bluuebunny/crossref_metadata_2025 huggingface dataset:
InternalBrace has Comparable Stiffness and Strength as Tightrope for Lisfranc Fixation
Authors: Hopkins Justin , Heyrani Nasser , Kreulen Christopher , Garcia Tanya , Christiansen Blaine , Giza Eric
Published: September 2017

Category:

Sports, Biomechanics

Introduction/Purpose:

Lisfranc injuries are characterized by disruption between the medial cuneiform and base of the second metatarsal. Conventional interfragmentary screws decreases the amount of diastasis, however is believed to decrease the natural physiological movement of the joint compared to suture button (Tightrope, Arthrex, Inc., Naples, FL). The InternalBrace (IB, Arthrex, Inc., Naples, FL) allows physiologic movement and collagen ingrowth, while also decreasing iatrogenic bone loss. It also prevents erosion of the suture button into the medial cuneiform and prevents irritation of the tibialis anterior tendon. We hypothesized that there was no significant difference in the mechanical properties of these three constructs.

Methods:

Three groups of 10 sawbone models were used in this study. Two fourth generation 20 mm cylinder sawbones with open cell foam were fixed together with either a 3.5 mm conventional screw, mini Tightrope or IB with a curved button and 4.75 mm biotenodesis screw. Sawbone constructs were held in a mechanical testing system (Model 809, MTS Systems Corp, Minneapolis MN) using custom fixtures. Constructs were loaded in axial tension at 0.5mm/sec until failure. Load-displacement data were plotted for each test. Yield, stiffness, ultimate strength (US), yield energy, post-yield energy and ultimate strength energy were calculated Additionally, the load and energy to 0.5 mm, 1.0 mm and 1.5 mm of displacement were captured to relate strength at clinically relevant displacements. The residuals of an ANOVA on all mechanical testing results were not normally distributed. Therefore non-parametric comparison was used to compare fixation types (Proc NPAR1WAY, SAS 9.4, SAS Institute).

Results:

Compared to IB, the screw demonstrated greater stiffness, yield load and energy, and ultimate load and energy, with smaller yield, ultimate and failure displacement. When comparing the Tightrope and IB, there was no difference in stiffness (p=0.82), although the Tightrope performed greater in terms of having a larger yield load, energy and displacement, a larger ultimate strength load, energy and displacement, and a larger failure load, energy and displacement. When assessing the load at various distances of displacement, there was no significant difference between the load at 0.5 mm displacement (p=0.5, Figure 1). At greater displacement, the load was greater in the Tightrope than the IB (Figure 1).

Conclusion:

In this study, IB has shown proper stiffness and strength for fixation of ligamentous lisfranc injury. However, if a diastasis of >0.5 mm is evident, concerns for a clinical failure should be examined. This is the first study examining the use of an IB for treatment of a ligamentous lisfranc injury. The data supports its current clinical indications and further studies in cadaveric models are recommended.
Fixation of calcaneal fractures through a mini-incision technique
Authors: Hudson Parke , Sahranavard Bahman , Johnson Michael , Watson Shawna , Terry Charles
Published: September 2017

Category:

Hindfoot, Trauma

Introduction/Purpose:

The management of calcaneal fractures is a source of debate among orthopaedic surgeons due to a high risk of complications. The goals of surgical fixation are to restore the alignment and articular surface of the calcaneus. A popular fixation technique is open fixation as it provides the best visualization of fracture fragments. However, the extensive soft tissue disruption often associated with a larger incision places patients at risk for wound healing complications and infection. Due to the high risk of complications, non-operative treatment is often recommended. However, malunion of calcaneus fracture with non- operative treatment leads to predictable complications as well. Due to wound concerns, fixation using a mini-incision technique has emerged as an option for restoring calcaneal anatomy while minimizing wound complications.

Methods:

From July 1, 2013 to December 31, 2015, 22 patients underwent surgical fixation of 25 displaced calcaneal fractures through a mini-incision technique. All patients were 18 years of age or older and had no history of prior fracture of the operative calcaneus. A chart review was performed to assess for complications defined as non-union, infection, or reoperation for any reason. To assess for restoration of calcaneal anatomy, preoperative and postoperative lateral radiographs were reviewed to assess the Angle of Gissane (normal: 130-145 degrees) and Bohler’s angle (normal: 20-40 degrees).

Results:

Of the 22 patients (25 fractures), 68.2% (15/22) were male and average age was 41.86 years old. History of tobacco use was present in 81.8% (18/22), alcohol use in 40.9% (9/22), and illicit drug use in 31.8% (7/22). Sixty-eight percent (17/25) of fractures were tongue type and 32% (8/25) were depression type. Average Bohler’s angle (BA) was 13.2 preoperatively and 26.4 degrees postoperatively. Of the 17 calcanei with an abnormal BA preoperatively, 14 (82.4%) had a normal BA restored by surgery. The average postoperative time at final radiograph was 3.9 months. Twelve percent (3/25) of fractures had complications. One reoperation for removal of painful hardware, one reoperation due to non-union and infection, and one reoperation due to infection only.

