Outcomes After Total Ankle Replacement in Association With Ipsilateral Hindfoot Arthrodesis.

BACKGROUND: Ipsilateral hindfoot arthrodesis in combination with total ankle replacement (TAR) may diminish functional outcome and prosthesis survivorship compared to isolated TAR. We compared the outcome of isolated TAR to outcomes of TAR with ipsilateral hindfoot arthrodesis. METHODS: In a consecutive series of 404 primary TARs in 396 patients, 70 patients (17.3%) had a hindfoot fusion before, after, or at the time of TAR; the majority had either an isolated subtalar arthrodesis (n = 43, 62%) or triple arthrodesis (n = 15, 21%). The remaining 334 isolated TARs served as the control group. Mean patient follow-up was 3.2 years (range, 24-72 months). RESULTS: The SF-36 total, AOFAS Hindfoot-Ankle pain subscale, Foot and Ankle Disability Index, and Short Musculoskeletal Function Assessment scores were significantly improved from preoperative measures, with no significant differences between the hindfoot arthrodesis and control groups. The AOFAS Hindfoot-Ankle total, function, and alignment scores were significantly improved for both groups, albeit the control group demonstrated significantly higher scores in all 3 scales. Furthermore, the control group demonstrated a significantly greater improvement in VAS pain score compared to the hindfoot arthrodesis group. Walking speed, sit-to-stand time, and 4-square step test time were significantly improved for both groups at each postoperative time point; however, the hindfoot arthrodesis group completed these tests significantly slower than the control group. There was no significant difference in terms of talar component subsidence between the fusion (2.6 mm) and control groups (2.0 mm). The failure rate in the hindfoot fusion group (10.0%) was significantly higher than that in the control group (2.4%; p < 0.05). CONCLUSION: To our knowledge, this study represents the first series evaluating the clinical outcome of TARs performed with and without hindfoot fusion using implants available in the United States. At follow-up of 3.2 years, TAR performed with ipsilateral hindfoot arthrodesis resulted in significant improvements in pain and functional outcome; in contrast to prior studies, however, overall outcome was inferior to that of isolated TAR. LEVEL OF EVIDENCE: Level II, prospective comparative series.

Comparison of extramedullary versus intramedullary referencing for tibial component alignment in total ankle arthroplasty.

BACKGROUND: The majority of total ankle arthroplasty (TAA) systems use extramedullary alignment guides for tibial component placement. However, at least 1 system offers intramedullary referencing. In total knee arthroplasty, studies suggest that tibial component placement is more accurate with intramedullary referencing. The purpose of this study was to compare the accuracy of extramedullary referencing with intramedullary referencing for tibial component placement in total ankle arthroplasty. METHODS: The coronal and sagittal tibial component alignment was evaluated on the postoperative weight-bearing anteroposterior (AP) and lateral radiographs of 236 consecutive fixed-bearing TAAs. Radiographs were measured blindly by 2 investigators. The postoperative alignment of the prosthesis was compared with the surgeon's intended alignment in both planes. The accuracy of tibial component alignment was compared between the extramedullary and intramedullary referencing techniques using unpaired t tests. Interrater and intrarater reliabilities were assessed with intraclass correlation coefficients (ICCs). RESULTS: Eighty-three tibial components placed with an extramedullary referencing technique were compared with 153 implants placed with an intramedullary referencing technique. The accuracy of the extramedullary referencing was within a mean of 1.5 ± 1.4 degrees and 4.1 ± 2.9 degrees in the coronal and sagittal planes, respectively. The accuracy of intramedullary referencing was within a mean of 1.4 ± 1.1 degrees and 2.5 ± 1.8 degrees in the coronal and sagittal planes, respectively. There was a significant difference (P < .001) between the 2 techniques with respect to the sagittal plane alignment. Interrater ICCs for coronal and sagittal alignment were high (0.81 and 0.94, respectively). Intrarater ICCs for coronal and sagittal alignment were high for both investigators. CONCLUSIONS: Initial sagittal plane tibial component alignment was notably more accurate when intramedullary referencing was used. Further studies are needed to determine the effect of this difference on clinical outcomes and long-term survivability of the implants. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Radioactive in situ hybridization for detecting diverse gene expression patterns in tissue.

