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Transcatheter aortic valve implantation (TAVI) is an established therapy for the treatment of aortic valve disease in appropriately selected patients. Previous studies using the self-expanding Portico transcatheter heart valve (THV), (Abbott Structural Heart, St Paul, MN, USA) have demonstrated the technical feasibility of this system albeit in the hands of relatively inexperienced Portico users. The objective of this study was to assess the real-world safety and efficacy of the Portico THV (with and without the FlexNav delivery system, Abbott Structural Heart) at the 30-day timepoint in an Australian cohort.This study was a retrospective real-world cohort analysis of 269 consecutive patients with severe aortic valve disease who underwent TAVI at multiple centres within Australia between February 2015 and April 2021. Of the 269 patients, 51.7% were female, mean Society of Thoracic Surgeons (STS) score was 5.2 (±6.8) and 98.5% had successful implantations. Thirty (30)-day post-implantation all-cause mortality was observed in one (0.4%) patient, major vascular complications in two (0.7%) patients, more-than-mild paravalvular leak in six (2.2%) patients and requirement for new permanent pacemaker implantation in 27 (10.2%) patients. Haemodynamic parameters at 30 days included mean effective orifice area (EOA) of 2.3 (±0.9) cmThis analysis of the Portico THV in a real-world setting suggested that the system is associated with satisfactory safety and efficacy parameters. Previously published datasets may not have found similar findings owing to lower operator experience with the Portico THV system.

The aim of this study was to assess the inferior talus-superior talus (inf-tal-sup-tal) angle (previously proven reliable in multiplanar-weight bearing imaging (MP-WB)) on both computed tomography (CT) and MP-WB scans. We sought to compare the angle between the two modalities in both AAFD and control groups, as well as to compare the groups to each other.Inf-tal-sup-tal angles were compared between a stage II AAFD group (n=38) with routine MP-WB and CT scans and a control group (n=20) with preoperative CT scans for lisfranc injuries and normal hindfoot alignment after healing.The CT inf-tal-sup-tal angle was significantly greater in AAFD compared to control (AAFD, 12±6; control, 5±4; p0.001), but was even greater with MP-WB. There was no significant correlation between inf-tal-sup-tal angles on MP-WB and CT (Pearson's=0.29, p=0.08).MP-WB imaging proved to be correlated more strongly with AAFD than CT by revealing greater hindfoot valgus. This confirmed that CT scans are useful in predicting AAFD, but cannot be used as a surrogate for MP-WB scans.

Few reports in the literature have described the conversion of a surgically fused ankle to a total ankle replacement. The takedown of an autofusion and conversion to a prosthesis has not been described. We report the case of a patient with severe rheumatoid arthritis with an ankle autofusion fixed in equinus and severe talonavicular arthritis that was converted to ankle replacement using the Salto XT revision system. We describe the reasons why the decision was made to perform total ankle arthroplasty while concomitantly fusing the talonavicular joint, and discuss the rationale of the various surgical treatment options considered. We describe the clinical and radiographic outcomes achieved in this case. At 12 months post-operatively the patient reported significant reduction of pain, increased FAOS scores and had increased ankle range of motion.

Background: Underlying bony deformity may be related to development of adult-acquired flatfoot deformity (AAFD). Multiplanar weightbearing (MP-WB) computed tomography can be used to identify subtalar deformity which may contribute to valgus hindfoot alignment. On coronal MP-WB images, 2 angles reliably evaluate the subtalar joint axis: the angle between the inferior facet of the talus and the horizontal (inftal-hor) and the angle between the inferior and superior facets of the talus (inftal-suptal). Although these angles have been shown to differ significantly between flatfoot patients and controls, no study has investigated their relationships with other components of AAFD. We hypothesized that these angles would correlate strongly with commonly used radiographic measures of AAFD. Methods: Forty-five patients with stage II AAFD and 17 control patients underwent MP-WB imaging and standard weightbearing radiographs. MP-WB measurements were correlated with standard radiographic measurements of AAFD. Differences between AAFD and control patients were assessed using independent samples t tests and Mann-Whitney U tests. To assess correlations between each MP-WB measurement and radiographic measurement, factorial generalized linear models (GLMs) were constructed. Results: Patients with AAFD differed from the controls in all measured angles ( P ≤ .001 for each). After accounting for differences between flatfoot and control patients, inftal-hor was not significantly correlated with any of the radiographic angles. Inftal-suptal, however, correlated with the AP coverage angle, AP talar–first metatarsal angle, calcaneal pitch, Meary’s angle, medial column height, and hindfoot alignment after accounting for differences between flatfoot patients and controls. Meary’s angle alone explained 48% of the variation in inftal-suptal angles. Conclusion: As measured on coronal MP-WB images, patients with stage II AAFD had more innate valgus in their talar anatomy as well as more valgus alignment of their subtalar joints than did control patients. It is possible that this information could be used to identify patients likely to have progression of deformity and may ultimately guide the approach to operative reconstruction. Level of Evidence: Level III, case-control study.

