post-traumatic, rheumatoid, or primary arthritis not responsive to conservative options that include physical therapy, activity modification, and non-steroidal anti-inflammatory drugs19. Also, lateral ankle instability may represent a cause of joint degeneration defined as ligamentous posttraumatic ankle osteoarthritis20. In addition, secondary osteoarthritis can be associated with systemic diseases: avascular necrosis of the talus, gout, hemophilia, post-infectious arthritis, and hereditary hemochromatosis21,22,23,24.
During the preoperative consultation, we routinely record the following clinical and functional scores: American Orthopaedic Foot &#38; Ankle Society (AOFAS) ankle and hindfoot score25,26,27, 12-Item Short Form Health Survey27,28, and Visual Analogue scale (VAS) pain score29.

<table><tbody><tr><td>Zimmer Total Ankle</td><td>Zimmer, Inc.</td><td>82-0175-162-00</td><td>Total Ankle Replacement</td></tr><tr><td>Calcaneus pin</td><td>Zimmer, Inc.</td><td>00-4501-040-00</td><td>Trans-calcaneal pin</td></tr><tr><td>4.0 mm Pin</td><td>Zimmer, Inc.</td><td>00-4501-040-04</td><td>Talar pin</td></tr><tr><td>5.0 mm Pin</td><td>Zimmer, Inc.</td><td>00-4501-040-05</td><td>Tibial pins</td></tr><tr><td>1.6 mm k-wire</td><td>Zimmer, Inc.</td><td>00-4501-040-01</td><td>1.6 mm Kirschner wire</td></tr><tr><td>Moonray BlueLIne Dual</td><td>SIMAD</td><td></td><td>Mobile C-arm</td></tr><tr><td>Pre-Cut Guide Drill</td><td>Zimmer, Inc.</td><td>00-4501-059-00</td><td>Precutting bone drill</td></tr><tr><td>Bur</td><td>Zimmer, Inc.</td><td>00-4501-076-00</td><td>Bone resection burr</td></tr><tr><td>Micro 100 Drill</td><td>Conmed Corporation</td><td>5053-009</td><td>Pneumatic handpieces</td></tr><tr><td>3.5 mm ULS screws</td><td>Zimmer, Inc.</td><td></td><td>Fibular fixation screws</td></tr><tr><td>Matlab version 2008</td><td>The MathWorks Inc.</td><td></td><td>Statistical software</td></tr></tbody></table>

treatment of ankle osteoarthritis with total ankle replacement through a lateral transfibular approach

Total ankle replacement (TAR) is a valid option for the treatment of ankle osteoarthritis. The traditional surgical approach for TAR is the anterior approach. Recently, the lateral transfibular approach to the ankle has gained popularity since a new TAR implant was designed to be performed via this approach that results in an ideal visualization of the center of rotation of the ankle and curved resections that allow for sparing bone cuts. The aim of the present paper is to present our preoperative, operative, and postoperative protocols for the treatment of the osteoarthritis of the ankle with TAR via lateral approach. We present our preoperative clinical and radiographic protocol. In addition, we describe our surgical technique with some technical tips. Finally, we report our follow-up schedule that includes the collection of clinical, functional, and radiographic data. The results of this procedure are encouraging: TAR through a lateral transfibular approach provides reliable pain relief and improvements in functional outcomes in patients with ankle osteoarthritis.

