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Following total joint arthroplasty, surgical site infections (SSI) and periprosthetic joint infections (PJI) are associated with increased patient morbidity and healthcare utilization. Current positive-pressure surgical sterile helmet system (SHS) were developed as a feasible, useful version of the body exhaust system.The use of SHS has not yet been proven to decrease infection rates in the orthopedic literature. The primary purpose of this study is to compare the infection rates between patients who underwent total ankle arthroplasty (TAA) with a surgical team wearing SHS versus without SHS.A retrospective chart review in patients undergoing primary TAA with the surgeon wearing SHS (Group 1) or standard surgical attire (Group 2) was conducted. The primary outcome was postoperative SSI and PJI. The rate of wound complications, revision rates, and associated procedures were also analyzed. We identified 109 patients in Group 1 and 151 patients in Group 2. The rate of SSI was 12.8% in Group 1 and 14.6% in Group 2 (p = .411). The rate of PJI was 0.92% in Group 1 and 2.6% in Group 2 (p = .411). There was no difference in revision rates between the two groups. This study suggests that SHS does not appear to protect against postoperative SSI or PJI after TAA. Conversely, we did not find a higher infection rate compared to standard surgical attire despite recent in-vitro studies suggesting SHS as a source of wound contamination. The utility of SHS does not appear to influence the prevalence of postoperative SSI or PJI.

The correction of the flexible pes planovalgus foot and ankle is a complicated and somewhat controversial topic. After conservative methods fail, there is a wide range of possible soft tissue and bony procedures. The appropriate work up and understanding of the pathomechanics are vital to the correct choice of procedures to correct these deformities. Once the work up and procedure selection are done, the operation must also be technically performed well and with efficiency, as most often the condition is corrected with a variety of procedures. This article discusses some of the most common procedures necessary to fully correct the pes planovalgus foot and discusses the authors' technique and pearls.

15 p.-2 fig.-3 tab., Single-cell RNA sequencing (scRNA-seq) and spatially resolved transcriptomics (SRT) have experienced rapid development in recent years. The findings of spaceflight-based scRNA-seq and SRT investigations are likely to improve our understanding of life in space and our comprehension of gene expression in various cell systems and tissue dynamics. However, compared to their Earth-based counterparts, gene expression experiments conducted in spaceflight have not experienced the same pace of development. Out of the hundreds of spaceflight gene expression datasets available, only a few used scRNA-seq and SRT. In this perspective piece, we explore the growing importance of scRNA-seq and SRT in space biology and discuss the challenges and considerations relevant to robust experimental design to enable growth of these methods in the field., H.C., P.M., D.B., R.H., N.J.S., J.B., and S.G. are members of the ESA Space Omics Topical Team, funded by the ESA grant/contract 4000131202/20/NL/PG/pt “Space Omics: Towards an integrated ESA/NASA – omics database for spaceflight and ground facilities experiments” awarded to R.H., which was the main funding source for this work. H.C. is also supported by the Horizon Centre for Doctoral Training at the University of Nottingham (UKRI grant no. EP/S023305/1). S.G. is supported by the Swedish Research Council VR grant 2020-04864. E.G.O. is supported through NASA Postdoctoral Fellowship 80NSSC21K0316.

Reoperation rates and complication rates can be high for patients receiving an osteochondral talar allograft transplant. Complications can include graft failure, delamination of the graft, arthrofibrosis, advancing osteoarthritis, nonunion of malleolar osteotomies, and partial or complete osteonecrosis of the talus. Graft failure refers to failure of graft incorporation with subsequent necrosis and subsidence. Treatment options for talar graft failure are limited, and outcomes for these treatments have rarely been reported. We present a review of the published data on the complications and treatments for failed talar allograft transplantation. A case report is presented on a young woman who experienced graft failure and osteonecrosis of her talar allograft transplant. Because of the size of the present osteonecrosis, an ankle arthrodesis was performed as the initial revision procedure. Talar necrosis was removed and revascularized from the ankle fusion with solid fusion was confirmed with computed tomography. Symptomatic adjacent joint pain quickly developed in the hindfoot after the ankle fusion, and 12 months later an ankle fusion conversion to total ankle arthroplasty was performed. The patient has returned to normal activity with significant reduction in pain at most recent follow-up visit. This patient was followed for 7 years from initial osteochondral talar allograft transplantation and for 2 years from conversion of ankle fusion to total ankle arthroplasty. It is important to understand the techniques, indications, and outcomes for the various revision options for talar allograft failure. This case report illustrates how multiple revision options can be used to provide the best outcome for the patient.

