Location of Activation of Tarsal Joints on

SPECT CT Scan Predicts Preoperative

Functional and Pain Scores on

Supramalleolar Osteotomy Patients

Christopher E. Gross, MD1; William Barfield, PhD1; Christine

Schweizer2; Helmut Rasch, MD3; Michael T. Hirschmann, MD4;

Beat Hintermann, MD2; Markus Knupp, MD4

1Department of Orthopedics, Medical University of South Carolina, Charleston, SC, USA2Department of Orthopedic Surgery and Traumatology, Kantonsspital Baselland Standort Bruderholz, Switzerland

3Department of Radiology, Kantonsspital Baselland Standort Bruderholz, Switzerland4Department of Orthopedic Surgery and Traumatology, Kantonsspital Baselland, Liestal, Switzerland

NO CONFLICTS TO DISCLOSE

The utility of the ankle

SPECT/CT scan to predict

functional and clinical outcomes in

supramalleolar osteotomy patients

We have no potential conflicts with this presentation.

Introduction

• Supramalleolar osteotomies (SMO) for

asymmetric ankle arthritis:

– improves functionality of patients

– Uncertain as to how/why the radiographic signs of

arthritis improve and patients have reduction in pain.

• ? How to analyze in vivo joint mechanics

prior to the supramalleolar osteotomy

– Look at bone metabolism!

SPECT/CT scan• Combined single-photon

emission computed

tomography and conventional

computed tomography

(SPECT/CT) is a hybrid

imaging modality that shows a

combination of metabolic and

structural information about

the ankle

In the Literature• Degenerative joint

in the ankle and

midfoot

• Painful total ankle

replacements

• Malalignment

• Osteochondral

lesions

• Diabetic foot

infection

• Accessory bones

• Stress fractures

• Tarsal coalitions

• Impingement and

soft tissue

Ankle arthritis and SPECT

• 6 patients with end-stage ankle DJD (Paul et al,

FAI 2015)

• In areas with radiotracer uptake:

– subchondral bone had an increase in

osteoblasts

– no functional osteoclasts

– increased randomly organized

collagen deposition

PurposeInvestigate if the location of bone scan activation is

related to pre and post-operative functional and pain

scores.

Hypothesis• Uptake in specific locations within the ankle joint

can be associated with worse pre- and post-

operative functional and pain scores.

• SPECT/CT scan can help predict which patients

will have a successful SMO

Methods

• 80 supramalleolar osteotomies performed

(4/2006-1/2015)

• All pts were evaluated pre and post-op

clinically and radiographically

• Pre and post-operative functional and pain

scores were recorded for each patient at an

average of 3.7±2 years post-operatively

• Failure rates recorded

Methods

• Activation was assessed on both the tibia and talus

including 18 locations on axial scans, 8 locations

sagittally, and 12 locations coronally on SPECT/CT

imaging

SCHEMA

Statistical analysis

• χ2 test: association between 2 categorical variables

• Two-sample, independent sample t-test: compare

mean difference between 2 groups.

• Significance level for all tests was p<0.05.

• SAS version 9.4 (Cary, NC; United States).

Results

• Varus patients (38 pts)

– medial opening wedge osteotomy (18, 22.5%)

– lateral closing wedge osteotomy (10, 12.5%)

– dome osteotomy (6, 7.5%)

– intra-articular osteotomy (4, 5%)

• Valgus pts (42 pts)

– medial closing wedge osteotomy (40, 50%)

– lateral opening osteotomy (2, 2.5%)

Pre-operatively

• Talonavicular (6) activation:

– worse malalignment (AOFAS Hindfoot-A subscore)

– worse a functional status (AOFAS-F)

• Subtalar joint activation (10):

– significantly worse (p<.05) pre-operative VAS pain

scores.

– worse AOFAS-F, AOFAS Hindfoot, and FAOS-S

scores

• Calcaneocuboid activation (1) did not have any

correlation to pre-operative pain or functional

scores.

Post-operatively

• Activation in these areas

were not associated with

any post-operative

functional or pain scores.

Failures

• Ten patients (12.5%) had a treatment failure

– Six patients: TAR

– Four patients: Arthrodesis

• Pre or post-operative alignment did not correlate to a

treatment failure

• Patients with hindfoot joint activation did not have a

higher rate of failure relative to other locations in the

ankle.

• The only significant (p=.036) poor prognostic

indicator was a bipolar lesion

Limitations

• Cannot quantify amount of radiotracer uptake

– Needed to rely on a 10 point SPECTRUM scale

• We are able to correlate certain pre- and post-

operative functional outcomes to areas of

radiotracer uptake

– Unclear if there are any clinical implications for this data

Conclusion

• Pre-operative SPECT/CT can be used to

clinically correlate patient-specific factors in

the pre and post-operative period

• We caution against performing a SMO in

patients with bipolar activation on a pre-

operative SPECT-CT scan

THANK YOU

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