Artificial talus has been used to treat severe ankle disorders, including avascular necrosis of the talus and ankle osteoarthritis, with favorable clinical outcomes. Consequently, joint-preserving surgery has become a viable treatment option even for hindfoot pathologies that previously required arthrodesis. In Japan, a novel alumina ceramic artificial talus has been developed, and several case series have demonstrated. The procedure combining an artificial talus with the tibial component of a total ankle arthroplasty (TAA) has been termed “combined TAA.” This narrative review summarizes the historical development of the artificial talus and reviews its current clinical applications and surgical techniques. We reviewed all published articles on artificial talus reported from Japan, as well as articles on metallic artificial talus used worldwide. In addition, we present characteristic cases from our own clinical experience that demonstrate the potential for the artificial talus. Initially, only a talar body prosthesis was used. However, complications frequently occurred at the junction between the talar body prosthesis and the talar neck, leading to revision surgery using a total talus prosthesis. Because the outcomes were favorable, the total talus prosthesis was adopted for primary surgery. Combined TAA has since been applied to revision TAA and ankle osteoarthritis. Furthermore, combined TAA can result in spontaneous correction of varus hindfoot malalignment, suggesting that combined TAA alone may be a viable treatment option even in cases previously thought to require calcaneal osteotomy or additional procedures. Procedures using artificial talus are promising. We believe that further innovations may expand the indications of artificial talus.

Purpose The in vivo kinematics after combined total ankle arthroplasty (TAA) remains unknown. This study evaluated and compared the three-dimensional kinematics of the talar component between standard TAA, using the talar component where only the surface of the talar dome was replaced, and combined TAA, using the iterative closest point algorithm and computed tomography (CT). Methods The combined TAA and standard TAA groups comprised 17 and 9 ankles, respectively. CT was performed with patients in active dorsiflexed and plantarflexed ankle positions at least 3 months post-operatively. Results From non-weight-bearing dorsiflexion to plantarflexion, a significant medial translation of the total talar prosthesis was observed in the combined TAA group compared with the standard TAA group. Rotation of the x-axis (inversion) and translation of the z-axis (lateral translation) were negatively correlated. Conclusions Combined TAA results in greater inversion of the ankle joint during plantarflexion than standard TAA.

Background: The current "treat-to-target (T2T)" strategic concept has been applied to systemic lupus erythematosus (SLE), stating "lupus maintenance treatment should aim for the lowest glucocorticoid (GC) dosage, and if possible, GCs should be withdrawn completely". We have already reported the successful trade-off between GCs and immunosuppressive agents (ISA) in the prevention of SLE flare. Objectives: We aimed at the retrospective evaluation of current SLE treatment status by focusing on the maintenance dose of GCs and the use of ISA as well as the rate of GC-free patients. Methods: We enrolled 121 patients with SLE patients who was visiting our medical center.All the patients met the American College of Rheumatology (ACR) 1997 or 2012 revised criteria for SLE classification and were followed-up for ≥ 6 months after diagnosis. We evaluated patient backgrounds, SLE disease activity index (SLEDAI) score, the dose of GC, and the use of ISA or biologics from the medical records. Results: Currently, 94% of patients achieved GC dosage of 5 mg/day (prednisolone equivalent) or less and the median GC dosage was 2 mg/day. In addition, 48 (40%) patients were successfully managed with hydroxychloroquine (HCQ) and/or ISA only (including never- and ex-users of GCs). The users of HCQ, ISA, and biologics were 63%, 68% and 7%. respectively. Among ISA, mycophenolate mofetil (38%) and tacrolimus (35%) were commonly used, including their combined use (16%). GC-free patients achieved the median SLEDAI of 1 despite the median SLEDAI of 10 at the first presentation and the median disease duration of 10.5 years, which were comparable with the remaining patients. Conclusion: The T2T strategy for GC dose is applicable for almost all the patients with SLE, and GC-free management is becoming a realistic treatment goal with the aggressive use of HCQ, ISA, and biologics. REFERENCES: [1] Nat Rev Rheumatol. 2022 Mar;18(3):146-157. [2] Intern Med. 2022;61(21):3189-3196. Acknowledgements: NIL. Disclosure of Interests: None declared.