Category: Ankle; Trauma Introduction/Purpose: It is controversial whether routine arthroscopy is beneficial at the time of ankle fracture fixation. This may be, in part, due to sparse information regarding the incidence of chondral injury in the setting of ankle fractures.The purpose of this study is to systematically review the incidence of chondral injures in patients with ankle fractures and to further characterize intra-articular chondral injuries of the talus, tibial plafond, medial malleolus, and lateral malleolus in patients who undergo ankle arthroscopy following an ankle fracture. Methods: The literature search was performed based on the PRISMA guidelines. Studies evaluating the incidence of chondral lesions at the time of arthroscopy for ankle fractures were included. The incidence of intraarticular chondral lesions was recorded, as well as location within the ankle, ankle fracture type, time of arthroscopy, characterization of chondral injury, complications, and outcome if available. All statistical analyses were carried out with statistical software package SPSS 24.0 (SPSS, Chicago, IL, USA). Multiple comparisons were used to compare incidence rates of chondral injury based on Weber classification, malleolar fracture type, and Lauge-Hansen classification, using Pearson chi-square test. For all analyses, p < 0.05 was considered statistically significant. Results: Fifteen studies with 1,355 ankle fractures were included. Of those ankles, 738 demonstrated evidence of chondral or osteochondral lesion (54.5%). Overall, 648 ankles had chondral lesions on the talus (47.8%), 207 ankles had lesions on the tibial plafond (15.3%), 165 has lesions of the lateral malleolus (12.2%), and 133 had lesions of the medial malleolus (9.8%). Weber C group had significantly higher incidence than Weber A group (p=0.015). Trimalleolar and isolated lateral malleolar fracture groups had significantly higher incidence of chondral injury than bimalleolar and isolated medial malleolar fracture groups (pConclusion: Our study found a high incidence of intra-articular chondral lesion in the setting of ankle fractures as demonstrated by arthroscopy, with more than half of all patients having a chondral lesion. Talar lesions were most common. This study may help direct greater attention to the Talus as a source of chondral injury particularly in higher grade fracture patterns.

Background:Hallux valgus is frequently associated with additional forefoot pathologies, including hammertoes and midfoot osteoarthritis (OA). However, the pathogenesis of these concurrent pathologies remains to be elucidated. We sought to determine whether there is a relationship between demographic and radiographic parameters and the incidence of secondary pathologies in the setting of a bunion, with an emphasis on second tarsometatarsal (TMT) OA and hammertoes.Methods:A total of 153 patients (172 feet) who underwent reconstruction for hallux valgus were divided into 3 groups: (1) bunion only (61 patients), (2) bunion with hammertoe without second TMT joint OA (78 patients), and (3) bunion with second TMT joint OA (14 patients). Preoperative age, sex, and body mass index (BMI) as well as hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsus adductus angle (MAA), ratio of second to first metatarsal length, and Meary’s angle were recorded. One-way analysis of variance (normality demonstrated) and Kruskal-Wallis (normality not demonstrated) tests were used to assess differences in continuous variables. Post hoc tests were conducted with the Bonferroni technique. Associations between discrete variables and the study groups were analyzed using χ2tests. Following the univariate analysis, multinomial logistic regression models were built to determine potential risk factors for hammertoe or TMT OA group placement.Results:Patients in the hammertoe and TMT OA groups were significantly older than patients in the bunion only group ( P < .001 for both pairwise comparisons) and had significantly higher BMIs ( P = .024 and P < .001, respectively). Patients in the TMT OA group had a significantly higher mean HVA than patients in the bunion-only group ( P = .004) and a significantly higher mean MAA relative to both other study groups ( P ≤ .001 for both comparisons). IMA, Meary’s angle, and the ratio of second to first metatarsal length did not differ significantly between groups. In the multivariate analysis, hammertoe group assignment was predicted only by age and HVA, while midfoot OA group assignment was predicted by age, HVA, BMI, and MAA.Conclusion:Our data show that older age and increased HVA were predictors of both second ray pathologies studied. Higher BMI and MAA were predictive only of TMT joint OA. These data may help identify patients with hallux valgus who are at greater risk for developing secondary pathologies.Level of Evidence:Level III, retrospective comparative series.

