Research Spotlight

Brodsky, J.W., Scott, D.J., Ford, S., Coleman, S. and Daoud, Y. (2021). “Functional Outcomes of Total Ankle Arthroplasty at a Mean Follow-up of 7.6 Years: A Prospective, 3-Dimensional Gait Analysis.” J Bone Joint Surg Am 103(6): 477-482.

Full text of this article.

BACKGROUND: In vivo gait analysis provides objective measurement of patient function and can quantify that function before and after ankle reconstruction. Previous gait studies have shown functional improvement for up to 4 years following total ankle arthroplasty (TAA), but to date, there are no published studies assessing function at ≥5 years following TAA. We hypothesized that patients who underwent TAA would show significant improvements in walking function at a minimum follow-up of 5 years, compared with their preoperative function, as measured by changes in temporospatial, kinematic, and kinetic gait parameters. METHODS: Three-dimensional gait analysis with a 12-camera digital motion-capture system and double force plates was utilized to record temporospatial, kinematic, and kinetic measures in 33 patients who underwent TAA with either the Scandinavian Total Ankle Replacement (Stryker; n = 28) or Salto Talaris Ankle (Integra LifeSciences; n = 5). Gait analysis was performed preoperatively and at a minimum follow-up of 5 years (mean, 7.6 years; range, 5 to 13 years). RESULTS: Significant improvements were observed in multiple gait parameters, with temporospatial increases in cadence (+9.5 steps/min; p < 0.0001), step length (+4.4 cm; p = 0.0013), and walking speed (+0.2 m/s; p < 0.0001), and kinematic increases in total sagittal range of motion (+2.0°; p = 0.0263), plantar flexion at initial contact (+2.7°; p = 0.0044), and maximum plantar flexion (+2.0°; p = 0.0488). Kinetic analysis revealed no loss of peak ankle power, despite patients aging. CONCLUSIONS: To our knowledge, this is the first study to report 7-year functional outcomes of TAA, quantified by objective, in vivo measurements of patient gait. Patients were shown to have sustained improvement in multiple objective parameters of gait compared with preoperative function. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Brinkman, W.T. and Gable, D. (2021). “Make new friends, but keep the old.” Ann Thorac Surg Apr 5;S0003-4975(21)00650-0. {Epub ahead of print].

Full text of this article.

In this issue of The Annals, Chang and colleagues report on their experience with Zone 2 TEVAR in patients with an acute B aortic dissection (ATBAD) and an unfavorable proximal landing zone. The authors should be commended for their good results in a challenging cohort of patients. We are, however, concerned with avoidance of standard techniques (such as left subclavian artery bypass and transposition) in favor of more complicated and “off-label” techniques to revascularize the LSCA. This paper’s conclusions suggest that these techniques are non-inferior to traditional approaches. [No abstract; excerpt from article].

Brinjikji, W., Nogueira, R.G., Kvamme, P., Layton, K.F., Delgado Almandoz, J.E., Hanel, R.A., Mendes Pereira, V., Almekhlafi, M.A., Yoo, A.J., Jahromi, B.S., Gounis, M.J., Patel, B., Abbasi, M., Fitzgerald, S., Mereuta, O.M., Dai, D., Kadirvel, R., Doyle, K., Savastano, L., Cloft, H.J., Haussen, D.C., Al-Bayati, A.R., Mohammaden, M.H., Pisani, L., Rodrigues, G.M., Thacker, I.C., Kayan, Y., Copelan, A., Aghaebrahim, A., Sauvageau, E., Demchuk, A.M., Bhuva, P., Soomro, J., Nazari, P., Cantrell, D.R., Puri, A.S., Entwistle, J., Polley, E.C. and Kallmes, D.F. (2021). “Association between clot composition and stroke origin in mechanical thrombectomy patients: analysis of the Stroke Thromboembolism Registry of Imaging and Pathology.” J Neurointerv Surg Mar 15;neurintsurg-2020-017167. [Epub ahead of print].

Full text of this article.