Background: Joint examination is an essential basic evaluation in treating rheumatoid arthritis (RA). However, physical examination and ultrasound (US) findings are not always consistent. Subclinical synovitis of the wrist is thought to be particularly common in RA patients [1]. Objectives: We aimed to clarify the discrepancy between physical examination and US findings on the wrist of RA patients. Methods: We compared physical examination with US findings in 235 RA patients who underwent US of the bilateral wrist joints. US was performed in three regions (radial, median, and ulnar) on dorsal longitudinal views, and US synovitis was defined as Gray Scale (GS) grade 2 or higher and/or Power Doppler Scale (PD) grade 1 or higher using a 4-point semiquantitative method from 0-3. Subclinical synovitis (SS) was defined as joints with ultrasound synovitis without swelling or tenderness on physical examination, and clinical synovitis (CS) was defined as joints with US synovitis with swelling and/or tenderness on physical examination. We analyzed the factors that lead to SS using a generalized linear mixed model. Results: SS was identified in 100 joints (21%), and CS in 129 joints (27%) of the total 470 joints bilaterally. Comparing the two groups, the total score of the three regions was significantly lower in SS than CS for both GS and PD (median 2 vs. 5 and 1 vs. 4, respectively, p<0.001). In addition, SS showed less counts of involved areas in each wrist joint than CS (median: 1 vs. 3, p<0.001). Furthermore, when radial and median regions were combined for the analyses of wrist synovitis localised in one or two regions, but not in all three regions, the synovitis only on the radial and/or median sides was detected in 55 of 100 SS joints (55%) and 26 of 129 CS joints (20%) (p<0.001), while the synovitis only on the ulnar side was observed in 18 joints (18%) and 13 joints (10%) in SS and CS, respectively (p=0.12). When the following factors (age, gender, disease duration, body mass index, DAS28-CRP and US synovitis findings) were included, SS was significantly associated with DAS28-CRP (OR=0.29, 95% CI [0.14, 0.57], p<0.001), total US score (OR=0.63, 95% CI [0.43, 0.92], p=0.016) and synovitis only on the radial and/or median sides (OR=4.29, 95% CI [1.01, 18.16], p=0.047). Conclusion: It was suggested that arthritis is difficult to detect on examination in the wrist joints of RA patients when the lesions are localised only to the radial and/or median sides. REFERENCES: [1] Nakagomi D et al. Arthritis Rheum. 2013; 65: 890-8. Acknowledgements: NIL. Disclosure of Interests: None declared.

