bluuebunny/crossref_metadata_2025 huggingface dataset:
Posterolateral Plate Fixation with Pantalarlock® is More Stable than Nail Fixation in Tibiotalocalcaneal Arthrodesis in a Biomechanical Cadaver Study
Authors: Gutteck Natalia
Published: November 2020

Category:

Ankle; Ankle Arthritis

Introduction/Purpose:

Despite the promising results of ankle joint arthroplasty, the tibiotalocalcaneal (TTC) arthrodesis remains an established procedure in treatment of combined pathology of the ankle and subtalar joint. Despite the promising results in biomechanical investigations, nonunion rates of up to 24% are described in recent studies. The objective of this work was a comparative study of the biomechanical properties of the posterolateral plate fixation with retrograde intramedullary nail fixation.

Methods:

Twenty four fresh-frozen human lower leg specimens (12 pairs) were used for the comparative biomechanical testing. Every specimen was preconditioned with 100N over 200 cycles. After every 250 cycles the force was increased by 50N from 200 to 600N. This was followed by cyclic loading in dorsi-/plantiflexion with 800N for 3000 cycles. All specimens were subjected to bone densitometry (DXA) and computed tomography.

Results:

Significantly higher number of spacimens with nails (4) failed during the cycling testing in dorsi-/plantarflexion and futher two during the cyclic testing with 800N. Two specimens with plates failed during the cyclic testing with 800N. Statistical analysis showed that the specimens with the plate were significantly more stable in each test direction. The Pearson correlation demonstrated for the specimens with plate a linear relationship between the stiffness and the determined bone density.

Conclusion:

We expect a considerable reduction of the pseudarthrosis rate and shorten the postoperative treatment phase in clinical set up and appropriate advantages in the treatment of high risk patients with severe deformity of the ankle, bone defects, neuropathic deformity, poor bone quality and osteoporosis. The choice of most predictable and stable implant is essential for the successful fusion. In conclusion, the posterolateral plate ostesynthesis for TTC arthrodesis is significantly stiffer compared to the nail osteosynthesis in osteoporotic bone model.
Diagnosing Syndesmosis Instability: Dynamic Ultrasound versus Arthroscopy: A Cadaveric Study
Authors: Hagemeijer Noortje , Sato Go , Bhimani Rohan , Lubberts Bart , Elghazy Mohamed Abdelaziz , Kerkhoffs Gino , Guss Daniel , DiGiovanni Christopher W.
Published: November 2020

Category:

Ankle

Introduction/Purpose:

To evaluate whether sagittal translation could be detected with ultrasound and arthroscopy and to compare the increasing tibiofibular sagittal translation seen with ultrasound (US) and Arthroscopy.

Methods:

Eight fresh lower leg cadaveric specimen amputated above the proximal tibiofibular joint were used in this study. The ankle syndesmosis was evaluated using a handheld US device (Butterfly iQ, Butterfly Network Inc, Guilford) and arthroscopy with intact-, and after sequent sectioning of anterior-inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), and posterior- inferior tibiofibular ligament (PITFL). Sagittal plane translation was simulated with 100N of anterior to posterior (A-to-P) and posterior to anterior (P-to-A) hook force which was applied 5cm above of the ankle joint (Figure 1). Pearson’s correlation, one- way repeated measures ANOVA, and Wilcoxon signed-rank test were used for comparison. Three cadavers were measured by two independent observers to assess reliability and analyzed using intraclass correlation coefficients (ICC).