We collected the results of a consecutive series of 114 patients (114 ankles) who underwent TAR via lateral transfibular approach between May 2013 and July 2016. All operative procedures were carried out by the senior author.
Data were analyzed with a statistical software (see Table of Materials). The ANOVA and kappa tests were performed40,41. For k-score, the 95% confidence intervals were defined. We considered p-values for tests significant at p&#60;0.05.
The mean AOFAS hindfoot score improved from 32.2 preoperatively (range 7-67) to 85.2 at the latest follow-up (range 59-100). The average Physical Health Composite Scale (PCS) of the SF-12 score improved from 30.7 preoperatively (range 19.4-53.6) to 44.9 at the latest follow-up (range 21.9-61.9); the average Mental Health Composite Scale (MCS) of the SF-12 score improved from 44.3 preoperatively (range 23.5-71.4) to 49.9 at the latest follow-up (range 35.0-65.2). The mean VAS pain score improved from 8.4 preoperatively (range 4-10) to 2.1 at the latest follow-up (range 0-6).
The differences between the preoperative scores and the follow-up scores were statistically significant. A summary of the representative results is provided in Table 1.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/56396/56396fig1.jpg" /> 
Figure 1. Preoperative measurements on lateral weight-bearing radiographs. Lateral weight-bearing ankle view of a patient with ankle osteoarthritis. The following measurements are marked: anterior distal tibial angle and tibio-talar ratio. ADTA: anterior distal tibial angle, the angle traced between the line that connects the anterior and posterior tibial edges at the level of the articular surface and the axis of the tibia. Tibio-talar ratio: draw a segment parallel to the ground starting from the posterior edge of the talus (C, corresponding to the intersection of the calcaneal cortex with the posterior subtalar surface) to the anterior edge of the talus (A, corresponding to the projection of the anterior edge of the talus onto the straight line); this segment is divided into two further segments by the axis of the tibia; the tibio-talar ratio is the ratio of the length of the posterior talar segment (BC) to the longitudinal length of the talus (AC), expressed as a percentage. Postoperative tibio-talar ratio is measured with the same technique.
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/56396/56396fig2.jpg" /> 
Figure 2. Preoperative measurements on antero-posterior weight-bearing radiographs. Antero-posterior weight-bearing ankle view of a patient with ankle osteoarthritis. The following parameters are measured: the lateral distal tibial angle and the tibio-talar surface angle. LDTA: lateral distal tibial angle, the lateral angle between the tibial axis and the straight line that connects the medial and lateral points of the articular surface of the tibia. Tibio-talar surface angle: the angle subtended medially by the tibial axis and the straight line that connects the medial and lateral edges of the talar articular surface. The postoperative tibio-talar surface angle is measured with the same technique.
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/56396/56396fig3.jpg" /> 
Figure 3. Skin incision for lateral transfibular approach to the ankle. The incision is made along the lateral malleolus curving toward the sinus tarsi.
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/56396/56396fig4.jpg" /> 
Figure 4. Antero-posterior weight-bearing control radiographs. Postoperative antero-posterior weight-bearing ankle view of TAR implanted through lateral transfibular approach 6 months after the surgery. The following measurement is marked: alpha angle. &#945;: alpha angle, the lateral angle between the anatomical axis of the tibia and the articular surface of the tibial component. The tibio-talar surface angle is also measured during the follow-up with the same technique shown in Figure 2.
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/56396/56396fig5.jpg" /> 
Figure 5. Lateral weight-bearing control radiographs. Postoperative lateral weight-bearing ankle view of TAR implanted through lateral transfibular approach 6 months after the surgery. The following measurements are marked: beta angle, gamma angle. &#946;: beta angle, the angle subtended anteriorly by the anatomical axis of the tibia and the articular surface of the tibial component. &#947;: gamma angle, it is subtended by a segment connecting the anterior and the posterior points of the talar component and a straight line drawn along the longitudinal axis of the neck of the talus. The tibio-talar ratio is also measured during the follow-up with the same technique shown in Figure 1.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Preoperative mean (range)</td>
			<td>Postoperative mean (range)</td>
			<td>p-value</td>
		</tr>
		<tr>
			<td>AOFAS</td>
			<td>32.2 
			(7-67)</td>
			<td>85.2 
			(59-100)</td>
			<td>&#60; 0.001</td>
		</tr>
		<tr>
			<td>VAS</td>
			<td>8.4 
			(4-10)</td>
			<td>2.1 
			(0-6)</td>
			<td>&#60; 0.001</td>
		</tr>
		<tr>
			<td>SF-12 PCS</td>
			<td>30.7 
			(19.4-53.6)</td>
			<td>44.9 
			(35.0-65.2)</td>
			<td>&#60; 0.001</td>
		</tr>
		<tr>
			<td>SF-12 MCS</td>
			<td>44.3 
			(23.5-71.4)</td>
			<td>49.9 
			(35.0-65.2)</td>
			<td>&#60; 0.001</td>
		</tr>
	</tbody>
</table>
Table 1. Summary of the representative results. Comparison of preoperative clinical scores and postoperative clinical scores. Data is presented as mean (range). AOFAS: American Orthopaedic Foot &#38; Ankle Society (AOFAS) ankle and hindfoot score. VAS: Visual Analogue scale pain score. SF-12 PCS: Physical Health Composite Scale of the 12-Item Short Form Health Survey. SF-12 MCS: Mental Health Composite Scale of the 12-Item Short Form Health Survey.