Conclusion:

Our results indicate the mini-incision technique is an effective option in restoring calcaneal anatomy while minimizing complications. The poor follow-up and multiple comorbidities present in patients in this study are likely common in the general calcaneal fracture population as well. These factors make techniques that reduce the risk for wound complications, such as the mini-incision, intriguing and potentially extremely useful. Further study comparing a mini-incision technique to more extensile approaches is needed.
Measuring Visualized Joint Surface in Hallux Metatarsophalangeal Arthroscopy
Authors: Hull Michael , Campbell John T. , Cerrato Rebecca , Jeng Clifford , Henn R. Frank
Published: September 2017

Category:

Arthroscopy, Midfoot/Forefoot

Introduction/Purpose:

Arthroscopy has been increasingly utilized to evaluate small joints in the foot and ankle. In the hallux metatarsophalangeal (MTP) joint, little data exist evaluating the efficacy of arthroscopy to visualize the articular surface. The goal of this cadaveric study was to determine how much articular surface of the MTP joint could be visualized.

Methods:

Ten (10) fresh cadaveric foot specimens were evaluated using standard arthroscopy techniques. Arthrosocopy was performed with gravity distraction utilizing a 1.9 mm 30° arthroscope and small joint instruments. The edges of the visualized joint surface were marked with curettes and Kirschner wires; the joints were then surgically exposed and imaged. The percentage of cartilage visualized (visualized / total cartilage x 100%) was measured using ImageJ® software. Measurements include surface area visualized on axial imaging as well as arc visualized on lateral imaging

Results:

On the distal 2-dimensional projection of the joint surface, an average 57.5% (49.6 – 65.3) of the metatarsal head and 100% (100-100) of the proximal phalanx base were visualized. From a lateral view of the metatarsal head, an average 72° (65-80) was visualized out of an average total articular arc of 199° (192-206), for an average 36.5% (32.2 – 40.8) of the articular arc.

Conclusion:

The results suggest that hallux MTP arthroscopy visualizes a sizable portion of the joint surfaces. However, incomplete visualization could potentially miss a hallux metatarsophalangeal lesion. Further imaging preoperatively may improve diagnostic confidence.
The V Sign in Lateral Talar Process Fractures
Authors: Jentzsch Thorsten , Hasler Anita , Renner Niklas , Peterhans Manuel , Sutter Reto , Espinosa Norman , Wirth Stephan
Published: September 2017

Category:

Ankle, Hindfoot, Trauma

Introduction/Purpose:

Lateral talar process fractures (LTPF) constitute 15% of ankle injuries in snowboarders. They are often misdiagnosed on conventional radiographs, which are also susceptible to rotational malpositioning due to pain. A positive V sign is an interruption of the contour of the lateral talar process. It has been suggested to be pathognomonic for LTPF. However, there are very few studies about this topic. The objectives were to study whether the V sign is useful in diagnosing LTPF.

Methods:

In an experimental study, two investigators evaluated lateral radiographs (n=108) of high resolution, solid foam, radiopaque distal foot and ankle models. Two other investigators, who obtained the radiographs, defined the gold standard. Four different models (no fracture, type A, B, or C fractures according to Hawkins) and three varying ankle joint positions (0°, 20°, and 40° of inversion, plantar flexion, and internal rotation) were the independent variables. The correct detection of a V sign on lateral radiographs (Figure 2 showing a positive V sign on a lateral radiograph in a type B LTPF) was the primary dependent variable and the detection of the fracture type and uncertainty in making this decision were the secondary dependent variables. The chosen study size surpassed the sample size calculation. The chi-squared test was used for categorical data.

Results:

There were fair interobserver agreements on the V sign and fracture types (kappa coefficient [k]=0.35, 95% confidence interval [CI] 0.18-0.53, p<0.001 and k=0.37, 95% CI 0.26-0.48, p<0.001). For the detection of the V sign, the mean sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio, and mean uncertainty were 77% (95% CI 67-86%), 59% (95% CI 39-78%), 85% (95% CI 75-92%), 46% (95% CI 29-63%), 2, and 38%. Increased inversion and type B fractures were associated with better detection of the V sign (p=0.035 and p=0.011 as well as p=0.001 and p=0.013, for each investigator). Plantar flexion and internal rotation were not associated with the V sign (p=0.31 and 0.33 as well as 0.35 and 0.53, for each investigator).

Conclusion:

It is not recommended to exclusively use the V sign for the evaluation of LTPF. If negative, LTPF cannot be excluded. However, if positive, it may be a helpful surrogate parameter for the presence of LTPF, especially type B fractures. Inversion may lead to better visualization of the V sign. This knowledge about the V sign is a valuable asset for the diagnostic skillset of an orthopaedic surgeon. Future clinical studies may focus on validating these experimental findings. [Notes: Level of evidence is not applicable to this study. This abstract has also been submitted to the swiss orthopaedics congress 2017.]
Tibiotalocalcaneal Arthodesis via a Nitinol Containing Intramedullary Nail
Authors: Kadakia Rishin , Labib Sameh , Bariteau Jason
Published: September 2017

Category:

Ankle, Ankle Arthritis, Hindfoot

Introduction/Purpose:

Tibiotalocalcaneal (TTC) arthrodesis is a common procedure used in the management of foot and ankle pathologies. TTC fusions are frequently performed in patients with limited bone stock and poor vascular status. Adequate compression at the arthrodesis site is vital to successful fusion as even small amounts of bone resorption greatly increase nonunion risk. A recently designed hindfoot nail contains a built in nickel titanium alloy (nitinol) that has psuedoelastic properties which maintains compression across joint surfaces in the setting of bone resorption. The authors present a case series of patients who were managed with this nitinol containing intramedullary hindfoot nail system.