Category: Bunion Introduction/Purpose: Hallux valgus deformity is well known to cause second ray pathology, commonly manifested as a second hammertoe or second tarsometatarsal (TMT) joint osteoarthritis (OA). This likely results from decreased weight-bearing capacity of the first metatarsal in the setting of worsening metatarsus primus varus, TMT joint hypermobility, or an excessively long second metatarsal or second toe. It is not known for sure, however, which radiographic and clinical factors in the setting of hallux valgus are protective of second ray pathology and which lead to second hammertoe, TMT joint OA, or both. We hypothesized that the formation of second ray pathology would be correlated with increasing age, increased body mass index (BMI), increased hallux valgus angle (HVA), increased intermetatarsal angle (IMA), and increased second metatarsal length. Methods: All consecutive patients who underwent operative reconstruction for symptomatic hallux valgus from January 2007 to July 2015 by the senior author were included. Patients were grouped into those with 1) bunion only 2) bunion with hammertoe and 3) bunion with second TMT joint OA. Preoperative age, sex, and BMI were recorded. Pre-operative HVA, IMA, metatarsus adductus angle (MAA), and first and second metatarsal lengths were measured on weight-bearing anteroposterior (AP) radiographs. Talar-first metatarsal angle was measured on weight-bearing lateral radiographs. One-way analysis of variance (normality demonstrated) and Kruskal-Wallis (normality not demonstrated) were used to assess differences in continuous variables. Post hoc tests were conducted with Bonferroni technique. Associations between discrete variables and the study groups were analyzed using chi-square tests. Results: Increased age was associated with both hammertoe (P = 0.000) and TMT joint OA (P = 0.006). Increased BMI was associated with TMT joint OA (P = 0.016). Increased HVA was associated with both hammertoe (P = 0.039) and TMT joint OA (P = 0.038). When analyzed categorically, 29.7% of patients with TMT joint OA had a moderate HVA (30.0-39.9 degrees) whereas 22.2% of patients with a bunion only had a moderate HVA (P < 0.05). A one-degree increase in HVA was associated with a 5% chance of having a hammertoe as compared to a bunion only. MAA correlated with TMT joint OA (P = 0.048) (Table 1). Conclusion: Our data suggests that increased age (a surrogate for bunion duration) and increased HVA may predispose patients with hallux valgus to second hammertoe and TMT joint OA formation. Increased BMI may lead to the development of TMT joint OA. Increased MAA may predispose to hammertoe formation. Increased MAA may lead to TMT joint OA. Alternatively, increased MAA could result as a consequence of midfoot cartilage and bone loss in the setting of hallux valgus. This data can help surgeons better inform patients about the optimal timing of bunion reconstruction with or without concomitant second ray surgery.