Background: Total talar replacement is a salvage procedure for end-stage osteonecrosis of the talus. A customized total talar implant is designed with use of computed tomography scans of the healthy opposite side and made of alumina ceramic. The use of such an implant is potentially recommended, with a guarded prognosis, for the treatment of traumatic, steroidal, alcoholic, systemic lupus erythematous, hemophilic, and idiopathic pathologies. The talus is surrounded by the tibia, fibula, calcaneus, and navicular bones, which account for a large portion of the articular surface area. Yoshinaga 9 reported that alumina ceramic prostheses were superior in terms of congruency and durability of articular cartilage compared with 316L stainless steel in an in vivo test in dogs. Therefore, alumina ceramic is an ideal material for replacement of the talus to preserve postoperative hindfoot mobility. Description: Total talar replacement is performed with the patient in a supine position. The anterior ankle approach is utilized to exteriorize the talus, facilitating dissection of the ligaments and joint capsule attached to talus. The first osteotomy is performed around the talar neck, perpendicular to the plantar surface of the foot. The talar head fragment is then removed. Subsequent talar osteotomies are performed parallel to the first cutting line, at approximately 2-cm intervals. The attaching articular capsule and ligaments are dissected in each step. The removal of the posterior talar bone fragments is succeeded by careful dissection of the ligament and joint capsule under the periosteum. After dissecting the remaining interosseous talocalcaneal ligament, the foot is distally retracted and a customized talar implant is inserted. After testing and confirming the stability and mobility of the implant, the wound is irrigated with use of normal saline solution. A suction drain is placed anterior to the implant, and the skin is closed after repairing the extensor retinaculum. Alternatives: In cases with a limited area of necrosis, symptoms may improve with a patellar tendon-bearing brace. However, in many cases of symptomatic osteonecrosis of the talus, nonoperative treatment is not expected to improve symptoms. Alternative surgical procedures include ankle arthrodesis and hindfoot arthrodesis, but there are risks of nonunion, leg-length discrepancy as a result of extensive bone loss, and functional decline because of loss of hindfoot motion. Rationale: Total talar replacement is a fundamentally unique treatment concept in which the entire talus is replaced with an artificial implant. Compared with ankle or hindfoot arthrodesis, this procedure preserves the range of motion of the foot and allows for earlier functional recovery. Postoperative results were satisfactory in the subjective evaluation, with no failure requiring revision. This procedure reduces the risk of postoperative failure in patients who are elderly and/or have underlying diseases, who often require a long recovery time. As the talus is a small bone with uniquely vulnerable vascularity, treatment of talar pathology is usually difficult; however, total talar replacement is a potential treatment option for patients with end-stage osteonecrosis of the talus without obesity. Expected Outcomes: The greatest advantage of total talar replacement is the preservation of ankle and hindfoot mobility. Second, a customized talar prosthesis based on a mirrored model of the contralateral, unaffected talus will allow the smooth transfer of body weight from the lower leg to the heel and forefoot—a requirement for a stable gait. Third, the artificial talar prosthesis has a potential advantage in that it minimizes leg-length discrepancy, preventing daily inconvenience for the patient. Twenty years after the development of the implant, replacement with a total talar prosthesis resulted in a median score of 97 out of 100 on the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale as an objective evaluation and yielded a significant improvement in the subjective evaluation of the Ankle Osteoarthritis Scale (AOS) in a follow-up study over 10 years. The median ankle joint range of motion was 45°, and complications requiring implant replacement never occurred. Important Tips: The skin incision should be placed at the center of the inferior tibial articular surface and curved medially to avoid the medial branch of the superficial peroneal nerve. During the resection of the talus, the attaching ligament and joint capsule are recommended to be debrided prior to osteotomy. Bone fragments should be removed as an entire block in order to avoid leaving small fragments. When inserting the artificial talus, pull the entire foot distally by grasping the heel in order to avoid excessive plantar flexion. During wound closure, the extensor retinaculum should be repaired to avoid skin bowstringing. Although favorable long-term results have been reported, postoperative outcomes in patients with high body mass index have not been adequately investigated. This procedure should be carefully selected on the basis of the physical characteristics of the patient. Acronyms and Abbreviations: AVN = avascular necrosis (osteonecrosis) SLE = systemic lupus erythematous CAD = computer-aided design CT = computed tomography JSSF = Japanese Society for Surgery of the Foot IQR = interquartile range AOS = Ankle Osteoarthritis Scale PWB = partial weight-bearing W = weeks

This systematic review investigated the functional outcomes and complications of reconstruction methods after talar tumor resection. A systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases identified 156 studies, of which 20 (23 patients) were ultimately included. The mean Musculoskeletal Tumor Society scores in the groups reconstructed using tibiocalcaneal fusion (n = 17), frozen autograft (n = 1), and talar prosthesis (n = 5) were 77.6 (range 66–90), 70, and 90 (range 87–93), respectively. Regarding complications, sensory deficits were observed in one patient (6%) and venous thrombosis in two patients (12%) in the tibiocalcaneal fusion group, while osteoarthritis was observed in one patient (100%) in the frozen autograft group. No complications were observed in the talar prosthesis group. Reconstruction with talar prosthesis seems preferable to conventional tibiocalcaneal fusion after talar tumor resection because it offers better function and fewer complications. However, as this systematic review included only retrospective studies with a small number of patients, its results require re-evaluation in future randomized controlled trials with larger numbers of patients.