Methods:

Patients treated by one board certified orthopaedic foot and ankle surgeon who were managed with the nitinol containing hindfoot nailing system were retrospectively reviewed over a two year span. Electronic medical records were reviewed to collect demographic information and details regarding the patient’s procedure. Operative specifics collected included the data of the procedure and the preoperative diagnosis. Records were reviewed postoperatively as well to document the incidence of postoperative complications and functional outcomes. Proximal migration of the distal interlocking screw on lateral radiographs were measured in a standardized fashion at two, six, and twelve weeks to objectively assess additional compression obtained through the nitinol nailing system.

Results:

Eight patients were included in the case series with an average follow up time of 7 months postoperative (minimum of 4 months for one patient). The most common preoperative diagnosis was posttraumatic arthritis (n = 4). One patient suffered from wound dehiscence postoperatively that required operative intervention within the first three months – this patient’s wound healed by six months with no further complications. All patients were cleared for full weight bearing and activities as tolerated by six months, except only had four months of follow up available. The compression obtained through this nailing system increased at each follow up for all patients. The average compression obtained was 2.9 mm at two weeks, 3.8 mm at six weeks, and 4.4 mm at twelve weeks.

Conclusion:

Tibiotalocalcaneal arthrodesis can be an excellent procedure that provides significant pain relief and restores function. The patients in this case series all had excellent results with only one postoperative complication that ultimately did not result in any functional deficits. Furthermore, patients all demonstrated increased compression at each follow up radiographs which demonstrates the sustained compression obtained at the arthrodesis site through this hindfoot nail system. Further prospective work with a larger patient cohort is warranted to determine if this nailing system is superior to other TTC hindfoot nails.
Extended Distal Chevron Osteotomy
Authors: Kang Chan , Song Jaehwang , Kang Donghun , Noh Chang-Kyun , Jun Ahn Ki
Published: September 2017

Category:

Bunion, Midfoot/Forefoot

Introduction/Purpose:

Numerous corrective osteotomies have been performed for surgical treatment of hallux valgus(HV). One of these procedures is distal chevron osteotomy, traditionally indicated for correction of mild to moderate HV. We proposed a new modification of the chevron osteotomy, extended distal chevron osteotomy, to provide even greater stability by extend the contact surface, as well as more effective and accurate correction of the angulation and rotational profile than conventional osteotomy.

Methods:

Between July 2013 and June 2014, the extended distal chevron osteotomy (DCO) was performed for the treatment of mild-to-moderate hallux valgus deformity in 63 feet (Group A) by the same surgeon. For the extended chevron, the first osteotomy was performed to cut 5-10 mm from the head of metatarsal to the proximal upper 1/3 of the neck. The second osteotomy was performed to cut 2.5~3.0 cm from the upper 1/3 of the neck toward horizontal plane of the plantar surface with an angle of 45~50 degree. Standard foot radiographic measurements, hallux valgus angle(HVA) and intermetatarsal angle(IMA), were recorded to compare with the values of 37 patients (Group B) who were treated by the traditional DCO technique.

Results:

Mean patient age was 45.3 (range 15–78) years, and 54 patients were available for follow-up at both one and two years postoperatively. Mean follow-up duration was 13.7 (range 4–26) months. In group A, mean HVA decreased from 32.3° preoperatively to 8.4° at final follow-up, while the angle of group B decreased from 32.4° to 11.4°. Mean IMA decreased from 15.1° preoperatively to 7.3° at final follow-up in group A, while the IMA decreased from 15.1° to 8.9° in group B. That way we could verify that the extended chevron osteotomy is more effective for stability and correcting of the angulation and rotational profile than traditional DCO.

Conclusion:

The extended chevron osteotomy achieved even greater stability and accurate correction of the deformity. Furthermore, it was more effective than traditional chevron osteotomy in terms of correction of the angulation and rotational profile.
Figure 8 (Heel open) short leg cast
Authors: Kang Chan , Song Jaehwang , Kang Donghun , Noh Chang-Kyun , Ahn Ki-Jun , Lee Gi-Soo
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

To report the results of applying heel open (figure 8) short leg cast on foot & ankle trauma or disease patients requiring short leg casts.

Methods:

380 patients who were confirmed and treated by diagnosed of foot & ankle trauma or diseases were included between November 2014 and July 2016. Comprised of 222 males and 158 females, their mean age was 46 years old. The bottom of the figure 8 cast covered the metatarsal head to half portion of the medial longitudinal arch, while leg portion covering consisted from the prominence of the both malleolus to halfway of the lower leg, resulting in complete exposure of the heel and distal portion of the achilles tendon. After application of the figure 8 cast, changes in the ROM in active ankle dorsiflexion & plantarflexion, passive foot inversion & eversion, and foot internal & external rotation were measured.