Background: The hindfoot moment arm is a reliable measurement of hindfoot valgus deformity in stage II adult-acquired flatfoot deformity (AAFD) and can be used to guide intraoperative correction of the hindfoot. There is currently little understanding of how the hindfoot moment arm relates to angular measurements of hindfoot alignment. The purpose of this study was to develop a new hindfoot alignment angle that can reliably quantify hindfoot valgus in patients with AAFD and to establish the relationship of this angle with the hindfoot moment arm. Methods: Preoperative hindfoot alignment radiographs were reviewed for 10 consecutive patients (10 feet) who were indicated for reconstruction for stage II AAFD. A second group of 10 patients (10 feet) without flatfoot were identified to serve as normal controls. The hindfoot moment arm and the new hindfoot alignment angle were measured in blinded fashion by 2 readers. Reliability was assessed using intraclass correlation coefficients (ICCs). The difference in angle between normal and flatfoot patients was assessed with a Mann-Whitney U test. A linear regression model was used to assess the relationship between hindfoot moment arm and the new hindfoot alignment angle. Results: Intra- and interrater reliability for the hindfoot alignment angle was excellent (ICC = 0.979 and 0.965, respectively). Flatfoot patients had greater mean angles than did normal patients (22.5 ± 4.9 vs 5.6 ± 5.4 degrees, P < .001). The hindfoot moment arm was correlated significantly with the hindfoot alignment angle ( P < .001), increasing by 0.81 mm for every degree increase in angle (adjusted R2 = 0.9046). Conclusion: These results indicate that the new hindfoot alignment angle is a reliable measure of hindfoot valgus and can differentiate between flatfoot and normal patients. In addition, the strong linear relationship between the hindfoot alignment angle and moment arm may allow for the use of this angle in the intraoperative correction of hindfoot valgus. Level of Evidence: Level III, retrospective case control study.

Preeclampsia (PE) is a hypertensive disease that affects 5-10% of pregnant women worldwide. Although a leading cause of maternal and perinatal morbidity/mortality, its origin is unknown. Abnormal placentation resulting in reduced placental perfusion is implicated. Early in pregnancy dNK cells are recruited to the maternal-fetal interface to promote uterine angiogenesis during decidualization. Uterine IL-15 activates dNK cells, which produce IFN-γ to orchestrate vessel remodeling. Using the BPH/5 mouse model that spontaneously develops the cardinal features of PE along with placental abnormalities, we tested the hypothesis that uterine inflammation is associated with dNK cell loss at the maternal-fetal interface prior to placenta formation. At the start of decidualization (e4.5-5.5), IL-15 mRNA was increased in BPH/5 implantation sites vs C57 controls (60-fold vs 20-fold respectively, p3 cells vs C57: 9.7 x 10 3 cells, p0.05), but blunted NKp46 mRNA expression (30-fold vs veh, p3 vs rIL-15/IL-15Rα: 0.4 x 10 3 cells, n=3-5, p inflammation and dNK cell loss, and that artificial increases in intrauterine IL-15 in control mice cause dNK cell loss. This suggests that increased uterine expression of IL-15 contributes to dNK cell loss at the maternal-fetal interface in BPH/5 mice, which could lead to impaired placental perfusion and development of PE in this model.

During early pregnancy dNK cells promote decidualization, which is critical for uterine angiogenesis and placentation. IL-15 activates dNK cells, which release IFN-γ to orchestrate vessel remodelin...

Category: Hindfoot Introduction/Purpose: In a previous study using novel multiplanar weight-bearing imaging (MP-WB), the inferior talus-superior talus (inftal-suptal) angle reliably evaluated the coronal orientation of the subtalar joint axis and was significantly greater in stage II adult-acquired flatfoot deformity (AAFD) patients compared to controls. Since the inftal-suptal angle relies solely on the morphology of the talus, which is theoretically unchanged at the time of flatfoot reconstruction, we hypothesized that it should be similar in pre-operative MP-WB scans compared to post-operative non-weight-bearing standard CT scans of a stage II AAFD group. We secondly hypothesized that the post-operative CT angle of AAFD patients is significantly greater than the pre-operative CT scan angle of controls. Such information could allow for the assessment of AAFD with a less expensive and more readily available tool. Methods: Patients enrolled in the authors’ institution’s Foot and Ankle Registry with a diagnosis of stage II (flexible) AAFD and undergoing flatfoot reconstruction surgery were identified. Both MP-WB scans and post-operative CT scans were obtained in the flatfoot group to assess deformity and healing of the lateral column lengthening or tarsometatarsal fusion, respectively. A control group with pre-operative CT scans for lisfranc injuries (unrelated forefoot pathology) and normal hindfoot alignment on exam after final healing was identified. Standard weight-bearing radiographic imaging was obtained pre-operatively in the AAFD group and after final healing in the control, and 5 previously-established radiographic parameters were measured. The inftal-suptal angle was measured in CT scans of the control and AAFD groups, and in MP-WB scans of the AAFD group. Differences in CT inftal- suptal and radiographic parameters between AAFD and controls were assessed with independent samples t-tests. The correlation between inftal-suptal angles measured by MP-WB and CT in the AAFD group was assessed with Pearson’s correlation coefficients. Results: 38 stage II AAFD patients (38 feet; 53% female; age 56.7±11.7 years) undergoing flatfoot reconstruction surgery from November, 2008 to December, 2014 and with MP-WB scans 61.9±77.5 days pre-operatively and CT scans 51.3±8.6 days post- operatively were identified. 20 patient controls (20 feet; 45% female; age 35.7±13.4 years) with CT scans 13.8±20.5 days pre- operatively from June, 2006 to October, 2013, were evaluated. All plain radiographic parameters differed significantly between AAFD and control groups (Table 1), verifying placement of patients into their respective groups based on previously-established norms. The inftal-suptal CT angle additionally differed between the AAFD and control groups (p < 0.001). The correlation between inftal-suptal angles measured by MP-WB and CT scans was relatively weak (Pearson’s=0.29) and did not reach statistical significance (p = 0.08). Conclusion: In summary, inftal-suptal angles of AAFD patients were significantly greater than those of controls on CT scans, and MP-WB imaging proved more predictive of AAFD than CT imaging. This study confirmed that while CT scans are useful in predicting stage II AAFD, they cannot be used as a surrogate for MP-WB scans, as they do not fully capture the amount of valgus. The most probable explanation of this is the re-formatting of CT scans into sagittal and coronal planes or a difference in the position of the foot during the scan, both leading to a potential difference in the planes of CT imaging and MP-WB imaging.

