bluuebunny/crossref_metadata_2025 huggingface dataset:
Optimal Topology of Multilayer Urban Traffic Networks
Authors: Ding Rui , Yin Jian , Dai Peng , Jiao Lu , Li Rong , Li Tongfei , Wu Jianjun
Published: October 2019

Previous urban traffic network‐based studies have been based mostly on single‐layer networks. Based on their shortcomings, starting from the perspective of a multilayer urban traffic network, this paper takes the different anticongestion abilities and network characteristics of various network structures under the condition of traffic congestion as the research object. Then, a comparative experiment is performed via simulation, and the optimal multilayer urban traffic network topology is obtained under different conditions. It is found that these scale‐free related multilayer networks have relatively strong ability to support more traffic flows and have higher anticongestion abilities, regardless of whether it is a lower‐layer or upper‐layer network. The research results are helpful to deepen our understanding of the characteristics of traffic network structures, help scholars further cognize the structural properties of multilayer urban traffic networks, practically help urban traffic network planners to further optimize the urban traffic network, and broaden the study of multilayer traffic networks.
Genome-Wide Analysis of the Nucleosome Landscape in Individuals with Coffin-Siris Syndrome
Authors: Kalmbach Alexander , Schröder Christopher , Klein-Hitpass Ludger , Nordström Karl , Ulz Peter , Heitzer Ellen , Speicher Michael R. , Rahmann Sven , Wieczorek Dagmar , Horsthemke Bernhard , Bramswig Nuria C.
Published: October 2019

The switch/sucrose non-fermenting (SWI/SNF) complex is an ATP-dependent chromatin remodeller that regulates the spacing of nucleosomes and thereby controls gene expression. Heterozygous mutations in genes encoding subunits of the SWI/SNF complex have been reported in individuals with Coffin-Siris syndrome (CSS), with the majority of the mutations in ARID1B. CSS is a rare congenital disorder characterized by facial dysmorphisms, digital anomalies, and variable intellectual disability. We hypothesized that mutations in genes encoding subunits of the ubiquitously expressed SWI/SNF complex may lead to alterations of the nucleosome profiles in different cell types. We performed the first study on CSS-patient samples and investigated the nucleosome landscapes of cell-free DNA (cfDNA) isolated from blood plasma by whole-genome sequencing. In addition, we studied the nucleosome landscapes of CD14+ monocytes from CSS-affected individuals by nucleosome occupancy and methylome-sequencing (NOMe-seq) as well as their expression profiles. In cfDNA of CSS-affected individuals with heterozygous ARID1B mutations, we did not observe major changes in the nucleosome profile around transcription start sites. In CD14+ monocytes, we found few genomic regions with different nucleosome occupancy when compared to controls. RNA-seq analysis of CD14+ monocytes of these individuals detected only few differentially expressed genes, which were not in proximity to any of the identified differential nucleosome-depleted regions. In conclusion, we show that heterozygous mutations in the human SWI/SNF subunit ARID1B do not have a major impact on the nucleosome landscape or gene expression in blood cells. This might be due to functional redundancy, cell-type specificity, or alternative functions of ARID1B.
An observation of the White-bellied Sea Eagle Haliaeetus leucogaster preying on Saltwater Crocodile hatchlings Crocodylus porosus in Bhitarkanika Wildlife Sanctuary, India
Authors: Palei Nimain Charan , Rath Bhakta Padarbinda , Acharya Bimal Prasanna
Published: October 2019

During our regular monitoring of Salt Water Crocodile in Bhitarakanika National Park in Odisha, eastern India, we for the first time photographed the predation of a hatchling Salt Water Crocodile by a White-bellied Sea Eagle. This information is very crucial as it aid in understanding the natural history of the species.
Moulting pattern and mortality during the final emergence of the Coromandel Marsh Dart Damselfly Ceriagrion coromandelianum (Zygoptera: Coenagrionidae) in central India
Authors: Thaokar Nilesh R. , Verma Payal R. , Andrew Raymond J.
Published: October 2019

The final emergence of the Coromandel Marsh Dart Damselfly Ceriagrion coromandelianum was studied for 50 days (22 January–12 March, 2011) from the botanical garden of Hislop College, Nagpur, India, (a semi controlled site) where small underground cement tubs/tanks are used to grow macrophytes by the Botany department.  In C. coromandelianum emergence is asynchronous, diurnal and occurs between 07.00h and 18.00h.  Stage-I starts when the ultimate instar nymph of C. coromandelianum leaves the water body, searches for a suitable place and then begins to shudder its body to detach the trapped pharate from the nymphal exuvia.  The pharate exerts pressure on the thoracic tergites to split the cuticle.  Stage-II starts when the head and thorax of the pharate emerges out of the split exuvia.  The pharate struggles to remove its trapped body from the nymphal exuvia.  During Stage-III, the wings expand but are opaque; pigmentation of the body occurs simultaneously all over the body.  Soon the whole body develops its species specific coloration while the expanding wings gain transparency, unfold and separate out and now the imago is ready for its maiden flight.  Stages I, II, and III occupy 31.66%, 11.73%, and 56.60% of the total moulting period, respectively.  A total of 243 emergences occurred during the observation period, 158 emergences occurred in tanks containing Pistia stratiotes, while 65 emergences in tubs containing Nymphaea nouchali indicating that C. coromandelianum prefers P. stratiotes over N. nouchali for oviposition.  Twenty deaths were recorded during the present observation.  Failure to moult (15%) and failure to emerge completely out of the exuvia (85%) were the two reasons for mortality.
Reveal, Don’t Conceal
Authors: Weissgerber Tracey L. , Winham Stacey J. , Heinzen Ethan P. , Milin-Lazovic Jelena S. , Garcia-Valencia Oscar , Bukumiric Zoran , Savic Marko D. , Garovic Vesna D. , Milic Natasa M.
Published: October 2019