BACKGROUND: We retrospectively evaluated the composition of retrieved clots from ischemic stroke patients to study the association between histological composition and stroke etiology METHODS: Consecutive patients enrolled in the Stroke Thromboembolism Registry of Imaging and Pathology (STRIP) were included in this study. All patients underwent mechanical thrombectomy and retrieved clots were sent to a central core lab for processing. Histological analysis was performed using martius scarlet blue (MSB) staining, and quantification for red blood cells (RBCs), white blood cells (WBCs), fibrin and platelets was performed using Orbit Image Software. A Wilcoxon test was used for continuous variables and χ(2) test for categorical variables. RESULTS: 1350 patients were included in this study. The overall rate of Thrombolysis In Cerebral Infarction (TICI) 2c/3 was 68%. 501 patients received tissue plasminogen activator (tPA) (37%). 267 patients (20%) had a large artery atherosclerosis (LAA) source, 662 (49%) a cardioembolic (CE) source, 301 (22%) were cryptogenic, and the remainder had other identifiable sources including hypercoagulable state or dissection. LAA thrombi had a higher mean RBC density (46±23% vs 42±22%, p=0.01) and a lower platelet density (24±18% vs 27±18%, p=0.03) than CE thrombi. Clots from dissection patients had the highest mean RBC density (50±24%) while clots from patients with a hypercoagulable state had the lowest mean RBC density (26±21%). CONCLUSIONS: Our study found statistically significant but clinically insignificant differences between clots of CE and LAA etiologies. Future studies should emphasize molecular, proteomic and immunohistochemical characteristics to determine links between clot composition and etiology.

Brener, M.I., George, I., Kosmidou, I., Nazif, T., Zhang, Z., Dizon, J.M., Garan, H., Malaisrie, S.C., Makkar, R., Mack, M., Szeto, W.Y., Fearon, W.F., Thourani, V.H., Leon, M.B., Kodali, S. and Biviano, A.B. (2021). “Atrial Fibrillation Is Associated With Mortality in Intermediate Surgical Risk Patients With Severe Aortic Stenosis: Analyses From the PARTNER 2A and PARTNER S3i Trials.” J Am Heart Assoc 10(7): e019584.

Full text of this article.

Background The impact of atrial fibrillation (AF) in intermediate surgical risk patients with severe aortic stenosis who undergo either transcatheter or surgical aortic valve replacement (AVR) is not well established. Methods and Results Data were assessed in 2663 patients from the PARTNER (Placement of Aortic Transcatheter Valve) 2A or S3i trials. Analyses grouped patients into 3 categories according to their baseline and discharge rhythms (ie, sinus rhythm [SR]/SR, SR/AF, or AF/AF). Among patients with transcatheter AVR (n=1867), 79.2% had SR/SR, 17.6% had AF/AF, and 3.2% had SR/AF. Among patients with surgical AVR (n=796), 71.7% had SR/SR, 14.1% had AF/AF, and 14.2% had SR/AF. Patients with transcatheter AVR in AF at discharge had increased 2-year mortality (SR/AF versus SR/SR; hazard ratio [HR], 2.73; 95% CI, 1.68-4.44; P<0.0001; AF/AF versus SR/SR; HR, 1.56; 95% CI, 1.16-2.09; P=0.003); patients with SR/AF also experienced increased 2-year mortality relative to patients with AF/AF (HR, 1.77; 95% CI, 1.04-3.00; P=0.03). For patients with surgicalAVR, the presence of AF at discharge was also associated with increased 2-year mortality (SR/AF versus SR/SR; HR, 1.93; 95% CI, 1.25-2.96; P=0.002; and AF/AF versus SR/SR; HR, 1.67; 95% CI, 1.06-2.63; P=0.027). Rehospitalization and persistent advanced heart failure symptoms were also more common among patients with transcatheter AVR and surgical AVR discharged in AF, and major bleeding was more common in the transcatheter AVR cohort. Conclusions The presence of AF at discharge in patients with intermediate surgical risk aortic stenosis was associated with worse outcomes-especially in patients with baseline SR-including increased all-cause mortality at 2-year follow-up. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01314313 and NCT03222128.

Blough, J.T. and Saint-Cyr, M.H. (2021). “Propeller Flaps in Lower Extremity Reconstruction.” Clin Plast Surg 48(2): 173-181.

Full text of this article.

Propeller flaps represent an outstanding alternative to conventional pedicled and free flap options in lower extremity reconstruction, offering significant advantages over the latter. An understanding of the perforasome concept, hot and cold perforator locations, and basic flap design enable the surgeon to readily harvest flaps based on any clinically relevant perforator in freestyle fashion. The purpose of this article is to review fundamentals of propeller flap design and harvest in the lower extremity and discuss reconstructive strategies by level of injury.