Background Ultrasonography (US) has been suggested to be useful in predicting flare in patients with rheumatoid arthritis (RA) after discontinuation of biological disease-modifying antirheumatic drugs (bDMARDs). Objectives This study aimed to investigate whether US can predict flare after discontinuation of bDMARDs in RA patients who have achieved stringent remission criteria. Methods We prospectively enrolled RA patients who maintained a simplified disease activity index ≤ 3.3 and discontinued bDMARDs and measured clinical assessment and US every 2-3 months for 2 years. The US examination was performed on 40 joints using the semi-quantitative method of 0-3 on the Grey-scale (GS) and Power Doppler (PD), and the total values for each patient were used as the GS score and PD score. Joints graded as GS score ≥ 2 or PD score ≥ 1 were counted as US arthritis. In addition, tendons at 36 sites were counted with or without tendinitis/tenosynovitis to obtain a tendon score. Results Thirty-six patients were enrolled and two patients who dropped out early without flare were excluded from the comparative analyses. At baseline, the median GS score was 7, PD score was 0, US arthritis was 0, and tendon score was 0. The total PD score was 0 in 26 patients (72%) and it was 1 in 5 patients (14%). There were no significant differences in US findings between the relapse group (20 patients) and the non-relapse group (14 patients). Positive and negative predictive value for PD-positive findings (total PD score ≥1) were 60% and 42%, and for total PD score ≥2 were 60% and 41%, respectively. Conclusion The PD score in the US findings at the time of bDMARDs discontinuation was not predictive for future disease flare. Disclosure of Interests Takehisa Ogura Speakers bureau: AbbVie G.K, Ayako Hirata: None declared, Takaharu Kagtagiri: None declared, Yuto Takakura: None declared, Hideto Kameda Speakers bureau: AbbVie G.K., Asahi Kasei Pharma, Astellas Pharma Inc., Bristol-Myers Squibb, Chugai Pharmaceutical Co. Ltd., Eisai Co. Ltd., Eli Lilly Japan K.K., Gilead Sciences, Janssen Pharmaceutical K.K., Mitsubishi Tanabe Pharma, Novartis Pharma K.K., and Sanofi Pharma, Grant/research support from: AbbVie G.K., Asahi Kasei Pharma, Astellas Pharma Inc., Chugai Pharmaceutical Co. Ltd., Eisai Co. Ltd., Mitsubishi Tanabe Pharma, Novartis Pharma K.K., and Sanofi Pharma

Background: Total talar replacement has been reported to have favorable short-term and intermediate-term results for the treatment of osteonecrosis of the talus. The purpose of this study was to evaluate the long-term clinical results of total talar replacement for a minimum of 10 years after the surgical procedure. Methods: From October 2005 to April 2011, 19 ankles in 18 patients (1 male and 17 female) were treated using a total talar prosthesis for osteonecrosis of the talus. The median follow-up period was 152 months (interquartile range [IQR], 138, 160 months). The Ankle Osteoarthritis Scale (AOS) score, the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale score, and the presence of osteophytes and degenerative changes in the adjacent joints were assessed preoperatively and at the final follow-up. Subsidence of the prosthesis was also assessed at the earliest opportunity for full weight-bearing and the final follow-up. The postoperative range of motion of the ankle was assessed at the final follow-up. Results: The median scores for all subscales of the AOS significantly improved. The median JSSF Ankle-Hindfoot Scale score significantly improved from 58 (IQR, 55, 59.5) to 97 (IQR, 87, 99.5). In the subcategories of this scale, the median pain score improved from 20 (IQR, 20, 20) to 40 (IQR, 30, 40), and the median function score improved from 28 (IQR, 26, 30.5) to 47 (IQR, 47, 50). The median postoperative range of motion of the ankle was 45° (IQR, 42.5°, 55°). Subsidence of the implant was not recognized at the final follow-up (p = 0.083). Proliferation of osteophytes and degenerative changes in the adjacent joints did not affect the overall results. Conclusions: The customized alumina ceramic total talar prosthesis produced stable clinical outcomes over 10 years, and the patients treated with total talar replacement showed favorable clinical results over this time frame. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Cartilage damage in RA has been evaluated by joint space narrowing (JSN) in X-ray, while it is not a direct evaluation of cartilage. Previously we have confirmed the usefulness of the direct imaging of finger joint cartilage by ultrasound (US) in patients with RA [1]. Objectives: We aimed to examine the temporal changes of US cartilage thickness in RA patients. Methods: We enrolled 53 RA patients in whom the cartilage thickness of finger joints was measured by US and had radiographs of both hands at baseline and 1-year later. The cartilage of metacapophalangeal and proximal interphalangeal joints of 2nd to 5th fingers were bilaterally visualized at the middle portion from a longitudinal dorsal view. Cartilage thickness was measured from the base of the cartilage to the interface artefact at the cartilage surface by static images. In addition, the JSN of the corresponding joints was scored using a hand X-ray by van der Heijde-modified Sharp method. Continuous variables from the two groups were analyzed using the Mann-Whitney U test or Wilcoxon signed-rank test. The relationships among the continuous variables were assessed using the Spearman’s rank correlation coefficient. Results: The median age of the patients was 68 years and the median disease duration was 6.3 years. The sum of total cartilage thickness from 16 joints per patient ranged from 3.1 to 9.1mm (median 6.5 mm) at baseline, and it was significantly correlated with total JSN score of the same joints (ρ=-0.63, p<0.001). The cartilage thickness was inversely correlated with disease duration (rho=-0.40, p=0.003), but not associated with age nor height. The decrease in cartilage thickness over 1 year was evident in patients with persistent moderate to high disease activity by the DAS28-CRP (n=10; median -6.2%) as compared with other patients (n=43; median -1.2%, p=0.004 versus active patients). Conclusion: This pilot study demonstrated the progression of cartilage damage by sustained RA activity, supporting the validity and usefulness of joint cartilage thickness evaluation by ultrasound in patients with RA. References: [1]Ogura T, et al. Arthritis Care Res 2019 Oct 25. Table 1. SALIENT FEATURES OF THE 9 PATIENTS PRESENTING WITH RETINAL TOXICITY DUE TO HCQ Sl.No Age Gender Weight (Kg) Primary Diagnosis Dose Duration (Years) Detection Method Used Recommended Dose (mg/Day) Received Dose (mg/Day) Cumulative Dose (grams) FUNDUS EXAM. SD-OCT HVF 10-2 F AF 1 47 F 58 SLE 290 400 438 3 RPE Changes Thinning/Photoreceptor Loss Defects seen - 2 20 F 46 SLE 230 200 146 2 Multiple Small Drusens In Paramacular Area Multiple Drusens Normal Perifoveal autofluorescence spots- drusens 3 23 F 50 SLE 250 400 146 1 RPE Changes RPE Disruptions Defects seen - 4 30 F 55 SLE 275 200 73 1 Normal Normal Paracentral Scotoma - 5 50 F 49 RA 245 200 511 7 Early Bull’s Eye Maculopathy RPE Atrophy Defects seen - 6 72 F 60 RA 300 200 730 10 RPE Atrophy FR Absent RPE Atrophy General reduction in sensitivity - 7 65 M 57.4 RA 287 200 146 2 RPE Changes RPE Disruptions & Thinning Noted Defects seen - 8 62 F 70 RA 350 200 219 3 Chorioretinal Atrophy Altered RPE Membrane Defects seen - 9 59 M 71.6 RA 358 200 292 4 RPE Changes RPE Disruptions Normal - F:Female; M:Male; SLE:Systemic Lupus Erythematosus; RA: Rheumatoid Arthritis, FUNDUS EXAM.: Fundus Examination; SD-OCT:Spectral Domain-Optical Coherence Tomography, HVF 10-2:Humphrey Visual Field 10-2; FAF: Fundus Autofluorescence, RPE:Retinal Pigment Epithelium; FR:Foveal Reflex Disclosure of Interests: None declared