Results:

In all cases, measurements of active ankle dorsiflexion & plantarflexion was less than 5 degrees, measurements of passive foot inversion & eversion was less than 5 degrees, foot internal & external rotation was less than 0 degrees, and were stably held without skin or soft tissue injury until cast removal. Notable were 22 cases of foot & ankle fractures treated with conservative therapy with figure 8 short leg cast resulting in bone union and stabilization without surgery. VAS discomfort score was an average of 2.6 (0~5) and figure 8 short leg cast was selected in all cases requiring a short leg cast.

Conclusion:

The use of figure 8 short leg cast in patients of foot & ankle trauma and diseases requiring short leg cast provides safety and prevention of skin necrosis and pressure sores from open heels while providing high patient satisfaction in daily life, such as heel touch. We believe that figure 8 short leg cast could replace the traditional short leg cast, if the safety of the figure 8 cast could be proven through long-term follow up study with various patient and cases.
The Use of Weight-Bearing CT Scan in the Evaluation of Hindfoot Alignment
Authors: Kaplan Jonathan , Myerson Mark , Welck Matthew , Tracey Joseph , Avila Adriana , Li ShuYuan
Published: September 2017

Category:

Hindfoot, Diagnostic Imaging

Introduction/Purpose:

Multiple techniques have been described in determining the hindfoot alignment radiographically. While these studies have traditionally showed good reliability, the 2-dimensional nature of radiographs fails to consider the contribution of the remainder of the foot on the overall alignment. A new technique has been recently published in which the hindfoot alignment is calculated using the Ground Reaction Force Calcaneal Offset off radiographs. This technique accounts for the individual forefoot contributions on overall alignment, however is still limited by the 2-dimensional nature of plain radiographs. The purpose of this study is to compare two accepted radiographic measurements, the hindfoot moment arm (HMA) and the hindfoot alignment angle (HAA), with a novel technique determining the ground reaction force calcaneal offset (GRF-CT) using 3- dimensional weight bearing CT Scans.

Methods:

Retrospective chart review was performed over a two-year period from 2014-2016 to identify patients with weight bearing hindfoot alignment radiographs and PedCat (Curvebeam, Warrington, USA) 3-D weight bearing CT scans. The HMA, HAA, and GRF-CT were measured by three different investigators. Each of these measurements were calculated two times on separate occasions by each investigator to determine the intra- and inter-observer reliability with each of these techniques

Results:

One-hundred and four patients underwent weight bearing hindfoot alignment radiographs and 3-dimensional weight bearing CT scans. There were 33 patients with varus deformities and 71 patients with valgus deformities. There was excellent intra- and inter-observer reliability with all three measurement techniques, however the GRF-CT showed the best intra- and inter-observer reliability with the lowest standard deviation

Conclusion:

The GRF-CT technique is more reliable than traditional radiograph techniques for measuring the hindfoot alignment. While the intra- and inter-observer reliability is good for all three techniques, the GRF-CT technique resulted in the best intra- and inter-observer reliability with the lowest standard deviation. This technique provides the most accurate hindfoot alignment as it takes into account the effect of forefoot on overall alignment, preventing inaccuracies of projection and foot orientation in contrast to traditional radiographic techniques, which may be valuable in surgical decision making.
Ultrasonographic Assessment of Synovitis with Lessor Toe Deformity Due to Rheumatoid Arthritis
Authors: Kashiwagura Takeshi , Nozaka Koji , Kura Hideji , Aonuma Hiroshi
Published: September 2017

Category:

Lesser Toes

Introduction/Purpose:

[Introduction] In recent years, joint ultrasonography has been widely used for the diagnosis and treatment of rheumatoid arthritis (RA), allowing visualization of synovitis. Its clinical usefulness in early diagnosis and evaluation of disease activity has been reported. Continuous inflammation, osteochondral destruction, and soft tissue destruction due to synovitis in toe joints result in various clinical pictures of the foot. In the lateral toes in the forefoot, subluxation or luxation of the metatarsophalangeal (MTP) joints may occur, leading to painful callosities and resultant disturbance in activities of daily living. Few reports have addressed toe deformity and joint ultrasonographic findings of synovitis in the forefoot. In this study, lateral MTP joints were assessed using joint ultrasonography in RA patients to examine the correlation with deformity.

Methods:

[Subjects] Seventy feet of 61 RA patients were examined in the outpatient clinic of our hospital. Patients who underwent surgery were excluded. The mean age of the patients was 66 years (24 to 92 years), and the mean duration of disease was 12 years and 9 months (1 month to 40 years). Biologic products were used for 23 feet. Joint ultrasonography was performed by the same examiner, using the same room and apparatus. Synovitis was defined as Grade 1 or more as determined by the power Doppler method. Based on foot radiographs in upright position obtained before and after ultrasonography, patients with luxation, subluxation, and joint fissure narrowing were classified into the deformity group, those with bone erosion and geode formation into the bone erosion group, and lack of abnormal findings into the normal group.

Results:

[Results] Synovitis was found in MTP joints in 41 (14.6%) of 280 toes. The incidence rates of synovitis in the deformity group, the bone erosion group, and the normal group were 27.3%, 13.1%, and 6.7%, respectively. Synovitis was found in 21.7% of patients on therapy with biologic products and in 38.3% of those without such therapy. There were no significant differences in the mean duration of the disease, visual analogue scale score, erythrocyte sedimentation rate, matrix metallopeptidase 3 level, or health assessment questionnaire score among the 3 groups.