Treatment of degenerative joint disease of the ankle has experienced a renaissance in the past decade as total ankle replacement has become a predictable alternative to ankle fusion for end-stage disease. There are several total ankle replacement systems on the market including the INBONE Total Ankle System. The INBONE I system was US Food and Drug Administration 510-k cleared for use in 2005 and consists of a saddle-shaped, fixed-bearing, two-component design with the polyethylene-bearing surface locked into the tibial baseplate. The INBONE II Total Ankle System is an evolution of the original INBONE Total Ankle System design. The INBONE II system retained several important design characteristics of the original INBONE Total Ankle System design, including the modular tibial stems, thicker polyethylene bearings, and intramedullary guidance, while adopting a sulcus talus articular configuration, extended length tibial base components, and optimizing for use with PROPHECY patient-specific instrumentation. In conclusion, the INBONE I and INBONE II Total Ankle Systems offer the advantages of a robust technique with advanced instrumentation when managing the arthritic ankle.

There has long been an interest in understanding how the hazards from spaceflight may trigger or exacerbate human diseases. With the goal of advancing our knowledge on physiological changes during space travel, NASA GeneLab provides an open-source repository of multi-omics data from real and simulated spaceflight studies. Alone, this data enables identification of biological changes during spaceflight, but cannot infer how that may impact an astronaut at the phenotypic level. To bridge this gap, Scalable Precision Medicine Oriented Knowledge Engine (SPOKE), a heterogeneous knowledge graph connecting biological and clinical data from over 30 databases, was used in combination with GeneLab transcriptomic data from six studies. This integration identified critical symptoms and physiological changes incurred during spaceflight.

Understanding the impact of space exploration remains biologically elusive. Cell Press is dedicating this month to spaceflight (Afshinnekoo et al., 2020), with the open science NASA GeneLab database enabling the study revealing mitochondria as a key biological feature from spaceflight (da Silveira et al., 2020).

Research on astronaut health and model organisms have revealed six features of spaceflight biology that guide our current understanding of fundamental molecular changes that occur during space travel. The features include oxidative stress, DNA damage, mitochondrial dysregulation, epigenetic changes (including gene regulation), telomere length alterations, and microbiome shifts. Here we review the known hazards of human spaceflight, how spaceflight affects living systems through these six fundamental features, and the associated health risks of space exploration. We also discuss the essential issues related to the health and safety of astronauts involved in future missions, especially planned long-duration and Martian missions.

Arthrodesis of the ankle or foot is a common procedure for chronic pain and disability. Nonunion remains a prevalent complication among arthrodesis procedures. Some patients present with an inherent risk of developing a nonunion. Allograft biologics have gained popularity in an effort to reduce complications such as nonunion. Various biologics bring unique properties while maintaining a singular purpose. Platelet-derived growth factor (PDGF) may be introduced into a fusion site to facilitate healthy bony consolidation. The purpose of this article is to review the benefits and modalities of PDGF and how it can improve patient outcomes in ankle and hindfoot fusions.