Watch this Scientific Journal Video about Treatment of Ankle Osteoarthritis with Total Ankle Replacement Through a Lateral Transfibular Approach at JoVE.com

Treatment of Ankle Osteoarthritis with Total Ankle Replacement Through a Lateral Transfibular Approach

We present our preoperative, operative, and postoperative protocols for the treatment of osteoarthritis of the ankle with total ankle replacement via lateral transfibular approach.

Total ankle replacement (TAR) is a valid option for the treatment of ankle osteoarthritis. The traditional surgical approach for TAR is the anterior ...

treatment-ankle-osteoarthritis-with-total-ankle-replacement-through

Nanyang Technological University

Research

JoVE Journal

Behavior

11.7K Views.  Galeazzi Orthopedic Institute for Research and Care. We presenteren onze preoperatieve, operationele en postoperatieve protocollen voor de behandeling van artrose van de enkel met totale enkelvervanging via laterale transfibular aanpak.

Video: Treatment of Ankle Osteoarthritis with Total Ankle Replacement Through a Lateral Transfibular Approach

Reverse Total Shoulder Arthroplasty

Reverse total shoulder arthroplasty was initially approved for use in rotator cuff arthropathy and well as chronic pseudoparalysis without arthritis in patients who were not appropriate for tendon transfer reconstructions. Traditional surgical options for these patients were limited and functional results were sub-optimal and at times catastrophic. The use of reverse shoulder arthroplasty has been found to effectively restore these patients function and relieve symptoms associated with their disease. The procedure can be done through two approaches, the deltopectoral or the superolateral. Complication rates associated with the use of the prosthesis have ranged from 8-60% with more recent reports trending lower as experienced is gained. Salvage options for a failed reverse shoulder prosthesis are limited and often have significant associated disability. Indications for the use of this prosthesis continue to be evaluated including its use for revision arthroplasty, proximal humeral fracture and tumor. Careful patient selection is essential because of the significant risks associated with the procedure.

Reverse total shoulder arthroplasty is indicated for the treatment of conditions that cannot be treated with conventional arthroplasty or other procedures. These primarily include degenerative and incapacitating conditions with irreparable rotator cuff and loss of the normal biomechanical coupling of the shoulder.

Reverse total shoulder arthroplasty was initially approved for use in rotator cuff arthropathy and well as chronic pseudoparalysis without arthritis in ...

Medicine

Autologous Microfractured and Purified Adipose Tissue for Arthroscopic Management of Osteochondral Lesions of the Talus

In recent years, regenerative techniques have been increasingly studied and used to treat osteochondral lesions of the talus. In particular, several studies have focused their attention on mesenchymal stem cells derived from adipose tissue. Adipose-derived stem cells (ADSCs) exhibit morphological characteristics and properties similar to other mesenchymal cells, and are able to differentiate into several cellular lines. Moreover, these cells are also widely available in the subcutaneous tissue, representing 10 - 30% of the normal body weight, with a concentration of 5,000 cells per gram of tissue.
In the presented technique, the first step involves harvesting ADSCs from the abdomen and a process of microfracture and purification; next, the surgical procedure is performed entirely arthroscopically, with less soft tissue dissection, better joint visualization, and a faster recovery compared with standard open procedures. Arthroscopy is characterized by a first phase in which the lesion is identified, isolated, and prepared with microperforations; the second step, performed dry, involves injection of adipose tissue at the level of the lesion.
Between January 2016 and September 2016, four patients underwent arthroscopic treatment of osteochondral lesion of the talus with microfractured and purified adipose tissue. All patients reported clinical improvement six months after surgery with no reported complications. Functional scores at the latest follow-up are encouraging and confirm that the technique provides reliable pain relief and improvements in patients with osteochondral lesion of the talus.