Conclusion:

[Discussion] Synovitis was also found in patients who showed no changes on imaging of the toes. Synovitis persisted in some patients even after establishment of toe deformity. Drug therapy, intensification of conservative therapy, and synovectomy should be considered to prevent further deformation.
Audit changes practice; simple education intervention can lead to better outcome for ankle fractures undergoing surgery
Authors: Kheiran Amin
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Unstable ankle fractures are common orthopaedic injuries and majority requires open reduction and internal fixation (ORIF). The goal of surgery is to achieve anatomical reduction and stable fixation of fracture. Recent literature reports malreduction rate as high as 25% to 33%. There is emerging evidence that malreduction leads to poor patient reported outcome (PROMs) and may render additional surgery. The aim of this study was to evaluate the quality of anatomical reduction and surgical fixation of ankle fractures and the effect of a simple education intervention on the adequacy of reduction of these fractures.

Methods:

An audit cycle was completed starting with retrospective review (phase 1) of 114 consecutive cases of ankle fracture that underwent ORIF between October 2006 and December 2007. Data was retrieved from theatre log and PACS. Age, fracture morphology, time to surgery, time to revision surgery and the quality of anatomical reduction were assessed by three surgeons using three radiological parameters (Pettrone’s criteria + Weber’s dime test). Paediatrics, pathological fractures, open fractures were excluded. The results were conveyed and interventions in the form of regional teaching and introduction of radiological criteria were implemented. Phase 2 (re-audit) was conducted with prospective review of 72 cases between December 2015 and June 2016. Inter-rater reliability was determined using kappa value. Chi- square test was used to compare malreduction rates between 2 phases. Logistic regression was performed for age, gender, time to ORIF with regards to revision surgery. P value < 0.05 was considered significant

Results:

Results of initial cohort showed significant rate of malreduced fixation in 25% of cases (29 out of 114). After implementation of interventions, malreduction rate reduced to 12.6% (9 out of 72). Of these nine malreduced cases, 3 cases underwent early revision surgery within the first 6 weeks of surgery. There was no significant correlation between age, gender and time to surgery, and time to revision surgery within 3 months of surgical fixation (p = 0.4). Using three radiological parameters (Weber’s dime test, tibiofibular overlap and medial clear space) the mean kappa values for inter-rater reliability was 0.786 (0.727- 0.861), representing a substantial agreement using three radiological parameters in order to avoid failure and or further surgery.

Conclusion:

This study demonstrates that simple education intervention locally can lead to better understanding of fixation and reduce the rate of malreduction of these fractures. We suggest using three radiological parameters in correction of corresponding anatomy of ankle mortise is a reliable tool to avoid malreduction. Malreductions were more likely to occur in complex fractures with syndesmotic injuries.
Which Surgical Method is More Effective in the Fifth Metatarsal Base Fracture?
Authors: Kim Jun-Beom , Ahn Chi , Park Byeong-Seop
Published: September 2017

Category:

Trauma

Introduction/Purpose:

The aim of this study was to evaluate and compare the clinical and radiological results of internal fixation with headless cannulated screw and locking compression distal ulna hook plate for the fracture at the base of fifth metatarsal bone, Zone 1.

Methods:

From April 2012 to April 2015, thirty cases (29 patients) were evaluated retrospectively. The mean follow up periods was 13 months. There were divided two groups based on use of the screw (group A, n=15) or the plate (group B, n=15).We measured the displacement to diastasis of the fracture on the foot oblique radiographs taken pre- and post-operatively in each group, checked the time to bone union and the difference of the reduction distance in each group. Clinical results were evaluated using American Orthopedic Foot and Ankle Society (AOFAS) midfoot score at 12 months postoperative.

Results:

In group A, the mean time to union was 54.2±9.3 days, the mean displacement to diastasis improved to 0.3±0.4 mm postoperatively (p<0.001), and the mean reduction distance was 2.9±1.0 mm. In group B, the mean time to union was 41.5±7.0 days, the mean displacement to diastasis improved to 0.06±0.2 mm postoperatively (p<0.001), and the mean reduction distance was 4.1±1.6 mm. AOFAS score was verified 97.7±3.4 in group A and 98.2±3.2 in group B. The time to union was significantly different between groups A and B (p=0.01).There were no complications.

Conclusion:

We suggest that the plate is more effective method for the shorter union time in surgical treatment of fifth metatarsal base fractures.
Mid- to Long-Term Results of Supramalleolar Osteotomy
Authors: Krähenbühl Nicola , Zwicky Lukas , Bolliger Lilianna , Hintermann Beat , Knupp Markus
Published: September 2017

Category:

Ankle Arthritis

Introduction/Purpose:

Good clinical and radiographic short-term results have been reported for patients who underwent realignment surgery of the hindfoot for treatment of early- and mid-stage ankle osteoarthritis. However, no mid- to long-term results have been reported. The aim of this study was to gain a better insight on the indications and contraindications for supramalleolar osteotomies. More specific, we assessed the survival rate of a consecutive cohort of 294 patients who underwent supramalleolar osteotomy for ankle osteoarthritis and investigated the effect on functional outcome, pain relief and patients’ satisfaction. Risk factors for failure were additionally determined. We hypothesized, that realignment surgery is a valuable treatment option for young and physically active patients suffering from early to mid-stage ankle osteoarthritis.