Talar bulk osteochondral allograft transplantation is a useful treatment strategy for large, uncontained osteochondral lesions of talus. Complications and high revision rates from osteochondral talar allograft transfer can be common. Talar graft failure is a devastating complication that results from failure of allograft incorporation within the host bone and subsequent resorption and sometimes subsidence can occur. Treatment options and outcomes for graft failure have rarely been reported. The purpose of this study is to evaluate treatment options and their outcomes for treating talar allograft failure. A systematic review was completed to find all reports of salvage treatments for talar graft failure and outcomes of these reports were analyzed. Eleven studies involving a total of 522 ankles, in 520 patients, met the inclusion criteria. The allograft failure rate was 11.5% in these studies with a reoperation rate of 18.9%. With limited reports, satisfactory outcomes for treatment of graft failure with ankle arthrodesis were 77.3%, 50% for revision allograft procedures, and 50% for total ankle arthroplasty. Considering the large failure rate and reoperation rate for bulk talar allograft transplantations, superior revision, and salvage options are needed. More prospective cohort studies focusing on consistent and standard outcome measures are needed to further assess revision options for failed talar allograft procedures.

Spaceflight causes astronauts to experience an unbalanced level of bone remodeling favoring resorption. The combination of an antiresorptive drug and weightlessness may have negative effects on the mechanical and structural properties of bone by increasing elastic stiffness but diminishing plasticity. At 16 weeks of age, skeletally postpubescent male mice (n = 32, C57BL/6) were evenly divided and subcutaneously given either zoledronate (45 µg/kg) or vehicle (saline, same volume). Three days postinjection, half of each group were divided to undergo 3 weeks of hindlimb unloading or act as a control undergoing normal ambulation (n = 8 for each of the 4 groups). Ex vivo µCT assays showed zoledronate preserving cancellous mineral, bone, and cortical bone. Hindlimb unloading reduced cortical bone. Three-point bending of the femoral mid-shaft showed zoledronate increased stiffness, ultimate force, and total energy (+28%, +17%, +15%, respectively). Hindlimb unloading reduced stiffness but increased postyield displacement, a measurement of plasticity (-29%, +20%, respectively). The combined treatment resulted in increased stiffness, with zoledronate not modulating the hindlimb unloading main effect on postyield displacement. Though stiffness increased, contrary to the hypothesis, the combination of zoledronate and hindlimb unloading did not result in a decreased plasticity.

Summary The Cotton osteotomy is a plantarflexion osteotomy of the medial cuneiform, which is typically utilized in the reconstruction of adult acquired pes planus, posterior tibialis tendon dysfunction stage II (Johnson and Strom), and forefoot varus. The purpose of this paper is to give an estimate of the angular correction in the sagittal plane for each millimeter of bone graft used in the Cotton osteotomy using 20 cadaveric specimens. We have demonstrated that a surgeon will gain roughly 1.9 degrees of plantar flexion of the medial column for every one millimeter graft inserted into the medial cuneiform. While we have not established the amount of correction that should be done, the effect of increasing the wedge size has been demonstrated and may be helpful to surgeons when performing the Cotton osteotomy.

Isolated subtalar joint fusion is a powerful procedure applied in the engagement of definitive treatment for hindfoot arthritis and/or deformity. Because of the importance of the subtalar joint in dynamic biomechanical gait pattern kinematics, disease intrinsic to the joint can prove debilitating [1]. Pathology associated with this important joint includes post-traumatic arthritis, flatfoot deformity, cavus foot deformity, inflammatory arthritis, and tarsal coalition [2]. Late-stage STJ arthritis from long-standing residual hindfoot deformity or failed joint salvage attempts are also indications for definitive fusion [3]. Certainly, subtalar joint fusion is often utilized in conjunction with other joint-modifying procedures such as total ankle replacement or global foot and ankle reconstructive procedures [4]. Reported union rates are high at 84–100% (Reference). Because of the high union rate and low complication rates, the procedure has a high patient satisfaction coefficient [5]. Case I shows significant deformity with STJ arthritic change and subsequent definitive fusion in conjunction with concomitant procedures in a long-standing recalcitrant flatfoot. Case 2 shows definitive STJ fusion secondary to post-traumatic arthritic change and calcaneal body collapse with decreased talar declination angle.