BACKGROUND:Comminuted talar fractures are rare. Generally, this fracture occurs as a result of high-energy injuries. Therefore, this operation is challenging for the surgeon. We started to replace the whole talus with a total talar prosthesis in cases of aseptic talar necrosis in 2005. Based on these results, replacement with a ceramic artificial talus was performed as the initial treatment for comminuted talar fractures.METHODS:From 2009 to 2016, a total of 6 feet of 6 patients with comminuted talar dome fractures or talar body defects were replaced with a ceramic artificial talus. The patients' mean age was 40.3 years (range, 19-59). Postoperative assessments were performed in accordance with the American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot score system. Postoperative range of motion and sports activities were also evaluated. Follow-up ranged from 12 to 84 (mean, 46.8) months.RESULTS:The postoperative AOFAS score was on average 78.8 (64-100). The postoperative range of motion was on average 10 degrees (5-20) for dorsiflexion and 31 degrees (15-50) for plantarflexion. Three patients had returned to sport activities.CONCLUSION:Prosthetic total talar replacement was a useful procedure for patients with comminuted talar fractures, which had good congruency of the custom-made implant with the adjacent joints, resulting in stability, and maintained ankle function. Furthermore, this procedure could prevent the complications of long-term external fixation and non-weight-bearing walking seen after open reduction and arthrodesis.LEVEL OF EVIDENCE:Level IV, retrospective comparative study.

