Background: Subtalar arthrodesis is the surgical procedure commonly performed to treat subtalar arthritis. Subtalar arthrodesis may have a higher nonunion rate if there is a preexisting adjacent joint arthrodesis. The aim of this retrospective cohort study was to compare the subtalar arthrodesis union rate of patients with native tibiotalar joints to that of patients with prior tibiotalar arthrodesis. The secondary aim was to assess risk factors for nonunion. Methods: A retrospective cohort study of consecutive patients that underwent a subtalar arthrodesis in a single center between 2010 and 2020. The primary outcome of union was determined based on bridging callus on radiographs and clinical symptoms. If there was uncertainty, then a nonweightbearing CT was acquired. Chi-squared test and Mann-Whitney tests compared differences in demographics and risk factors for nonunion between groups. A logistical regression model was performed to determine risk factors for nonunion. Results: Eighteen patients had an adjacent ankle arthrodesis and 53 patients did not. The successful subtalar arthrodesis union rate in those with a preexisting ankle joint arthrodesis (44.4%) was approximately half that in those without an ankle joint arthrodesis (86.8%) ( P < .001). On multivariate logistic regression, an adjacent ankle arthrodesis was the only significant risk factor for nonunion. The odds ratio of nonunion of the subtalar joint with an adjacent ankle arthrodesis present was 4.90 (95% CI 1.02-23.56) compared to a subtalar arthrodesis with a native ankle joint. In addition, 9.4% of patients without an ankle arthrodesis underwent a revision subtalar arthrodesis compared with 44.4% of those with an adjacent ankle arthrodesis ( P = .001). Conclusion: In our study, we found that patients undergoing a subtalar arthrodesis with an adjacent ankle arthrodesis have a significantly increased risk of nonunion compared with those undergoing a subtalar arthrodesis with a native ankle. Patients with a previously fused ankle need counseling about the high risk of nonunion and potential additional surgery.
Introduction: Patients with hip fractures can become cold during the perioperative period despite measures applied to maintain warmth. Poor temperature control is linked with increasing complications and poorer functional outcomes. There is generic evidence for the benefits of maintaining normothermia, however this is sparse where specifically concerning hip fracture. We provide the first comprehensive review in this population. Significance: Large studies have revealed dramatic impact on wound infection, transfusion rates, increased morbidity and mortality. With very few studies relating to hip fracture patients, this review aimed to capture an overview of available literature regarding hypothermia and its impact on outcomes. Results: Increased mortality, readmission rates and surgical site infections are all associated with poor temperature control. This is more profound, and more common, in older frail patients. Increasing age and lower BMI were recognized as demographic factors that increase risk of hypothermia, which was routinely identified within modern day practice despite the use of active warming. Conclusion: There is a gap in research related to fragility fractures and how hypothermia impacts outcomes. Inadvertent intraoperative hypothermia still occurs routinely, even when active warming and cotton blankets are applied. No studies documented temperature readings postoperatively once patients had been returned to the ward. This is a point in the timeline where patients could be hypothermic. More studies need to be performed relating to this area of surgery.
We would like to thank Dr Pattisapu and colleagues for their interest in our article on subtalar arthrodesis rates, dependent on the presence of an adjacent ankle arthrodesis or not. 1 This is a retrospective cohort study designed to either confirm or refute our clinical suspicion that patients who had undergone a previous ipsilateral ankle fusion had a higher rate of subtalar nonunion than those patients without an ankle arthrodesis. Clearly, as this was a retrospective study, CT scans were only available for those patients who were symptomatic and had signs of nonunion. From a pragmatic perspective, there is no benefit in performing a CT scan in an asymptomatic patient. Pragmatism prevails in poorer-resourced health care systems across the globe. Therefore, it would be our usual practice to obtain CT scans in patients of concern at a minimum of 6 months postsurgery.Dr Pattisapu and colleagues state that "patients with isolated subtalar fusions are far less likely to have symptoms than those who have combined ankle and subtalar fusions."We have not found this to be the case and therefore disagree that this group would be subject to higher rates of CT scanning, thereby artificially increasing the nonunion rate in patients with ipsilateral ankle and subtalar fusions.It is our usual practice to mobilize all hindfoot and ankle arthrodesis patients at 6 weeks in a removable boot. Although radiographs are obtained at this stage, they are used to ensure that there has been no significant shift or failure of the hardware or construct. We would not expect to see bone union at this stage, and it is not looked for.Ultimately, this study demonstrates that there are higher rates of subtalar nonunion in patients with ipsilateral ankle arthrodesis than those without. We would, therefore, contest Dr Pattisapu's point that we have not added to the debate on ankle arthrodesis vs ankle replacement in patients requiring subtalar fusion, when the literature has shown higher rates of subtalar union in patients with arthroplasty 2 compared to our series of fused ankles.Finally, we would very much like to agree that identifying the rates of subtalar fusion in patients with or without ankle arthrodesis is challenging and we would very much welcome the results of a prospective randomized controlled trial with computed tomography-proven union as an endpoint.
Background: There is sparse data on the incidence of thromboembolic and medical complications following total ankle replacements. The aim of this systematic review was to determine the risk of deep vein thrombosis and pulmonary embolism as well as mortality and medical complications following ankle replacements. Methods: A systematic review was undertaken using all levels of evidence following PRISMA guidelines. Of the 1657 articles identified, 25 met the inclusion criteria. The inclusion criteria were a primary total ankle replacement with the recording of medical complications and/or thromboembolic events and/or mortality data. Two reviewers independently reviewed all articles. Quantitative methods were used to pool the percentages with complications across studies. Results: The pooled percentage with reported symptomatic deep vein thrombosis across 18 studies was 0.07% (95% CI 0.001%-0.59%). The pooled percentage with reported postoperative pulmonary embolism across 8 studies was 0.01% (95% CI 0.001%-0.03%). The pooled postoperative reported mortality was 0.06% (95% CI 0.001%-0.24%). Other medical complications had low incidences. Conclusion: Our study indicates rates of reported thromboembolic events of less than 1 in 1000. Notably the level of evidence analyzed was mainly Level III and IV, likely underestimating the true incidence of these events because of recall and medical record limitations, and we had insufficient information on usage of chemoprophylaxis among these patients Level of Evidence: Level IV, systematic review based on all levels of evidence including case series.
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