Bone grafting and biologics play a large role in foot and ankle reconstruction surgery. Frequently there is a large void that must be backfilled for a successful surgery. Other times, a failed surgery needs some biological stimulation to go onto a successful osseous union. An array of synthetic, allografts, and autograft harvest techniques have been described for the management of these nonunions and malunions. This chapter will provide an overview on techniques, pearls, and available options for grafting in foot and ankle surgery.

Lesser toe deformities are a common pathology seen by foot and ankle surgeons. There are numerous fixation choices for these difficult deformities. Historically, Kirschner wires have been utilized in maintaining the corrected toe as it goes onto fusion or stable resection arthroplasty. K-wires have several inherent risks, documented well in the literature, which has led to the development of the intramedullary implant. The one-component metallic implant has become the mainstay treatment for complex hammertoe deformity. The purpose of this chapter is to highlight the development of the one-component metallic hammertoe fixation prosthesis and explore the advantages and disadvantages of the individual systems.

Ankle arthroscopy is a commonly employed surgical technique to provide a minimally invasive approach to managing intra-articular ankle pathology. Common indications include osteochondral defect, ankle synovitis, impingement syndrome, early arthritis, chronic ankle pain, intra-articular assessment of ankle trauma, painful os trigonum (posterior hindfoot endoscopy), and ankle instability. Additionally ankle arthrodesis can be performed arthroscopically.

Acute deltoid injuries may occur with ankle fractures. They are often left to heal without repair, possibly leading to chronic medial ankle instability. Stress radiographs identify the need for surgical repair of fractures or soft tissue damage. Gravity stress views have benefits over manually stressing the ankle. MRI can explore the extent of medial soft tissue injuries. Arthroscopy can evaluate and potentially treat deltoid injuries. Interposition of the deltoid may preclude adequate fracture reduction. Except with deltoid tear, fractures should be reduced and fixated, then the deltoid assessed. With persistent instability, primary repair may prevent long-term sequelae.

Supramalleolar osteotomies are powerful osteotomies that realign the tibiotalar and optimize hindfoot position in the presence of varus, valgus, procurvatum, recurvatum, as well as internal and external rotation of the tibia. Although used in the pediatric and hemophilic population earlier, supramalleolar osteotomy is a relatively new reconstructive surgical technique that was introduced in 1995. Conducted primarily in cancellous bone, supramalleolar osteotomies offer rapid, reliable bony consolidation compared with dome osteotomies and complex arthrodesis.

Arthrodesis of the ankle or foot is a common procedure for chronic pain and disability. Nonunion remains a prevalent complication among arthrodesis procedures. Some patients present with an inherent risk of developing a nonunion. Allograft biologics have gained popularity in an effort to reduce complications such as nonunion. Various biologics bring unique properties while maintaining a singular purpose. Platelet-derived growth factor (PDGF) may be introduced into a fusion site to facilitate healthy bony consolidation. The purpose of this article is to review the benefits and modalities of PDGF and how it can improve patient outcomes in ankle and hindfoot fusions.

While the medial double arthrodesis has gained significant popularity for hindfoot arthrodesis in recent years, much has been touted about the efficiency and cost savings of the procedure in comparison to its triple counterpart without any literature to reinforce this claim. The purpose of this retrospective study was to compare the hardware costs and operative time between the medial double and triple arthrodeses. A total of 276 patients (277 feet) were identified via CPT codes with 47 hindfoot cases (47 feet) meeting the inclusion criteria consisting of 21 medial double (6 males, 15 females) and 26 triple (8 males, 18 females) arthrodeses. No significant difference was noted in age, body mass index, gendr, chronic steroid use, preoperative osteopenia/osteoporosis, tobacco abuse, surgical side, presence of diabetes, immune compromised state, kidney disease, rheumatoid arthritis, or liver disease. Mean medial double operative (OR) time 106 ± 31 minutes (range = 73-201 minutes) with a procedure time of 84 ± 29 minutes (range = 44-163 minutes) was identified versus an OR time of 127 ± 23 minutes (range = 91-200 minutes) and procedure time of 104 ± 23 minutes (range = 50-169 minutes) for the triple arthrodesis group. The mean fixation cost for the triple arthrodesis was found to be higher with the mean triple hardware cost $2932.75 ± $736.60 (range = $1434.00 to $3980.00) against the medial double’s $1197.59 ± $635.57 (range = $463.20 to $2019.00). Both efficiency and cost were found to favor the medial double for hindfoot arthrodesis at a level of statistical significance level ( P = .0028 for OR time, P = .0033 for procedure time, and P < .0001 for cost). Levels of Evidence: Therapeutic, Level III, a retrospective comparative series