The aim of this study is to report a protocol for the arthroscopic treatment of osteochondral lesions of the talus using microfractured and purified adipose-derived stem cells.

In recent years, regenerative techniques have been increasingly studied and used to treat osteochondral lesions of the talus. In particular, several ...

Transtubular Endoscopic Posterolateral Decompression for L5-S1 Lumbar Lateral Disc Herniation

We report a novel technique for C-arm free transtubular L5 nerve decompression under CT-based navigation to reduce the radiation hazard. This procedure is performed under general anesthesia and neuromonitoring. The patient is placed in a prone position on an operating carbon table. A navigation reference frame is placed percutaneously into the contralateral sacroiliac joint or spinous process. Then, CT scan images are obtained. After instrument registration, the L5-S1 foraminal level is confirmed with a navigated probe, and the entry point is marked. Using an approximately 2 cm skin incision, the subcutaneous tissue and muscles are dissected. The navigated first dilator is aimed at the L5-S1 Kambin&#39;s triangle, and sequential dilation is performed. The 18 mm tube is used and fixed to the frame. The bone around the Kambin&#39;s triangle is removed with a navigated burr. For lateral disc herniation, the L5 nerve root is identified and retracted, and the disc fragment is removed. The navigation-guided tubular endoscopic decompression is an effective procedure. There is no radiation hazard to the surgeon or the operating room staff.

Presented here is a novel technique of C-arm free transtubular posterolateral decompression for lumbar foraminal stenosis and lateral disc herniation under O-arm navigation.

We report a novel technique for C-arm free transtubular L5 nerve decompression under CT-based navigation to reduce the radiation hazard. This procedure is ...

Neuroscience

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from symptomatic severe aortic valve stenosis. This is also reflected in the recently updated international guidelines on managing patients with valvular heart disease. A transfemoral&#160;(TF) TAVI&#160;approach has proven superior to alternative access strategies. With the introduction of intravascular lithotripsy (IVL), patients with calcified iliofemoral vascular disease and borderline intraluminal diameters have also become candidates for percutaneous TF-TAVI. Moreover, IVL reduces the risk of major vascular complications by modifying the superficial and deep vascular calcium, thereby changing the vessel compliance and controlling luminal expansion. In this way, IVL has shown to safely facilitate TF delivery of TAVI devices in patients with calcified peripheral artery disease. The present article aims to provide a detailed step-by-step description on how to perform IVL-assisted TF-TAVI safely and efficiently. Furthermore, a literature review on the outcomes obtained with this technology is included, along with a concise discussion on this unique TAVI approach.

Transcatheter aortic valve implantation (TAVI) has been shown to generate the best clinical outcomes when performed by the percutaneous transfemoral approach. Intravascular lithotripsy (IVL) can facilitate a transfemoral process in patients with calcified iliofemoral vascular disease and borderline intraluminal diameters. The present protocol describes IVL-assisted transfemoral TAVI.

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from ...

C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 level (OLIF51) is technically difficult because of the anatomical structures. We present a novel simultaneous technique of OLIF51 with percutaneous pedicle screw fixation without fluoroscopy. The patient is placed in a right lateral decubitus position. A percutaneous reference pin is inserted into the right sacroiliac joint. An O-arm scan is performed, and 3D reconstructed images are transmitted to the spinal navigation system. A 4 cm oblique skin incision is made under navigation guidance along the pelvis. The internal/external and transverse abdominal muscles are divided along the muscle fibers, protecting the iliohypogastric and ilioinguinal nerves. Using a retroperitoneal approach, the left common iliac vessels are identified. Special muscle retractors with illumination are used to expose the L5-S1 intervertebral disc. After disc preparation with navigated instruments, the disc space is distracted with navigated trials. Autogenous bone and demineralized bone material are then inserted into the cage hole. The OLIF51 cage is inserted into the disc space with the help of a mallet. Simultaneously, percutaneous pedicle screws are inserted by another surgeon without changing the lateral decubitus position of the patient.
In conclusion, C-arm-free OLIF51 and simultaneous percutaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This novel technique reduces surgical time and radiation hazards.