Background: Cartilage damage in rheumatoid arthritis (RA) has been evaluated by joint space narrowing (JSN) in X-ray, despite the fact that it is not a direct evaluation of cartilage. We have recently reported that direct evaluation of finger joint cartilage thickness evaluated by ultrasound (US) is valid and useful for patients with RA 1) . Objectives: In this study, we aimed to examine the progression of cartilage damage in RA patients. Methods: Forty-six patients with RA who had completed the US evaluation of finger joint cartilage thickness at baseline and after 1 year were included in this study. The cartilage thickness of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of 2nd to 5th fingers were bilaterally visualized and measured at the middle portion of MCP and PIP joints from a longitudinal dorsal view, with approximately 90 degrees flexion. Cartilage thickness was measured from the base of the cartilage to the interface artefact at the cartilage surface by calculating the pixel counts on DICOM images. Results: In patients, 78% were female, the median age was 68 years and the median disease duration of the patients was 6 years. The median DAS28-CRP at baseline was 2.6. The sum of total cartilage thickness from 16 joints per patient ranged from 3.1 to 9.1 mm (median 6.4 mm) at baseline, and it was significantly correlated with disease duration (ρ=-0.423, p=0.003). A significant decrease from the baseline in the cartilage thickness (median -1.6%) was observed after 1 year (p=0.041). Furthermore, patients with persistently moderate/high disease activity for 1 year by DAS28-CRP (n=9) showed a greater decrease in the cartilage thickness than the remaining patients with controlled disease activity (n=37) (median -5.9% versus -1.5%, respectively, p=0.029). Conclusion: This study further supported the validity and usefulness of joint cartilage thickness evaluation by US in patients with RA. References: [1]Ogura T, et al. Arthritis Care Res 2019 Oct 25. Disclosure of Interests: Takehisa Ogura: None declared, Ayako Hirata: None declared, Sayaka Takenaka: None declared, Yuki Inoue: None declared, Takaharu Kagtagiri: None declared, Yuto Takakura: None declared, Hideki Ito: None declared, Hideto Kameda Grant/research support from: Abbvie, Asahi-Kasei, Chugai, Eisai, Mitsubishi-Tanabe and Novartis, Consultant of: Abbvie, Boehringer, Celgene, Eli Lilly, Janssen, Novartis, Sanofi, UCB, Speakers bureau: Abbvie, Asahi-Kasei, BMS, Chugai, Eisai, Eli Lilly, Janssen, Mitsubishi-Tanabe, Novartis and Pfizer

Total ankle arthroplasty is a useful surgical procedure for osteoarthritis of the ankle, but aseptic loosening of components is an issue. We report here a case of aseptic implant loosening with metallosis after total ankle arthroplasty using the TNK ankle (Kyocera, Kyoto, Japan), which occurred despite the components being ceramic. We also report favorable results from our method of treatment using a total talar prosthesis in the revision surgery. During the revision surgery, synovial metallosis was found, probably related to superficial damage to the screw affixing the tibial component to the bone. Because both the tibial and talar components were loose, all the components and the remaining talar bone were removed. A new tibial component and a custom-made alumina-ceramic total talar prosthesis was inserted. Pain relief was achieved and maintained through the latest follow-up visit at 42 months after revision surgery. Dorsiflexion of the ankle improved from 0° to 5° and plantarflexion remained unchanged from its preoperative range of 20°. The American Orthopaedic Foot & Ankle Society ankle-hindfoot score improved from 38 to 80 points. To the best of our knowledge, this is the first reported case of an alumina-ceramic total ankle prosthesis loosening caused by metallosis resulting from screw abrasion. Favorable treatment results were obtained by using a total talar prosthesis in the revision surgery.

Plantar fasciopathy is the most common cause of plantar heel pain and is considered to be a type of enthesopathy. The short-term efficacy, safety, and dose-response relationship of high-molecular-weight hyaluronic acid (HA) was investigated in patients with plantar fasciopathy.

Subtalar distraction arthrodesis is performed in certain situations where there is loss of subtalar height, reduced talar declination and evidence of anterior tibiotalar impingement. Standard evaluation includes the assessment of the lateral talocalcaneal angle, calcaneal pitch, talocalcaneal height and talar declination angle on a weight bearing lateral radiograph. We present a case of erosive valgus subtalar osteoarthritis with subtalar collapse managed with a subtalar distraction arthrodesis. A weight bearing CT (WB-CT) scan was used in the assessment. The value of WB-CT for this indication is discussed, along with a discussion on surgical technique, complications and future directions.