Circular external fixation is a useful treatment option for the correction of complex trauma, extremity deformity, osteomyelitis, and reconstruction of the foot and ankle. The goal of the present study was to determine the degrees of bolt rotation required to create enough wire tension to cause structural failure of the lateral calcaneal wall when stressed with both olive and smooth wires in a cadaveric model. Ten fresh, thawed, below-the-knee specimens were tested at the San Diego Cadaveric Academic Research Symposium. The mean bolt rotation required to pull an olive wire through the lateral wall of the calcaneus was 79.8° ± 32.81°, and the mean bolt rotation required to "walk" a skinny wire (narrow diameter) and create 1 mm of cortical bone failure was 50.5° ± 30.91°. The results of the present investigation further define and elucidate the appropriate "Russian tensioning" technique applicable for external fixation of the calcaneus using olive or skinny wires in the case of fracture repair or compression arthrodesis.

Degenerative joint disease of the ankle is a debilitating etiology, in which treatment has been disputed in the literature among healthy active patients. Total ankle arthroplasty had recently gained popularity as long- term outcomes are being reported and advancement in the design of the implants themselves evolves. Multiple implants are available on today's mar- ket including the INBONE (Wright Medical technologies, Arlington, TN) Total Ankle System. The second gen- eration INBONE total ankle arthro- plasty was launched and approved for use in the United States by the FDA in 2005. The second generation INBONE implant has a talar sulcus, allow- ing for a more biomechanically stable articulation between the polyethelene insert and the talar component (Figure 1). The initial INBONE implant had a flat articulation with the poly leading to instability. This paper will help to demonstrate the advantages of INBONE II versus INBONE I Total Ankle System in management of arthrosis of the ankle joint. D egenerative joint disease of the ankle is a debilitating etiology, in which treatment has been dis- puted in the literature among healthy active patients. Total ankle arthro- plasty had recently gained popular- ity as long-term outcomes are being reported and advancement in the design of the implants them- selves evolves. Multiple implants are available on today's market, includ- ing the INBONE (Wright Medical Technology, Inc, Arlington, TN) Total Ankle System. The second- generation INBONE total ankle arthroplasty was launched and approved for use in the United States by the Food and Drug Administration (FDA) in 2005. The second-generation INBONE implant has a talar sulcus, allowing for a more biomechanically stable articulation between the polyethylene insert and the talar component (Figure 1). The initial INBONE implant had a flat articulation with the poly leading to instability. This article will help demonstrate the

Total ankle replacement is now acknowledged as a viable alternative to ankle arthrodesis for end-stage ankle arthritis. The authors present a series of 14 patients who were converted from the Agility total ankle replacement to an INBONE total ankle replacement. This report is unique in that anterior and posterior approaches are discussed and detailed. Although the authors present successful conversion of the Agility total ankle replacement to an INBONE total ankle replacement, the difficulty of this procedure is demonstrated by the high complication rate and 2 early failures.