C-arm-free oblique lumbar interbody fusion at the L5-S1 level (OLIF51) and simultaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This technique does not expose the surgeon or operating staff to radiation hazards.

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 ...

The Use of Mixed Reality in Custom-Made Revision Hip Arthroplasty: A First Case Report

The technology of 3D printing and visualization of anatomical structures is rapidly growing in various fields of medicine. A custom-made implant and mixed reality were used to perform complex revision hip arthroplasty in January 2019. The use of mixed reality allowed for a very good visualization of the structures and resulted in precise implant fixation. According to the authors' knowledge, this is the first described case report of the combined use of these two innovations. The diagnosis preceding the qualification for the procedure was the loosening of the left hip's acetabular component. Mixed reality headset and holograms prepared by engineers were used during the surgery. The operation was successful, and it was followed by early verticalization and patient rehabilitation. The team sees opportunities for technology development in joint arthroplasty, trauma, and orthopedic oncology.

A complex revision hip arthroplasty was performed using a custom-made implant and mixed reality technology. According to the authors&#39; knowledge, this is the first report of such procedure described in the literature.

The technology of 3D printing and visualization of anatomical structures is rapidly growing in various fields of medicine. A custom-made implant and mixed ...

The Transition to an Anterior-Based Muscle Sparing Approach Improves Early Postoperative Function but is Associated with a Learning Curve

Surgeons considering transitioning to an anterior-based approach for THA are concerned about the learning curve and the reported marginal clinical benefit. Accordingly, the first cohort of THAs, which were implanted by a single surgeon using the anterior-based muscle-sparing approach (ABMS), was analyzed. The goal of the study was to test 1) whether patient-reported outcomes improved and 2) whether the complication rate decreased with the number of THAs performed. A retrospective cohort study on the first 30 primary THA cases (27 patients) of one surgeon (January 2021-April 2021) using the ABMS approach was conducted. These 30 THAs were compared to 30 primary THA cases (30 patients) done immediately prior to the transition by the same surgeon (September 2020-December 2020) using the posterior approach (PA). The Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score (HOOS Junior), and Forgotten Joint Score (FJS) obtained 6 weeks and 6 months after surgery were compared. In addition, three consecutive groups based on equal numbers of THAs were compared for the incidence of complications and surgery time. At 6 weeks after THA, the OHS was 6 points higher after the ABMS approach (p = 0.0408), and the OHS was comparable at 6 months. The HOOS Junior and FJS were similar at 6 weeks and 6 months after surgery.&#160;In the first 10 THAs using the ABMS approach, one patient had a greater trochanter fracture, and one patient had an intraoperative proximal femur fracture. No further immediate interoperative or postoperative complications occurred. Surgery time significantly reduced with the number of THAs performed. Transitioning from the PA to the ABMS approach is associated with a learning curve, which is limited to the first 20 cases. The effect of improved clinical outcomes is apparent within the early postoperative period. After 6 months, THA patients do well regardless of the approach.

The anterior-based muscle-sparing approach for total hip arthroplasty (THA) is associated with a learning curve. However, the improved clinical outcome in the early post-operative phase makes the consideration to transition worthwhile.

Surgeons considering transitioning to an anterior-based approach for THA are concerned about the learning curve and the reported marginal clinical ...

An Effective Surgical Strategy for Anteromedial Osteoarthritis of the Knee with Simultaneous Popliteal Cysts Drainage

Unicompartmental knee arthroplasty (UKA) is an established treatment option for anteromedial osteoarthritis, and popliteal cysts are a common finding in the knee among patients with chronic osteoarthritis pain. The two are so closely related that popliteal cysts are commonly discovered during the unicompartmental knee arthroplasty preoperative examination. However, only a few reports exist on the management and outcome of popliteal cysts in the patients receiving UKA for knee osteoarthritis (OA) and popliteal cysts. As such, it is crucial to evaluate different treatment strategies and their management of popliteal cysts. In this paper, we evaluate a surgical strategy for patients with knee anteromedial osteoarthritis and symptomatic popliteal cysts. These patients were treated with UKA and internal drainage of the popliteal cyst. The results shown here, spanning 1-year post-operation follow-up, demonstrated that UKA and internal drainage is an effective surgical protocol for treating anteromedial osteoarthritis with symptomatic popliteal cysts.