Reports highlighting the problems with the standard practice of using bar graphs to show continuous data have prompted many journals to adopt new visualization policies. These policies encourage authors to avoid bar graphs and use graphics that show the data distribution; however, they provide little guidance on how to effectively display data. We conducted a systematic review of studies published in top peripheral vascular disease journals to determine what types of figures are used, and to assess the prevalence of suboptimal data visualization practices. Among papers with data figures, 47.7% of papers used bar graphs to present continuous data. This primer provides a detailed overview of strategies for addressing this issue by (1) outlining strategies for selecting the correct type of figure depending on the study design, sample size, and the type of variable; (2) examining techniques for making effective dot plots, box plots, and violin plots; and (3) illustrating how to avoid sending mixed messages by aligning the figure structure with the study design and statistical analysis. We also present solutions to other common problems identified in the systematic review. Resources include a list of free tools and templates that authors can use to create more informative figures and an online simulator that illustrates why summary statistics are meaningful only when there are enough data to summarize. Last, we consider steps that investigators can take to improve figures in the scientific literature.
Bleeding After Hospital Discharge Following Acute Coronary Syndrome: Incidence, Types, Timing, and Predictors
Authors: Ismail Nafiu , Jordan Kelvin P. , Kadam Umesh T. , Edwards John J. , Kinnaird Tim , Mamas Mamas A.
Published: October 2019

Background

The incidence and predictors of bleeding after acute coronary syndrome are unclear within the real‐world setting. Our objective was to determine the incidence, types, timing, and predictors of bleeding complications following hospital discharge after acute coronary syndrome.

Methods and Results

We used the Clinical Practice Research Datalink, with linkage to Hospital Episode Statistics, to determine the incidence, timing, and types of bleeding events within 12 months after hospital discharge for acute coronary syndrome. We assessed independent associations between postdischarge bleeding and baseline patient characteristics using a competing risk regression model, accounting for death as a competing event. Among 27 660 patients surviving to hospital discharge, 3620 (13%) experienced bleeding complications at a median time of 123 days (interquartile range, 45–223 days) after discharge. The incidence of bleeding was 162/1000 person‐years (95%
CI
, 157–167/1000 person‐years) within the first 12 months after hospital discharge. Bruising (949 bleeds [26%]) was the most common type of first bleeding event, followed by gastrointestinal bleed (705 bleeds [20%]), whereas intracranial bleed was relatively rare (81 bleeds [2%]). Significant predictors of postdischarge bleeding included history of bleeding complication, oral anticoagulant prescription, history of peripheral vascular disease, chronic obstructive pulmonary disease, and advanced age (>80 years). Predictors for postdischarge bleeding varied, depending on the anatomic site of the bleeding event.

Conclusions

Bleeding complications after hospital discharge for acute coronary syndrome are common. Patients who experience these bleeding events have distinct baseline characteristics, which vary by anatomic site of the bleed. These characteristics can inform risk‐benefit considerations in deciding on favorable combination and duration of secondary antithrombotic therapy.
Home, Again: Refugee Return and Post-Conflict Violence in Burundi
Authors: Schwartz Stephanie
Published: October 2019

Conflict between returning refugees and nonmigrant populations is a pervasive yet frequently overlooked security issue in post-conflict societies. Although scholars have demonstrated how out-migration can regionalize, prolong, and intensify civil war, the security consequences of return migration are undertheorized. An analysis of refugee return to Burundi after the country's 1993–2005 civil war corroborates a new theory of return migration and conflict: return migration creates new identity divisions based on whether and where individuals were displaced during wartime. These cleavages become new sources of conflict in the countries of origin when local institutions, such as land codes, citizenship regimes, or language laws, yield differential outcomes for individuals based on where they lived during the war. Ethnographic evidence gathered in Burundi and Tanzania from 2014 to 2016 shows how the return of refugees created violent rivalries between returnees and nonmigrants. Consequently, when Burundi faced a national-level political crisis in 2015, prior experiences of return shaped both the character and timing of out-migration from Burundi. Illuminating the role of reverse population movements in shaping future conflict extends theories of political violence and demonstrates why breaking the cycle of return and repeat displacement is essential to the prevention of conflict.
Plurality in the Theological Struggle against Apartheid
Authors: van Wyngaard George J. (Cobus)
Published: October 2019