Methods:

Two hundred and ninety-four patients (298 ankles) underwent realignment surgery between December 1999 and June 2013 in our institution. For four patients who were operated on both feet, only the measurements from the foot operated first were used for further analysis. The patients were assessed clinically and radiographically preoperatively, six and 16 weeks postoperatively and thereafter annually. The examination was done by independent examiners who were not involved in the treatment of the patients or analysis of the data. Kaplan-Meier survival analysis was performed with total ankle replacement and arthrodesis of the ankle joint as endpoints. A Cox proportional hazards model was performed to identify risk factors for failure.

Results:

The mean time to follow-up was 5.0 ± 3.7 years. The overall five-year survival rate was 88%. Thirty-eight patients (12.9%) either underwent secondary total ankle replacement or ankle arthrodesis (thirty total ankle replacements, eight ankle arthrodesis). A lost to follow-up was reported in eleven patients (3.7%). Overall, the AOFAS Hindfoot score increased from 53.2 preoperatively (SD, 19.9) to 72.7 (SD, 19.2) postoperatively. Risk factors for failure following realignment surgery were age at the time of surgery and a Takakura score of 3b preoperatively. An interaction by trend was also found between age and smoking, indicating that the increased risk in elderly patients was larger in smokers than in non-smokers at the time of surgery.

Conclusion:

We found good mid- to long-term results for supramalleolar osteotomies in patients with ankle osteoarthritis. The present data suggests that corrective osteotomies need to be considered in the surgical treatment of young and active patients with early- to mid-stage ankle osteoarthritis (Takakura stage 1 to 3a). This is particularly important, as ankle replacement at young age cannot be considered a lifetime solution. However, care should be taken in elderly patients who smoke at the time of surgery.
Posterior tibial tendon integrity can be screened using plain anteroposterior foot radiography
Authors: Lee Seung Yeol , Park Moon Seok , Sung Ki Hyuk , Chun Sangho , Kim Sung Jin , Sangyeop Shin , Choi Hyun , Koo Seungbum , Lee Kyoung min
Published: September 2017

Category:

Hindfoot

Introduction/Purpose:

Posterior tibial tendon’s condition has traditionally been evaluated using ultrasonography or magnetic resonance imaging, but recent advancements in radiography have increased the resolution of radiographic soft tissue images. We performed this study to examined whether the posterior tibial tendon could be screened using anteroposterior foot radiographs, based on interobserver agreement and accuracy.

Methods:

We retrospectively evaluated consecutive patients who underwent weight-bearing foot radiography and ultrasonography based on a suspicion of posterior tibial tendinopathy. The integrity of the posterior tibial tendon was evaluated by two orthopaedic surgeons (8 years and 3 years of experience) using foot radiographs, and scored as having normal or abnormal tendon integrity (Fig). We evaluated interobserver agreement between the two surgeons, and the ultrasonography and radiography findings were compared to evaluate diagnostic accuracy.

Results:

We included 21 patients with a mean age of 51.5 ± 15.7 years (5 men and 16 women). Ultrasonography revealed 4 patients with normal tendon integrity, 6 patients with tenosynovitis and no tendinopathy, 8 patients with tendinopathy and tendon continuity, and 3 patients with loss of tendon continuity. The surgeons provided consistent radiographic findings for 81.0% of the patients (17/21; kappa = 0.576, p = 0.007). Based on the ultrasonographic findings, the surgeons provided accuracies of 76.2% (16/21) and 61.9% (13/21).

Conclusion:

The results indicate that weight-bearing anteroposterior foot radiography can be used to evaluate posterior tibial tendon integrity, which may allow physicians to predict the prognosis of patients with PTTD, to determine the extent of surgical treatment, and to evaluate the postoperative tendon integrity.
Significant Differences Exist in Patient Demographics of Foot and Ankle Surgeries between High Quality Prospective Studies and National Databases
Authors: Lin Zilan , Boaz Ray , Gross Christopher
Published: September 2017

Category:

Trauma

Introduction/Purpose:

Several high profile studies have compared surgical and non-operative treatments in specific types of major foot and ankle surgeries and serve as management guidelines for many Orthopaedic surgeons. However, the external validity of these studies has not been examined and should be confirmed in order to confidently apply the study conclusions to the national population and modify clinical practice. The purpose of the current study was to compare patient demographic information collected from major high quality, prospective studies in foot and ankle surgeries and from same surgical procedures recorded in a nationwide database of the United States patient population.

Methods:

Patient demographic information from surgical procedures for achilles tendon rupture, syndesmotic injury, calcaneal fracture, and lisfranc injury were pulled from American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between 2005 – 2014 by using CPT codes listed in Table I. The same information was collected from several randomized control or prospective cohort studies identified for each type of procedure (Table I). Patient age and body mass index (BMI) were compared by using two sample T-test, while Fisher’s exact test was used to compare patient sex. Study data on age and BMI that did not provide both mean and standard deviation were not included in analysis.