The molecular determinants of pathogenic leukocyte migration across the blood-nerve barrier (BNB) in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are unknown. Specific disease modifying therapies for CIDP are also lacking. Fibronectin connecting segment-1 (FNCS1), an alternatively spliced fibronectin variant expressed by microvascular endothelial cells at sites of inflammation in vitro and in situ, is a counterligand for leukocyte α4 integrin (also known as CD49d) implicated in pathogenic leukocyte trafficking in multiple sclerosis and inflammatory bowel disease. We sought to determine the role of FNCS1 in CIDP patient leukocyte trafficking across the BNB in vitro and in severe chronic demyelinating neuritis in vivo using a representative spontaneous murine CIDP model. Peripheral blood mononuclear leukocytes from 7 untreated CIDP patients were independently infused into a cytokine-treated, flow-dependent in vitro BNB model system. Time-lapse digital video microscopy was performed to visualize and quantify leukocyte trafficking, comparing FNCS1 peptide blockade to relevant controls. Fifty 24-week old female B7-2 deficient non-obese diabetic mice with spontaneous autoimmune peripheral polyneuropathy (SAPP) were treated daily with 2 mg/kg FNCS1 peptide for 5 days via intraperitoneal injection with appropriate controls. Neurobehavioral measures of disease severity, motor nerve electrophysiology assessments and histopathological quantification of inflammation and morphometric assessment of demyelination were performed to determine in vivo efficacy. The biological relevance of FNCS1 and CD49d in CIDP was evaluated by immunohistochemical detection in affected patient sural nerve biopsies. 25 μM FNCS1 peptide maximally inhibited CIDP leukocyte trafficking at the human BNB in vitro. FNCS1 peptide treatment resulted in significant improvements in disease severity, motor electrophysiological parameters of demyelination and histological measures of inflammatory demyelination. Microvessels demonstrating FNCS1 expression and CD49d + leukocytes were seen within the endoneurium of patient nerve biopsies. Taken together, these results imply a role for FNCS1 in pathogenic leukocyte trafficking in CIDP, providing a potential target for therapeutic modulation.

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is a popular surgical treatment for the patients with end-stage ankle arthritis. Along with development of the implant, indication for TAA has been extended to the severe deformity due to osteoarthritis or rheumatoid arthritis. However, a certain rate of complication after TAA is still remaining. The main reasons for failed TAA are the complications of talar component such as aseptic loosening or subsidence. We developed artificial talar prosthesis and indicated for the patient with idiopathic necrosis of the talus. This time we applied this new implant combined with tibial component of the TAA for the patient with end-stage ankle arthritis having severe collapse of the talus. The purpose of this study is to evaluate the outcomes of TAA with artificial talus. Methods: 【Materials】Thirteen patients (13 ankles) treated by TAA with artificial talus since 2007 to 2014 were investigated. The mean duration of follow-up was 35 months (range; 12 to 66 months). Twelve patients (12 ankles) were suffering from osteoarthritis of the ankle, and 1 was from rheumatoid arthritis. The mean age at the surgery was 71 year-old(range; 61 to 81 year-old). 【Methods】Clinical outcomes were evaluated by Visual Analog Scale (VAS) scores. Functional outcomes were assessed by scoring system produced by the Japanese Society for Surgery of the Foot (JSSF ankle-hindfoot scale) before surgery and at the final follow- up. Results: Postoperative VAS was improved from 8.9 to 2.3. Postoperative JSSF scale were improved from 41 to 87. There were no case that required the revision surgery due to implant failure or deep infection. Conclusion: The ankle has small joint surface compared with other weight-bearing joints, that causes the complications of talar component. For the patients with severe deformity or osteonecrosis of the talus, indications of TAA should be applied carefully. Patients of end-stage ankle arthritis with poor bone stock in the talus may have been unsatisfied with use of previous implant models of TAA. The artificial talus could be a possible option to solve this problem. In the current study, TAA with artificial talus remained favorable clinical and functional results for the patient with severe deformity or poor bone stock in the talus.