Popliteal cysts are frequently found during the pre-operative examination of patients with osteoarthritis being prepared for the unicompartmental knee arthroplasty. These symptomatic cysts usually require treatment. To do this, a unicompartmental knee arthroplasty was performed with internal drainage of the popliteal cyst under the same anesthetic.

Unicompartmental knee arthroplasty (UKA) is an established treatment option for anteromedial osteoarthritis, and popliteal cysts are a common finding in ...

Surgical Approach and Complications of Stand-alone Lateral Trans-Psoas Interbody Fusion

Interbody fusion of the lumbar spine is a standard procedure for symptomatic degenerative lumbar spine disease if conservative treatment fails. Surgical decompression and fusion of the segment can be achieved using several different techniques. Over the last decades, minimally invasive techniques, such as lateral interbody fusion (LLIF), have been developed to reduce tissue damage and complications and allow quicker patient recovery. With growing popularity, indications for LLIF have expanded to treat spinal deformities and foraminal/central stenosis. Mechanically, it allows for an unsurpassed fixation through the left-to-right apophyseal ring placement of the cage. LLIF utilizes a minimally disruptive retroperitoneal corridor and includes both trans-psoas and pre-psoas approaches. For the pre-psoas approach, the risk of damage from manipulation of the intramuscular lumbar plexus is reduced compared to a trans-psoas approach. However, increased risks of major vascular, ureteral, bowel injury and sympathetic plexus damage are reported.
This article aims to provide a detailed and comprehensive guide on stand-alone lateral trans-psoas interbody fusion, including its indications, surgical procedure, potential complications, and outcomes based on a decade of experience from a single center.

Interbody fusion of the lumbar spine can be achieved surgically using different techniques. Minimally invasive techniques, including lateral interbody fusion, have been developed within recent decades to reduce rates of complications and allow for quicker patient recovery. We provide insight into stand-alone lateral trans-psoas interbody fusion, highlighting potential complications and pitfalls.

Interbody fusion of the lumbar spine is a standard procedure for symptomatic degenerative lumbar spine disease if conservative treatment fails. Surgical ...

Management of Failed Latarjet and Off-tract Hill-Sachs Lesion: Arthroscopy-assisted Remplissage and Open Eden-Hybinette Procedure

This case report describes a 49-year-old former semi-professional judo player with recurrent right shoulder instability following his first dislocation in 2006. He underwent two unsuccessful arthroscopic Bankart repairs due to improper anchor positioning. In March 2020, an open Latarjet procedure was performed to address his ongoing instability, but he suffered another dislocation in January 2023 after a fall. Physical examination revealed a full range of motion, normal rotator cuff strength, and a positive apprehension test. X-rays showed a broken coracoid bone block, screw displacement, and a significant Hill-Sachs lesion. CT confirmed resorption of the previous coracoid graft and an off-track Hill-Sachs lesion. The patient underwent revision surgery, combining an arthroscopic-assisted Remplissage with an Eden-Hybinette procedure. One year postoperatively, the patient reported improved outcomes. Managing recurrent shoulder instability after failed surgeries is challenging. While the Latarjet procedure has a 10% recurrence rate, revision options such as distal tibial allograft and Eden-Hybinette procedures offer promising results. This case emphasizes the importance of combined surgical approaches and individualized treatment plans, particularly for patients with significant humeral bone loss, to enhance stability and reduce recurrent instability.

Here, we describe a modified technique for arthroscopy-assisted Remplissage and open Eden-Hybinette procedure for patients with failed Latarjet and off-tract Hill-Sachs lesions.

This case report describes a 49-year-old former semi-professional judo player with recurrent right shoulder instability following his first dislocation in ...

Treatment of Ankle Osteoarthritis with Total Ankle Replacement Through a Lateral Transfibular Approach

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