Results:

In the NSQIP database, 1,633 achilles tendon repair and 8,852 syndesmotic injury cases were identified, but few calcaneal fracture surgeries and no lisfranc injury cases were found. For surgical cases with syndesmotic injury repair, age, sex and BMI all differed significantly between NSQIP data and the aggregate values of published studies, with the NSQIP patients being older and have more females and larger BMI (Tables II-IV). By comparing individual study data with NSQIP, 1 of 3 studies showed the same trend in age, 2 of 3 in sex, and 1 of 1 in BMI. For cases with Achilles tendon rupture repair, both aggregate and individual comparisons with 2 studies showed statistical difference on age, with NSQIP patients being older (Table II).

Conclusion:

Although the results were somewhat mixed, statistical significance did exist in patient demographic characteristics between published clinical data and a national database in the same foot and ankle surgeries. Caution should be warranted when interpreting clinical studies and before generalizing it onto the national population.
Pes Planus and Distal FIbular Stress Fractures
Authors: Liu Jet , Granberry William
Published: September 2017

Category:

Ankle, Hindfoot

Introduction/Purpose:

Fibular stress fractures accounts for 4.6% to 21% of all stress fractures. There have been isolated reports of distal third fibular stress fractures within 4-7 cm of the tip of the lateral malleolus in young and athletic patients related to overuse injuries. We examine a case series of middle aged female patients with planovalgus foot deformities and associated hindfoot valgus who presented with distal third fibular stress fractures. We propose that this type of distal fibular stress fracture is a result of increased stress loading of the distal fibula at the superior margin of tibio-fibular interosseous ligaments.

Methods:

From October 2015 through September 2016, we evaluated six patients (six cases) who presented to Baylor College of Medicine foot and ankle specialty clinic. These patients were found to have distal fibular stress fractures. Detailed initial history was documented. The diagnosis of distal fibular stress fracture was confirmed with both clinical examination and radiographic evidence among all patients. Additionally, all patients were found to have planovalgus deformity with associated hindfoot valgus. Radiographic measurements were taken in all patients, including lateral talo-calcaneal angle, Meary’s angle, calcaneal inclination angle, and AP tibio-talar angle. Distance of distal fibular stress fracture location to tip of lateral malleolus, as well as the distance between medial cuneiform and 5th metatarsal were measured. Single independent observer performed all measurements.

Results:

Among the six patients in the study, all were female, with average age of 58 years (45-64). Four patients carried the diagnosis of osteopenia and/or osteoporosis from DEXA scan. There is no evidence of association with tobacco use or alcohol use. The mean radiographic distance between location of stress fracture to tip of lateral malleolus is 5.8 cm (4.2cm-7 cm). There was evidence of pes planus from Meary’s angle, which averaged 6.7° (3°-11°) convex downward, and measurement of calcaneal inclination angle averaged 19° (13°-30°). Furthermore, measurement of tibio-talar angle averaged 1.7° valgus alignment consistent with chronic hindfoot valgus deformity. While all patients were treated successfully with immobilization, one patient underwent medial calcaneal osteotomy to correct the hindfoot valgus after recurrent fracture.

Conclusion:

It is hypothesized that increased stress loading of the fibula due to lateralization of the load axis contributes to this condition. The apex of this stress culminates in the lateral aspect of the fibula above the distal tibio-fibular ligament complex and results in a characteristic valgus fracture of the fibula. The increased stress from deformity results in the fracture rather than increased load from exercise or other repetitive stress. The significance of this proposition is that recognition of this type of fracture should lead the clinician to address the underlying planovalgus deformity in the treatment of this fracture type.
How Accurate is Clinical Evaluation in Hindfoot Coronal Alignment?
Authors: Lopez Valeria , Slullitel Gaston , Calvi Juan Pablo , Alvarez Victoria , Calvo Ana
Published: September 2017

Category:

Ankle

Introduction/Purpose:

Hindfoot coronal alignment has to be considered in the assessment of patients with foot and ankle complaints, since it guides treatment of certain pathologies. Even when there are multiples techniques described for clinical and radiographic analysis, none of them are widely accepted. The purpose of the present study was to assess the correlation between clinical and radiographic hindfoot alignment measures and to evaluate the reproducibility of both methods.

Methods:

We evaluated 85 patients with foot and/or ankle symptoms. Hindfoot clinical alignment was evaluated through photographs and radiographic alignment was quantified on Long Axial View radiographs. Measurements were made by two observers.

Results:

Intraobserver ICC for clinical analysis was good for both observers (ICC 0.78 for each one). Interobserver ICC was moderate for both measurements (ICC 0.58 and 0.56). Regarding radiographic assessment, there was significant intraobserver reliability (observer 1: r = 0.95 and observer 2: r = 0.99; P = <.0001). The interobserver reliability was also significant, r = 0.92 for the first measurement and r = 0.95 for the second measurement; P = <.0001. The correlation between both methods was weak for both observers. Observer 1: ICC 0.072; P = .24 for the first measurement and ICC 0.167 P = .029 for the second measurement. Observer 2: ICC 0.23 P = < .001 for the first measurement and ICC 0.137 P = .021 for the second measurement.