The church struggle against apartheid remains a key case study in ecumenical public theology, with particular relevance for the Reformed tradition. The importance of Christian theology in both the justification of and opposition to apartheid is well known. Also, the process of ecumenical discernment for responding to apartheid became a significant marker in global ecumenical reflection on what today we might describe as public theology. However, the idea of a theological struggle against apartheid risks ironing out the different theological positions that oppose apartheid. This article highlights some of the attempts to analyze the theological plurality in responses to apartheid. Then it proceeds to present an alternative way of viewing this plurality by focusing on the way in which different classic theological questions were drawn upon to analyze apartheid theologically. Using as examples the important theologians David Bosch, Simon Maimela, and Albert Nolan, it highlights how apartheid was described as a problem of ecclesiology, theological anthropology, and soteriology. It argues that this plurality of theological analyses allows us to rediscover theological resources that might be of particular significance as race and racism take on new forms in either democratic South Africa or the contemporary world. Simultaneously, it serves as a valuable example in considering a variety of theological questions when theologically reflecting on issues of public concern.
Spatial Correction of Multimodel Ensemble Subseasonal Precipitation Forecasts over North America Using Local Laplacian Eigenfunctions
Authors: Vigaud N. , Tippett M. K. , Yuan J. , Robertson A. W. , Acharya N.
Published: October 2019

The extent to which submonthly forecast skill can be increased by spatial pattern correction is examined in probabilistic rainfall forecasts of weekly and week-3–4 averages, constructed with extended logistic regression (ELR) applied to three ensemble prediction systems from the Subseasonal-to-Seasonal (S2S) project database. The new spatial correction method projects the ensemble-mean rainfall neighboring each grid point onto Laplacian eigenfunctions and then uses those amplitudes as predictors in the ELR. Over North America, individual and multimodel ensemble (MME) forecasts that are based on spatially averaged rainfall (e.g., first Laplacian eigenfunction) are characterized by good reliability, better sharpness, and higher skill than those using the gridpoint ensemble mean. The skill gain is greater for week-3–4 averages than week-3 leads and is largest for MME week-3–4 outlooks that are almost 2 times as skillful as MME week-3 forecasts over land. Skill decreases when using more Laplacian eigenfunctions as predictors, likely because of the difficulty in fitting additional parameters from the relatively short common reforecast period. Higher skill when increasing reforecast length indicates potential for further improvements. However, the current design of most subseasonal forecast experiments may prove to be a limit on the complexity of correction methods. Relatively high skill for week-3–4 outlooks with winter starts during El Niño and MJO phases 2–3 and 6–7 reflects particular opportunities for skillful predictions.
An Analysis of Alternatives for the COSMIC-2 Constellation in the Context of Global Observing System Simulation Experiments
Authors: Cucurull L. , Mueller M. J.
Published: October 2019

Observing system simulation experiments (OSSEs) were conducted to evaluate the potential impact of the six Global Navigation Satellite System (GNSS) radio occultation (RO) receiver satellites in equatorial orbit from the initially proposed Constellation Observing System for Meteorology, Ionosphere, and Climate-2 (COSMIC-2) mission, known as COSMIC-2A. Furthermore, the added value of the high-inclination component of the proposed mission was investigated by considering a few alternative architecture designs, including the originally proposed polar constellation of six satellites (COSMIC-2B), a constellation with a reduced number of RO receiving satellites, and a constellation of six satellites but with fewer observations in the lower troposphere. The 2015 year version of the operational three-dimensional ensemble–variational data assimilation system of the National Centers for Environment Prediction (NCEP) was used to run the OSSEs. Observations were simulated and assimilated using the same methodology and their errors assumed uncorrelated. The largest benefit from the assimilation of COSMIC-2A, with denser equatorial coverage, was to improve tropical winds, and its impact was found to be overall neutral in the extratropics. When soundings from the high-inclination orbit were assimilated in addition to COSMIC-2A, positive benefits were found globally, confirming that a high-inclination orbit constellation of RO receiving satellites is necessary to improve weather forecast skill globally. The largest impact from reducing COSMIC-2B from six to four satellites was to slightly degrade weather forecast skill in the Northern Hemisphere extratropics. The impact of degrading COSMIC-2B to the COSMIC level of accuracy, in terms of penetration into the lower troposphere, was mostly neutral.
Parenting stress mediates the association between cyanotic congenital heart disease and internalising problems in children and adolescents
Authors: Chang Ling-Yin , Chiu Shuenn-Nan , Wang Chia-Ching , Weng Wen-Chin , Chang Hsing-Yi
Published: October 2019

Background:

Children and adolescents with cyanotic congenital heart disease have been found to be at an increased risk of internalising problems. The underlying mechanisms, however, remain uncertain.

Aims:

To examine the association between cyanotic congenital heart disease and internalising problems and assess whether parenting stress mediates this association.

Method:

The study sample was 699 children and adolescents (aged 2–17 years) with congenital heart disease (253 with cyanotic congenital heart disease and 446 with acyanotic congenital heart disease) in Taiwan. The Child Behavior Checklist and the Parenting Stress Index were used to assess internalising problems and parenting stress, respectively. A series of multiple regression models was conducted using the SPSS PROCESS procedure to test the association between types of congenital heart disease and internalising problems and the mediating role of parenting stress. A bootstrapping approach was applied to determine the significance of mediation.