Knowing the timing, level, cellular localization, and cell type that a gene is expressed in contributes to our understanding of the function of the gene. Each of these features can be accomplished with in situ hybridization to mRNAs within cells. Here we present a radioactive in situ hybridization method modified from Clayton et al. (1988)(1) that has been working successfully in our lab for many years, especially for adult vertebrate brains(2-5). The long complementary RNA (cRNA) probes to the target sequence allows for detection of low abundance transcripts(6,7). Incorporation of radioactive nucleotides into the cRNA probes allows for further detection sensitivity of low abundance transcripts and quantitative analyses, either by light sensitive x-ray film or emulsion coated over the tissue. These detection methods provide a long-term record of target gene expression. Compared with non-radioactive probe methods, such as DIG-labeling, the radioactive probe hybridization method does not require multiple amplification steps using HRP-antibodies and/or TSA kit to detect low abundance transcripts. Therefore, this method provides a linear relation between signal intensity and targeted mRNA amounts for quantitative analysis. It allows processing 100-200 slides simultaneously. It works well for different developmental stages of embryos. Most developmental studies of gene expression use whole embryos and non-radioactive approaches(8,9), in part because embryonic tissue is more fragile than adult tissue, with less cohesion between cells, making it difficult to see boundaries between cell populations with tissue sections. In contrast, our radioactive approach, due to the larger range of sensitivity, is able to obtain higher contrast in resolution of gene expression between tissue regions, making it easier to see boundaries between populations. Using this method, researchers could reveal the possible significance of a newly identified gene, and further predict the function of the gene of interest.

Poverty and Place in the Context of the American South

In the United States, poverty has been historically higher and disproportionately concentrated in the American South. Despite this fact, much of the conventional poverty literature in the United States has focused on urban poverty in cities, particularly in the Northeast and Midwest. Relatively less American poverty research has focused on the enduring economic distress in the South, which Wimberley (2008:899) calls “a neglected regional crisis of historic and contemporary urgency.” Accordingly, this dissertation contributes to the inequality literature by focusing much needed attention on poverty in the South.

Each empirical chapter focuses on a different aspect of poverty in the South. Chapter 2 examines why poverty is higher in the South relative to the Non-South. Chapter 3 focuses on poverty predictors within the South and whether there are differences in the sub-regions of the Deep South and Peripheral South. These two chapters compare the roles of family demography, economic structure, racial/ethnic composition and heterogeneity, and power resources in shaping poverty. Chapter 4 examines whether poverty in the South has been shaped by historical racial regimes.

The Luxembourg Income Study (LIS) United States datasets (2000, 2004, 2007, 2010, and 2013) (derived from the U.S. Census Current Population Survey (CPS) Annual Social and Economic Supplement) provide all the individual-level data for this study. The LIS sample of 745,135 individuals is nested in rich economic, political, and racial state-level data compiled from multiple sources (e.g. U.S. Census Bureau, U.S. Department of Agriculture, University of Kentucky Center for Poverty Research, etc.). Analyses involve a combination of techniques including linear probability regression models to predict poverty and binary decomposition of poverty differences.

Chapter 2 results suggest that power resources, followed by economic structure, are most important in explaining the higher poverty in the South. This underscores the salience of political and economic contexts in shaping poverty across place. Chapter 3 results indicate that individual-level economic factors are the largest predictors of poverty within the South, and even more so in the Deep South. Moreover, divergent results between the South, Deep South, and Peripheral South illustrate how the impact of poverty predictors can vary in different contexts. Chapter 4 results show significant bivariate associations between historical race regimes and poverty among Southern states, although regression models fail to yield significant effects. Conversely, historical race regimes do have a small, but significant effect in explaining the Black-White poverty gap. Results also suggest that employment and education are key to understanding poverty among Blacks and the Black-White poverty gap. Collectively, these chapters underscore why place is so important for understanding poverty and inequality. They also illustrate the salience of micro and macro characteristics of place for helping create, maintain, and reproduce systems of inequality across place.