Total ankle replacement (TAR) is a viable alternative to ankle fusion in certain patients with end-stage ankle arthritis. Despite the importance of understanding alignment and movement of the prosthesis, there is no standardized radiographic method for evaluating the position and movement of the INBONE 2 prosthesis. The aims of this study were to describe a radiographic measurement protocol for INBONE 2 for clinical practice and research while determining the interobserver and intraobserver reliability using standard weightbearing radiographs. Fifteen patients were randomly selected with operative dates from January 2011 to January 2014 who underwent primary TAR using the INBONE 2 prosthesis. Most recent preoperative and first postoperative weightbearing anteroposterior and lateral radiographs were pulled and deidentified. Three foot and ankle surgeons blinded from the patient selection and deidentification, measured the described measurements on separate occasions. Intraobserver reliability: surgeon 1 had acceptable reliability for 9 of 13 continuous radiographic measurements (69.2%), surgeon 2 had acceptable reliability for 8 of 13 measurements (61.5%), and surgeon 3 had acceptable reliability for 12 of 13 measurements (92.3%). Interobserver reliability: among the first measurements, 6 of 13 continuous radiographic measurements (46.2%) had acceptable reliability. Among the second measurements, 7 of 13 measurements (53.8%) had acceptable reliability. Among the first and second measurements combined, 7 of 13 measurements (53.8%) had acceptable reliability. This study promotes the need for meticulous evaluation of annual radiographic findings following TAR in an effort to avoid catastrophic failure and represents moderate agreement can be obtained by employing the proposed measurements for surveillance of INBONE 2 TAR at annual postoperative visits. Measurements on the anteroposterior radiograph appear to demonstrate more consistent results for surveillance than lateral measurements. The intraobserver reliability results were somewhat superior to the interobserver reliability, implying more relevance for a single surgeon applying these measurements annually for postoperative surveillance. Levels of Evidence: Diagnostic, Level III

Introduction: The historic primary treatment for end-stage first metatarsophalangeal (MTP) joint arthritis has been fusion. Traditionally, this has been accomplished by metaphyseal apposition between the proximal phalanx and metatarsal using crossed compression screws. Recently, locked plates have been introduced that help support this technique by offering added stability. We present our experience with 45 first MTP fusions in 45 feet using a locked plate and compression screw. Methods: A retrospective review of 45 patients who met the study criteria with a hallux rigidus correction using a locked plate with a compression screw was performed. Charts and radiographs were independently reviewed by 2 authors not involved in the index procedures to assess outcomes. Results: There was a 93% fusion rate (42/45 feet) with 3 nonunions. The mean time to union was 51.1 days (range = 29-116 days, SD = 24.4). The mean patient age was 58.1 years (range = 29-80 years, SD = 10.1). The mean time to partial weight bearing was 7.0 days (range = 0-53 days, SD = 13.8) and the mean time to full weight bearing was 62.0 days (range = 29-57 days, SD = 17.9). Discussion: We report on the results of first MTP fusion using a compression screw and locked plate technique. The results show that this is an effective means of creating a first MTP joint arthrodesis. Levels of Evidence: Therapeutic, Level IV, Case series

The following case of a 37-year-old male describes a very rare form of psoriasis known as psoriatic onychopachydermoperiostitis. There have been fewer than 20 cases reported worldwide. (J Am Podiatr Med Assoc 99(2): 140–143, 2009)

Treatment of degenerative joint disease of the ankle has experienced a renaissance in the past decade as total ankle replacement has become a predictable alternative to ankle fusion for end-stage disease. There are several total ankle replacement systems on the market including the INBONE Total Ankle System that was US Food and Drug Administration 510-k cleared for use in 2005 and consists of a saddle-shaped, fixed-bearing, two-component design with the polyethylene-bearing surface locked into the tibial baseplate. The INBONE II Total Ankle System is an evolution of the original INBONE Total Ankle System design. This new system retains several important design characteristics of the original INBONE Total Ankle System design, including the modular tibial stems, thicker polyethylene bearings, and intramedullary guidance. In conclusion, the INBONE I and INBONE II Total Ankle Systems offer the advantages of a robust technique with advanced instrumentation when managing the arthritic ankle.