Results:

Compared with acyanotic congenital heart disease, cyanotic congenital heart disease was associated with increased levels of internalising problems (B=2.52, P<0.01), and this association was mediated by parenting stress (B=0.97, 95% bias-corrected bootstrap confidence interval 0.24, 1.75). In particular, parents of children with cyanotic congenital heart disease reported significantly more parenting stress compared with parents of children with acyanotic congenital heart disease (B=4.63, P<0.01), which contributed to elevated levels of internalising problems in the offspring (B=0.21, P<0.001).

Conclusion:

Cyanotic congenital heart disease conferred risks for internalising problems in children and adolescents, and this association was mediated by parenting stress. Interventions to decrease internalising problems in children and adolescents with cyanotic congenital heart disease may be more effective by targeting parenting stress.
Patient Related Outcome Measures (PROMs) in Morton’s Neuroma: Conservative vs. Surgical Management at One-Year Follow-Up
Authors: Faulkner Alastair , Mayne Alistair , Harrold Fraser
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Morton’s neuroma is a common condition affecting the foot and is associated with chronic pain and disability. Conservative management including a combination of orthotic input; injection or physiotherapy, and surgical excision are current treatment options. There is a paucity of literature regarding patient related outcome measures (PROMs) data in patients managed conservatively. We sought to compare conservative with surgical management of Morton’s neuroma using PROMs data in patients with follow-up to one year.

Methods:

Prospective data collection commenced from April 2016. Patients included had to have a confirmed Morton’s neuroma on ultrasound scan. Patient demographics including age, sex and BMI were collected. The primary outcome measures were the Manchester Foot Score for pain (MOX-FQ), EQ time trade off (TTO) and EQ visual analogue scale (VAS) taken pre-operatively; at 26-weeks and at 52-weeks post-operatively.

Results:

194 patients were included overall: 79 patients were conservatively managed and 115 surgically managed. 19 patients were converted from conservative to surgical management. MOX-FQ pain scores: pre-op conservative 52.15, surgical 61.56 (p=0.009), 6-months conservative 25.1, surgical 25.39 (p=0.810), 12 months conservative 18.54, surgical 20.52 (p=0.482) EQ-TTO scores: pre-op conservative 0.47, surgical 0.51 (p=0.814), 6-months conservative 0.41, surgical 0.49 (p=0.261), 12 months conservative 0.26, surgical 0.37 (p=0.047) EQ-VAS scores: pre-op conservative 63.84, surgical 71.03 (p=0.172), 6-months conservative 46.10, surgical 52.51 (p=0.337), 12 months conservative 30.77, surgical 37.58 (p=0.227) Satisfaction at 12 months: conservative 17 (21.5%), surgical 32 (27.8%) p=0.327

Conclusion:

This is one of the first studies investigating long-term PROMs specifically in conservative management for Morton’s neuroma patients. There was no significant difference in pain score and EQ-VAS between all conservative treatments and surgical management at 12 months There was no significant difference in satisfaction at 12 months between conservative and surgical groups.
Opioid Consumption Following Outpatient Foot and Ankle Surgery: A Prospective Analysis
Authors: Heiman Erick M. , Wu Kevin , Idarraga Alexander J. , Bohl Daniel D. , Lin Johnny , Holmes George B. , Lee Simon , Hamid Kamran S.
Published: October 2019

Category:

Prescription Practices

Introduction/Purpose:

Opioid abuse has recently reached the conscience of the US healthcare system and news cycle. This epidemic is in part propagated by surgeon over-prescription for common procedures. The purpose of this study is to examine postoperative opioid use following outpatient foot and ankle surgery in order to potentially guide prescription patterns of postoperative narcotics.

Methods:

Patients undergoing outpatient foot or ankle surgery, performed by one of four fellowship-trained orthopedic foot and ankle surgeons from a single institution, were prospectively enrolled from January to November 2018. Subjects were consented to participate in a phone interview within 7 days of their surgery, with subsequent interviews as needed for continued monitoring. Information collected included: age, gender, procedure, smoking status, payor type, analgesic regimen, number of tablets remaining, pain scale, pain control satisfaction, additional analgesic medications taken, reason for stopping opioid medications, and any adverse reactions encountered.

Results:

A total of 94 subjects were consented to participate. Of these, 11 were lost to follow up and 2 withdrew from the study, leaving 81 (86%) subjects for analysis. The mean (± standard deviation) number of opioid pills prescribed was 52.2 (±16.4; range: 6-80) pills. Subjects were satisfied or somewhat satisfied with their pain control in 91% of cases. On average, 18.4 (±14.9) pills were consumed by subjects, stopping consumption on post-operative day 4.8 (±3.6). There was no statistically significant difference in narcotic medications consumed whether undergoing ankle surgery (16.4, ±13.7) or foot surgery (20.7, ±15.9) (p=0.11). Overall, an average of 34.3 (±19.3) pills remained unconsumed at the completion of narcotic use, equaling a total of 2,706 excessively prescribed pills in the study cohort.