Conclusion:

We found a weak intra and interobserver correlation between clinical and radiographic assessment. However, we emphasize the importance of performing a complete clinical evaluation and to complement it with a standardized radiographic examination, including a reproducible technique and measurement method.
Muscular Vein Thrombosis Previous to Immobilization in Acute Tendo Achilles Rupture
Authors: Lopez Valeria , Slullitel Gaston , Ortiz Cristian , Wagner Emilio , Pinton Gustavo Norberto , Alvarez Victoria
Published: September 2017

Category:

Ankle

Introduction/Purpose:

Thromboembolic complications during lower-limb immobilization after Achilles tendon ruptures are common. Both operative and nonoperative treatments of Achilles rupture include a period of immobilization which is a well- documented risk factor for distal vein thrombosis. Curiously, there is a gap in literature linking the diagnosis of thromboembolic events to the Achilles rupture previous to the inmobilization. The term DTV refers to the anterior/posterior tibial or the peroneal veins, i.e. those that correspond to arterial structures and comprise the profound vein system. Although still with little agreement, the role of muscular vein thrombosis or isolated gastrocnemius or soleus vein thrombosis are gaining relevance within the current published data, despite there is no report of it association with tendo Achilles rupture before or after the initiation of treatment.

Methods:

Case report: Five consecutive patients with a diagnosis of traumatic Achilles rupture were evaluated. All patients sustained non traumatic injuries. One of the patients was a heavy smoker, and two of them had BMI over 25. We routinely execute an ultrasound to locate the rupture site and at the same time color ultrasound Doppler was performed by an expert in vascular echography, before the initiation of treatment. In all cases a thrombosis of the calf muscle veins was found. Surgical treatment was not advice in any of the patients and definitive treatment was conservative.

Results:

Calf muscle veins are deep veins in the distal lower extremity that are nonpaired and not associated with named tibial arteries. These veins make up a complex venous system of the musculature of the posterior leg and include the soleal and gastrocnemius veins that run as sinusoids within the muscles of the same name. The soleal sinusoids may drain into the midperoneal or posterior tibial veins, whereas the gastrocnemius sinusoids may empty directly into the popliteal vein. Although the real incidence of MVT is extremely variable, in patients presenting with symptoms and signs suspicious for distal vein thrombosis, muscular veins have been shown to be the most common location for thrombosis with 23% to 41% of all patients.

Conclusion:

Our group of patients was diagnosed before immobilization was established. One plausible explanation could be that the muscle trauma associated with the tendinous rupture may have some influence in the thrombi generation triggering endothelial dysfunction, or affecting the calf muscle pump creating venous stasis, conditions that favour the VTE appearance. It is our perspective that although not well stablished there is at least a theoretical risk of further propagation to the profound venous system and subsequently to the pulmonary system, and this fact not only conditions the treatment of MVT itself, but also the treatment of the Achilles rupture.
Remodeling of the Calcaneocuboid Joint in the Flatfoot
Authors: Manoli Arthur
Published: September 2017

Category:

Hindfoot

Introduction/Purpose:

Although the flatfoot has been successfully treated with a lateral column lengthening (LCL) for over half of a century, there has been controversy recently about whether the lateral column is actually short in a flatfoot, especially the acquired type. Some ask, “How can the normal, hard bones actually change and shorten?” And, if it is not short, perhaps the lengthening procedure is producing a non-physiologic state with abnormal anatomy. Would the flatfoot patient be better served with other procedures that don’t include a lateral column lengthening? Level of Evidence: Therapeutic Level IV.

Methods:

After observing a very dramatically changed calcaneocuboid (CC) joint when performing a double calcaneal osteotomy with a medial soft tissue reconstruction for a Johnson-Strom Stage II posterior tibial tendon insufficiency, it was decided to carefully observe, photograph, and record any changes in the CC joint at surgery in a consecutive series of 21 patients who were operated on who had this disorder(Figure 1). In total, there were fourteen double heel osteotomies, with medial soft tissue reconstructions for Johnson-Strom Stage II deformities, five triple arthrodeses for Stage III deformities, and two lateral column lengthenings with an ankle arthrodesis for a Stage IV deformity. All of the patients had a triple hemisection heel cord lengthening for hindfoot equinus.

Results:

Every patient studied had some changes to the CC joint which were generally related to the amount of deformity present. At a minimum, the calcaneal side of the joint drifted proximally, laterally and dorsally, with bone being laid down on the outside of the calcaneus, resulting in the joint being larger. There was drifting and abduction of the lateral portion of the articular surface of the joint. In some joints the lateral portion looked like a distinct but confluent facet. Often times, a marginal osteophyte was present laterally and dorsally in the widened area of the calcaneus and “kissing” osteophytes were seen on the cuboid. All of these remodeling changes resulted in the calcaneal side of the joint being short, and facing laterally and dorsally.

Conclusion:

These findings give evidence to the rationale for performing of a LCL proximal to the calcaneocuboid joint to treat the acquired flatfoot. When performing a LCL one should attempt to restore length to the calcaneal side of the joint, and to redirect it medially and plantarward. We do not remove the marginal spurs, rather they are maintained to provide an area to insert a retrograde fixation screw. If the patient has lateral column pain after the bone graft has incorporated, the screw and spurs are removed.