Category: Ankle Arthritis Introduction/Purpose: Ceramic 2-component total ankle prosthesis, TNK-Ankle, has been used clinically as standard prosthesis in severe ankle osteoarthritis or rheumatoid arthritis for long years in Japan. Two-component prosthesis would require more precise replacing because of more constraint than mobile type. We would report the outcomes of total ankle arthroplasty (TAA) with TNK-Ankle investigated radiographically using custom image measurement software and compared with clinical scores. Methods: Twenty four cases of total ankle arthroplasty with TNK-Ankle for osteoarthritis in stage 3b and 4 operated by an expert surgeon from 2009 to 2013 have investigated on X-rays of preoperative unaffected and postoperative affected ankles. Clinical outcomes by JSSF score based on AOFAS score and SAFE-Q, patient-based questionnaire, were compared with radiographic measurements. Image analysis performed with custom OpenCV software programmed for this study. This could match translucent X-ray images, an unaffected lateral ankle image and an implanted lateral ankle image with TNK-Ankle, and measure differences in geometry of ankle joint for tibia and talus between two images. Results: Postoperative clinical outcomes were improved from preoperative on JSSF (from 57 to 90) and generally affirmative on each item of SAFE-Q at forty-six months follow-up. But three ankles had some subsidence and loosening of prostheses, two ankles needed revision surgeries. Their ankles were classified for revision and loosening group, and the other ankles were classified for non-loosening group. X-ray image measurements with the custom software had elucidated two dimensional geometry of postoperative implanted ankle compared to preoperative unaffected ankle joint and its differences between two groups. In Revision and loosening group, the top of tibial plafond of tibial component of TNK-Ankle was placed 7 mm anterior to the top of unaffected tibial plafond and more than 4 mm anterior in non-loosening group. Inclination of component in loosening and revision group was a little more than in non-loosening group. Conclusion: In this study it was indicated that a few case may have loosening and revision after TAA even if it was performed on correct indication and by an expert surgeon, and clinical results may be concerned in geometry of implanted ankle. Precise replacing of total ankle prostheses by means of navigation and image-guided surgery may produce better results means. Data accumulation by more radiographic measurements with digital tools must become useful for future navigation system. Custom- made software development suitable to research demand like this study would be more efficient.

BACKGROUND:Treatment of osteonecrosis of the talus is challenging. Total talar replacement has the potential to restore the function of the ankle joint without an associated leg-length discrepancy. The purpose of the present study was to investigate postoperative function and pain after total talar replacement in patients with osteonecrosis of the talus. METHODS:Fifty-five ankles in fifty-one consecutive patients with osteonecrosis of the talus who were treated with a total talar replacement from 2005 to 2012 were included in the investigation. Scores according to the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale and the Ankle Osteoarthritis Scale (AOS) were assessed before surgery and at the final follow-up evaluation. RESULTS:According to the JSSF ankle-hindfoot scale, the score for pain improved from a mean (and standard deviation) of 15 ± 9.4 points (range, 0 to 20 points) to 34 ± 5.6 points (range, 20 to 40 points); the score for function, from 21.2 ± 9.7 points (range, 4 to 38 points) to 45.1 ± 4.0 points (range, 37 to 50 points); the score for alignment, from 6.0 ± 2.8 points (range, 5 to 10 points) to 9.8 ± 0.9 points (range, 5 to 10 points); and the total score, from 43.1 ± 17.0 points (range, 11 to 68 points) to 89.4 ± 8.4 points (range, 76 to 100 points). According to the AOS scale, the score for "pain at its worst" improved from a mean of 6.1 ± 3.3 points (range, 0 to 9.9 points) to 2.0 ± 1.7 points (range, 0 to 6.3 points). CONCLUSIONS:Prosthetic talar replacement is a useful procedure for patients with osteonecrosis of the talus as it maintains ankle function.

Idiopathic osteonecrosis of the talus is a rare but severe condition that directly affects the ability to walk and is difficult to treat either conservatively or surgically. We report the case of a 72-year-old female with idiopathic necrosis of the talus treated with total talar replacement surgery. A custom-made aluminum-ceramic total talar prosthesis was prepared using the mirror image of the computed tomography and radiographic data from the contralateral ankle. The talus was exposed and removed using an anterior approach, and the total talar prosthesis was inserted. The prosthesis was placed in a stable position between the tibia, calcaneus, and navicular, with no signs of instability with ankle joint movement. The ankle was immobilized in a short-leg cast for 3 weeks. At the latest follow-up examination, 2 years after surgery, the patient was walking without pain. Examination of the left ankle showed 20° of dorsiflexion and 40° of plantar flexion. The American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 90, which had improved from a preoperative score of 45. Radiographic examination showed that the prosthesis was in a stable position in the ankle mortise, and no degenerative or destructive changes were observed in the surrounding bones. This is the first reported case of total talar replacement with a prosthesis for idiopathic talar necrosis. Although the long-term outcome is still unknown, this procedure could provide a good treatment option for idiopathic necrosis of the talus.