Conclusion:

There is a substantial excess of opioid pain medication prescribed to patients for outpatient foot and ankle surgeries, with a wide variation in prescription patterns. Based on our institutional data, a prescription of 35 opioid pills should be sufficient for approximately two-thirds of outpatient procedures and 50 pills should be sufficient for approximately 95% of patients regardless of whether the procedure is for the ankle or foot. This quality improvement assessment has influenced physician practice in our group and prospective follow-up analysis after intervention is warranted.
A New Intraoperative Measurement that Predicts Ankle Syndesmotic Joint Malreduction
Authors: Abarca Mario , Besa Pablo , Palma Joaquin , Mora Eduardo , Mery Pablo , Villa Andres , Filippi Jorge
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Distal tibio-fibular syndesmotic reduction (SR) is an independent predictor of good functional outcome following ankle surgery. Classic intraoperative fluoroscopic parameters have shown to be poor predictors of distal SR. Syndesmotic malreduction (S-MR) has been reported up to 52% of surgically treated patients. Grenier et al proposed the Anteroposterior Tibio Fibular Ratio (APTF) to evaluate normal sagittal syndesmotic anatomy, showing good interobserver agreement and high correlation between both sides in normal ankles. We propose the use of the comparative APTF index (cAPTF), calculated as the absolute difference of APTF index between the normal and surgically treated ankle, to guide intraoperative sagittal SR. The aim of this study was to determine the capability of the intraoperative cAPTF to predict S-MR.

Methods:

Prospective observational study. Patients who required syndesmotic fixation for an unstable ankle fracture and who had a contralateral healthy ankle were prospectively enrolled. Intraoperative APTF was measured under fluoroscopy in both ankles according to Grenier et al and the cAPTF was calculated. No surgeons were informed of APTF measurements during the procedure. Bilateral postoperative CT was obtained, and quality of SR was evaluated using the method described by Dikos et al. To estimate the discriminatory power of the cAPTF, a receiver operative characteristic (ROC) curve was obtained and the area under the curve was calculated. Youden index was used to determine the ideal cAPTF cut-off value for S-MR and its sensitivity, specificity, positive likelihood ratio (LR+) and negative probability (LR-) were calculated.

Results:

Forty-seven patients were enrolled. Sixteen (34%) had S-MR on the postoperative CT. The cAPTF varied between 0.005 and 0.435. The cAPTF cut-off value to predict S-MR was 0.161. A cAPTF value greater than 0.161 had Sensitivity 100%; specificity 94%; LR+ 15.50; and LR- 0.06, for predicting malreduction of the syndesmosis. The area under the ROC curve was 0.99.

Conclusion:

Intraoperative cAPTF index demonstrated excellent discriminatory power for predicting syndesmotic malreduction. We propose the routine use of this new method to improve the results of syndesmotic reduction.
Comparison of the Rate of Nonunion or Delayed Union in Fifth Metatarsal Fractures Receiving Anti- Inflammatory Medications
Authors: Barnds Brandon , Heenan G. Matthew , Tarakemeh Armin , Schroeppel J. Paul , Mullen Scott , Vopat Bryan G.
Published: October 2019

Category:

Midfoot/Forefoot, Trauma

Introduction/Purpose:

Controversy exists regarding the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on fracture healing. Our retrospective study uses a private payer database to isolate patients diagnosed with 5th metatarsal (MT) fractures and compare the rate of delayed open reduction and internal fixation (ORIF) or non/malunion repair as a surrogate for nonunion or delayed union, in those prescribed anti-inflammatories and those not prescribed anti-inflammatories.

Methods:

Data was collected from the PearlDiver Technologies Humana dataset using CPT and ICD-10 codes. All patients included had a diagnosis of 5th MT fracture and did not receive ORIF or repair of non/malunion within 60 days of diagnosis. Two groups were then created based on the presence or absence of insurance claim records for anti-inflammatory medications within 60 days of diagnosis. The number of patients in each group who underwent ORIF or non/malunion repair after 60 days post- diagnosis was determined, and the rates were compared using a chi-square analysis.

Results:

10,626 patients had a diagnosis of 5th MT fracture and did not undergo early repair/ORIF (within 60 days). 1,615 had records of insurance claims for anti-inflammatories within 60 days of diagnosis, leaving 9,011 who did not receive these medications. 18 (1.11%) patients who received an anti-inflammatory medication underwent ORIF or repair of non/malunion after 60 days post-diagnosis. 44 (0.49%; p=0.0055) subjects who did not receive an anti-inflammatory prescription underwent ORIF or repair of non/malunion after 60 days post-diagnosis.

Conclusion:

The rate of delayed ORIF or non/malunion repair of 5th MT fractures, a surrogate for delayed union or nonunion in an insurance database study, was significantly higher in subjects receiving anti-inflammatories within 60 days of diagnosis. This study isolates a specific fracture and finds a negative correlation between NSAIDs and fracture healing. Further, this provides valuable information to help guide future higher level studies.
Maintenance of Correction of the First Tarsometatarsal Joint Arthodesis Procedure with a First Metatarsal to Second Metatarsal Screw Technique: A Preliminary Report
Authors: Brandão Roberto A. , Greschner Joseph M. , Langan Travis M. , Goss David A. , Hyer Christopher F.
Published: October 2019

Category:

Bunion

Introduction/Purpose:

Fusion of the first tarsometatarsal joint is common for the treatment of moderate to severe hallux abductovalgus deformity. Despite arthrodesis of the first tarsometatarsal joint, recurrence of the deformity remains a concern. The addition of a screw from the 1st metatarsal base to the 2nd metatarsal base allows for increased stability and can help create a “spot weld” between the metatarsal bases to prevent loss of deformity correction. The additional screw construct is termed the intermetatarsal screw in this study. The purpose of the current study is to determine the long-term maintenance of angular correction of the 1st and 2nd intermetatarsal angle, hallux abductus angle, and tibial sesamoid position after undergoing a 1st tarsometatarsal joint arthrodesis with the addition of the intermetatarsal screw.