Category: Hindfoot Introduction/Purpose: Underlying bony deformities may contribute to the development of adult acquired flatfoot deformity (AAFD), although the exact pathogenesis remains unknown. Subtalar valgus tilt and underlying talar deformity can both be accurately assessed using multiplanar weightbearing computed tomography (MP-WB). On coronal MP-WB images, two angles have been used to reliably evaluate the subtalar joint axis in AAFD: (1) the angle between the inferior facet of the talus and the horizontal (inftal-hor), and (2) the angle between the inferior and superior facets of the talus (inftal-suptal). While previous work showed that these angles differ significantly between AAFD patients and controls, it is not known how they correlate with radiographic measures of flatfoot. We hypothesized that they would correlate strongly with commonly used radiographic measures of AAFD. Methods: 45 patients with stage II AAFD and 17 control patients underwent MP-WB imaging as well as standard weightbearing radiographs. Inftal-hor and inftal-suptal were measured on the coronal MP-WB images of all patients. These measurements were then correlated with standard radiographic measurements used to assess AAFD: talar-first metatarsal angle on antero-posterior (AP) and lateral views, talocalcaneal angle on AP and lateral views, talonavicular coverage angle, calcaneal pitch, medial column height, and hindfoot alignment. Basic demographic data including age, sex, and body mass index (BMI) were also collected. Differences between AAFD and control patients were assessed using independent samples t-tests and Mann-Whitney U tests. To examine the correlation between each MP-WB measurement and each radiographic measurement, a factorial generalized linear model (GLM) was constructed with presence of flatfoot, the radiographic measurement, and their interaction as covariates. Results: The flatfoot group was older than the control group (p=0.049); the two groups did not differ in terms of sex or BMI. The patients with AAFD differed significantly from the controls in all measured angles (p≤0.001 for each). Inftal-hor and inftal- suptal correlated with radiographic measures of flatfoot to the same degree in patients with and without AAFD. After accounting for differences between flatfoot and control patients, inftal-hor did not significantly correlate with any of the radiographic angles. Inftal-suptal, however, did significantly correlate with AP coverage angle, AP talar-first metatarsal angle, calcaneal pitch, Meary’s angle, medial column height, and hindfoot alignment (Figure). Conclusion: As measured on coronal MP-WB images, patients with stage II AAFD had more innate valgus in their talar anatomy as well as more valgus alignment of their subtalar joints than did control patients. The inftal-suptal angle correlated significantly with other measures of flatfoot deformity including arch collapse and forefoot abduction. Though causation cannot be established directly from this study, the data does suggest that AAFD may develop in patients with a valgus inclined subtalar joint axis. This information can be used to identify those patients likely to develop progressive flatfoot deformity and may ultimately guide the approach to surgical reconstruction.