Methods:

A retrospective, single-center chart and radiographic review was performed of 17 consecutive patients who underwent primary hallux abductovalgus correction with a 1st tarsometatarsal joint arthrodesis using the intermetatarsal screw fixation by the senior author. The study period was from January 1, 2017 to May 14, 2018. Three observers independently reviewed radiographic data including preoperative weight bearing, 1st weight bearing, and final weight bearing plain film radiographs. Preoperative films were used if they were within 3 months of the surgery and the radiographic time line for the post-operative intervals were at 12 ± 2 weeks, 18 ± 4 weeks, 26 ± 4 weeks, 52 ± 12 weeks, and the final follow-up visit. Radiographic data evaluated were initial improvement and long-term maintenance of intermetatarsal angle, hallux abductus angle, and tibial sesamoid position.

Results:

17 consecutive patients were identified for review that met inclusion criterea. Mean follow up time was 8.12 months (SD ± 3.68). Bony union was achieved in all patients. There was 1 symptomatic recurrent bunion, 1 case of symptomatic hardware, and 1 case of transient neuritis. Average preoperative IMA was 16.05º (±2.34), HAA was 33.05º (±6.24), and tibial sesamoid position was 5.77 (±0.9). Average IMA improvement was 8.38º (±2.21), HAA improvement was 17.25º (±8.21), and TSP improvement was 3.29 (±1.36) positions. Average loss of IMA was 1.03º (±1.24), HAA was 4.14º (±5.34), and tibial sesamoid position was 0.65 (±0.86) positions. Wilcoxon signed rank test showed statistical significance in all radiographic parameters; both in initial improvements and loss of correction (p<0.005).

Conclusion:

The current study shows the addition of an intermetatarsal screw for 1st tarsometatarsal joint arthrodesis has good union rates, a low complication rate, and maintains correction. Further clinical and comparative studies with a larger patient cohort may yield additional useful information.
Endoscopically Assisted Percutaneous Achilles Tendon Repair: A Biomechanical and Clinical Pilot
Authors: Carpenter Daniel , Dederer Katherine , Weinhold Paul , Tennant Joshua N
Published: October 2019

Category:

Arthroscopy, Sports, Trauma

Introduction/Purpose:

Achilles tendon rupture treatment includes non-operative, minimally invasive, and open repair techniques. Clinical outcomes of a cohort of patients undergoing a percutaneous endoscopically assisted technique (PEAT) were compared to those of a cohort of non-operatively treated Achilles tendon ruptures. The PEAT repair technique described is a novel method which avoids a proximal lateral incision. We sought to determine clinical outcomes from a cohort undergoing this procedure as well as its basic biomechanical properties.

Methods:

Clinical: With IRB approval a cohort of operatively treated patients was assessed with the following PROs: Return to sport, VAS pain score, Satisfaction Likert, patient reported complications, single heel lift, patient reported medical & smoking history, ATRS (Achilles Tendon Rupture Score). Chart review of diagnostic modality, injury mechanism, time to surgery, tourniquet times, and surgeon reported complications were also collected. Biomechanical: 6 pairs (12) of age and sex matched fresh frozen lower extremity specimens (mid tibia to toes) with average age 71.5 (48-89) (8 F specimens, 4 M specimens) underwent either open (Kessler) repair or percutaneous repair. Specimens were cycled 10N-43 N for 100 cycles, and 20N-86 N for 200 cycles, measuring displacement and ultimate load to failure.

Results:

Clinical: 30 patients operatively treated with the PEAT procedure, 22 contacted by phone. Avg. follow up 2.5 years (1.2- 3.8); Avg ATRS 94.1 (81-100, SD 4.8); “very satisfied” 19/20; Avg VAS 0.3. We had a re-rupture rate of 3.33% (1/30). Biomechanical data: At 10-43 N for 100 cycles, all 12 specimens survived for duration of testing with biomechanical equivalence. At 20-86 N for 200 cycles, percutaneous repairs with greater cyclical displacement (1.7 cm vs 1.0 cm); 1/6 percutaneous with early failure; 11/12 specimens survived.

Conclusion:

The PEAT repair of Achilles tendon rupture showed excellent clinical outcomes with low complications and with biomechanical testing suggesting equivalent strength at low loads.
Epidemiology of Achilles Tendon Injuries in Collegiate Level Athletes in the United States
Authors: Chan Jimmy J. , Chen Kevin K. , Guzman Javier Z. , Vulcano Ettore
Published: October 2019

Category:

Hindfoot, Sports, Trauma

Introduction/Purpose:

Achilles tendon rupture is a potentially devastating injury particularly for National Collegiate Athletic Association (NCAA) athletes. Little has been studied regarding the incidence and implications of Achilles tendon ruptures in this patient population. Better characterization of the factors commonly found in athletes who rupture their Achilles may provide clues to aid in their prevention.

Methods:

Achilles injuries across 16 sports among NCAA men and women during the 2004-05 to 2013-14 academic years were analyzed using the NCAA Injury Surveillance Program (NCAA-ISP). Achilles tendon rupture rates per 100,000 athlete-exposures (IR), operative rate, annual injury rate trends, re-injury rates, mechanism of injury, in-season status (pre/in/post-season) and time loss distributions were compiled and calculated. A sub-analysis of contact sports and sports played by both genders (C-BG) was performed to determine if there were significant differences in risks in patients who played in contact sports.

Results:

N=255 Achilles tendon injuries were identified over 10 academic years (IR: 2.17). The injury rate was higher in males compared to females (IR=2.33 vs. 1.89 respectively). Achilles injuries were most common in Men’s Basketball (IR=4.26), Soccer (IR=3.06), and Football (IR=2.69). The top three women’s sports with Achilles injury were Gymnastics (IR=16.73), Basketball (IR=3.32), and Soccer (IR=1.81). Thirty-three injuries were operative (13.1%) and 14.9% (N=38) were season-ending injuries. The average time loss was 10.65 days when excluding patients who had season/career ending injuries. Reinjury rate was 11.0% (N=28). 61.2% of all injuries occurred during the regular season (N=156) with 36.0% (N=92) and 2.7% (N=7) occurring in pre- and post- season, respectively. There was a significantly greater number of injuries in contact (N=198) versus non-contact sports (N=50) (p<0.001).

Conclusion:

Achilles tendon ruptures can be devastating injuries in professional and collegiate athletes. In our study, nearly 15% of all NCAA Achilles tendon ruptures resulted in season ending injuries or significant time loss and over 13% of injuries required operative management with a majority of injuries occurring during practice. In addition, a significantly higher proportion of athletes who played a contact sport had Achilles injuries. Better understanding of what circumstances more often tend to result in Achilles injuries can help establish prevention strategies.
Outcomes Following a Modified Broström Procedure and Arthroscopic Debridement of Medial Gutter Osteoarthritis Combined With Chronic Lateral Ankle Instability
Authors: Cho Byung-Ki , Choi Seung-myung
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

There is limited information regarding the outcomes of operative treatment for ankle instability with coexisting arthritic changes in the medial gutter. This study was performed to evaluate the intermediate-term clinical and radiological outcomes following a modified Broström procedure and arthroscopic debridement in middle-aged patients with combined medial gutter osteoarthritis and chronic lateral ankle instability.

Methods:

Twenty-four patients with medial gutter osteoarthritis related to chronic lateral ankle instability were followed for more than 3 years after operative treatment. All patients showed medial joint space narrowing of Takakura stage II at the time of surgery. The clinical evaluation consisted of the American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) for medial ankle pain during walking, and Foot and Ankle Ability Measure (FAAM).

Results:

Mean AOFAS and FAAM scores significantly improved from 51.2 and 45.7 points preoperatively to 80.3 and 78.4 points at final follow-up, respectively (P < .001). Although mean pain-VAS significantly improved from 6.8 points to 3.1 points (P < .001), 5 patients (20.8%) complained of gait discomfort with considerable pain of 4 or more points. There was only 1 patient (4.2%) with recurrent ankle instability, while 6 patients (25%) showed a progression of arthritis stage.

Conclusion:

Modified Broström procedure combined with arthroscopic debridement appears to be an effective operative option for medial gutter osteoarthritis secondary to chronic ankle instability. Despite the onset of arthritis, most patients were able to achieve significant improvement in reducing pain while eliminating instability.
Experiences of Living with Bilateral Total Ankle Replacement and Ankle Arthrodesis: A Qualitative Study from a Patient Perspective
Authors: Conlin Catherine , Pinsker Ellie , Khan Ryan , Daniels Timothy R.
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

Total ankle replacement (TAR) and ankle arthrodesis are both effective treatments for end-stage ankle arthritis, however differences in treatment outcomes may be better understood using a qualitative inquiry among individuals who have undergone both procedures. The purpose of this study was to investigate patients’ experiences and impressions of living with bilateral TAR and ankle arthrodesis.

Methods:

The sample consisted of 10 patients, selected purposively from a larger cohort, who could speak English and had a TAR on one side and ankle arthrodesis on the contralateral side. All procedures were completed by a single experienced surgeon. Semi-structured interviews were conducted at least one year after completion of the most recent procedure (TAR or arthrodesis). Qualitative data analysis was performed in accordance with a descriptive phenomenological theoretical approach, from which codes and themes were derived.

Results:

Interviews revealed advantages and disadvantages associated with both TAR and ankle arthrodesis from the patients’ perspective. Two overarching domains in which differences between their TARs and ankle fusions emerged: psychological and musculoskeletal. Within these domains, concepts of vigilance (as previously described by Pinsker) and strategizing the use of one ankle over the other emerged as themes that unified nearly all patients. Specific differences between the two procedures with respect to stability versus flexibility were commonly identified. Overall, patients preferred their TAR.

Conclusion:

This study provides insight into the lived experiences of a unique group of patients who have both an ankle arthrodesis and TAR. Patients evaluated the impact of TAR and ankle arthrodesis on their lives and overwhelmingly favoured TAR. The findings of this study can help clinicians to better counsel patients on expectations after TAR and ankle arthrodesis, and may aid researchers improve patient-report measurement instruments to better capture the outcomes that are important to patients.
Postoperative Medial Cuneiform Position is Correlated with Patient-Reported Outcomes Following Cotton Osteotomy for Reconstruction of the Stage II Adult Acquired Flatfoot Deformity
Authors: Conti Matthew S. , Garfinkel Jonathan H. , Kunas Grace C. , Deland Jonathan T. , Ellis Scott J.
Published: October 2019

Category:

Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

During reconstruction of the stage II adult acquired flatfoot deformity (AAFD), residual supination of the midfoot is often addressed with an opening wedge medial cuneiform (Cotton) osteotomy after adequate correction of the hindfoot valgus deformity. The purpose of this study was to determine if there was a correlation between postoperative alignment of the medial cuneiform using the previously described cuneiform articular angle (CAA) on lateral radiographs and postoperative patient-reported outcomes using the Foot and Ankle Outcome Score (FAOS).

Methods:

Sixty-three feet in 61 patients with stage II AAFD who underwent a Cotton osteotomy as part of a flatfoot reconstruction were included the study. The CAA, medial arch sag angle (MASA), and lateral talo-first metatarsal (Meary’s) angles were measured on postoperative weightbearing lateral radiographs at a minimum of 40 weeks postoperatively. Pearson’s correlation analysis was used to determine if there was an association between postoperative radiographic angles and FAOS at a minimum of 24 months postoperatively. Patients were also divided into mild plantarflexion (CAA> or =-2 degrees) and moderate plantarflexion (CAA<-2 degrees) groups, and Wilcoxon rank-sum tests were used to identify whether there were differences in clinical outcomes between the two medial cuneiform positions. A postoperative CAA of -2 degrees was chosen because it is two standard deviations from the average postoperative CAA following a flatfoot reconstruction (Castaneda et al. FAI 2012).

Results:

Postoperative CAA was significantly positively correlated with the postoperative FAOS symptoms (r=.27, P=.03), daily activities (r=.29, P=.02), sports activities (r=.26, P=.048), and quality of life (r=.28, P=.02) subscales. A positive correlation indicates that higher postoperative FAOS scores are associated with a decreased amount of plantarflexion of the medial cuneiform (i.e. a more positive CAA). Patients in the mild plantarflexion group had statistically and clinically better outcomes compared with the moderate plantarflexion group in the FAOS symptoms (P=.04), daily activities (P =.04), and sports activities (P=.01) subscales (Figure 1). Graft size was correlated with postoperative CAA (r =-.30, P = .02) but not correlated with any postoperative FAOS subscale (all P values > .40).

Conclusion:

Our study suggests that the surgeon should avoid excessive plantarflexion of the medial cuneiform and use the Cotton osteotomy judiciously as part of a flatfoot reconstruction for stage II AAFD.
Sinus Tarsi Approach for Open Treatment and Internal Fixation of Displaced Intra-articular Calcaneal Fractures in High-Risk Patients: The New Gold Standard?
Authors: Davies James P. , Smith W. Bret , Steinlauf Steven , Millikin Mary
Published: October 2019

Category:

Ankle, Diabetes, Hindfoot, Trauma

Introduction/Purpose:

Intra-articular calcaneal fractures offer unique challenges. Wound problems and infection are significant complications in the surgical treatment of calcaneal fractures which in turn can be debilitating to patients and outcomes. The literature suggests varying wound complication rates but 21% up to 33% using the traditional extensile lateral approach in some studies. The extensile lateral approach has historically been accepted as the gold standard for fixation and treatment of these fractures. Recently there has been resurgent interest in alternative approaches to the fixation of intra-articular calcaneal fractures. Of interest is the potential of the sinus tarsi approach to decrease wound complications while having comparable reduction quality to the higher wound risk extensile lateral approach.

Methods:

A multi-center retrospective chart review study was implemented. The study objective was to review wound complication of the sinus tarsi approach compared with outcomes from the traditional extensile approach for fixation of displaced intra-articular calcaneal fractures. Specifically; examining a population of patients considered at high risk for wound issues, comparing radiographic and clinical outcomes.

Results:

In the high-risk group, only one primary complications resulted, including one patient with a history of an open fracture. All fractures healed with adequate maintenance of alignment. Chi- squared analysis resulted in a statistically significant difference in complication rates between sinus tarsi and the traditional extensile lateral approach at the 95% confidence level.

Conclusion:

In both high-risk and lower-risk cohorts of patients, a low rate of infection and wound problems was encountered. A limited approach through a sinus tarsi incision provides a viable option to treat displaced intra-articular calcaneus fracture patients with risk factors for wound issues. The patients all healed both their soft tissue wounds and fractures. Functional return was consistent with other study populations. Our study adds another cohort of patient data demonstrating the advantage of the sinus tarsi approach when compared to the extensile lateral in terms of decreased wound complications while maintaining quality of reductions and clinical outcomes.