Results:

A-to-P translation values obtained with US and Arthroscopy had a correlation of -0.14, and P-to-A translation correlation of 0.44. Using US, intact translation was 0.94+-0.62 with A-to-P hook and 0.87+-0.5 with P-to-A hook. Subsequent A- to-P and P-to-A translation increased with 0.07+-0.96mm and 0.04+-0.76 after AITFL cut, with 0.53+-0.9 and 0.15+-0.5 after IOL cut, and with 0.81+-1.3mm and 0.45+-0.8 after PITFL cut (p-values between 0.122 and 0.270) . Using arthroscopy, intact translation was 0.40 +-0.3 with A-to-P hook and 0.99+-0.5 with P-to-A hook. Subsequent A-to-P and P-to-A translation increased from intact with; 0.001+-0.3 and 0.30+-0.4 after AITFL cut, 0.19+-0.4 and 0.74+-0.7 after IOL cut, and 0.40+-0.5 and 1.1+-0.9 after PITFL cut (p-values between 0.005 and 0.037). No statistical differences between US and Arthroscopy were found.

Conclusion:

US was unable to differentiate between the different stages of injury, even though a similar increase in translation was seen as compared to arthroscopy. Probably this is due to the high variability seen in the US translation values. As US does have several advantages over arthroscopy; availability, non-invasiveness, low costs, and allowance of using the contralateral side as a direct comparison, this technique should be further explored as a potential diagnostic assessment technique of diagnosing occult syndesmotic instability in the sagittal plane.
Portable Dynamic Ultrasonography is a Useful Tool for the Evaluation of Suspect Syndesmotic Instability: A Cadaveric Study
Authors: Hagemeijer Noortje , Bhimani Rohan , Saengsin Jirawat , Lubberts Bart , Waryasz Gregory R. , Kerkhoffs Gino , DiGiovanni Christopher W.
Published: November 2020

Category:

Ankle; Sports; Trauma

Introduction/Purpose:

To evaluate syndesmotic instability by measuring the tibiofibular clear space (TFCS) opening using a portable ultrasound device. In addition, we assessed the optimal amount of external rotation torque required to detect syndesmotic instability.

Methods:

Eight fresh lower leg cadaveric specimen amputated above the proximal tibiofibular joint were used. Using a portable ultrasound device (Butterfly iQ, Butterfly Network Inc) the ankle syndesmosis was evaluated in the intact stage, and after sequentially sectioning of the anterior-inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), and posterior-inferior tibiofibular ligament (PITFL)(Figure 1). In each ligamentous sectioning stage TFCS in millimeter (mm) was measured with ultrasound while consecutively 0N, 45N, 60N, 75N, and 90N external rotation directed torque was applied to the ankle. To evaluate which amount of torque would be sufficient to detect syndesmotic instability the delta increase of TFCS opening at different states of torque compared to the unstressed state was calculated. One-way repeated measures ANOVA was used to detect whether an increase in delta-TFCS opening could be detected between the intact state and consecutive syndesmotic ligament transection stages. Correction for multiple comparisons was performed using the Bonferroni-Holm correction.

Results:

Under all torque-loading conditions TFCS (mean+-SDmm) opening increased as additional syndesmosis ligaments were transected (p-values<0.001). With all ligaments intact an increase of TFCS opening was detected during torque increment, ranging from 4.50+-1.2mm at 0N to 5.7+-1.00mm at 90N. After AITFL transection this amount increased from 5.2+-1.4mm at 0N to 6.5+-1.8mm at 90N. After AITFL+IOL transaction from 6.2+-1.3mm at 0N to 10.6+-6.2mm increase at 90N, and after AITFL+IOL+PITFL transection the TFCS opening increased from 6.8+-1.2mm at 0N to 11.1+-2.8mm at 90N. Significant difference from intact was seen after transection of the IOL, already from the unstressed (0N) state on (difference 3.0+-1.4mm, p-value 0.036). Additionally, the AITF+IOL could also be differentiated from AITFL transection stage at 45N with a difference in TFCS opening of 2.06+-1.2mm (p-value 0.006).

Conclusion:

Portable dynamic ultrasonography is a useful tool to evaluate suspect syndesmotic instability. TFCS opening increased as additional ligaments of the syndesmosis were transected and application of 45N torque seems to be sufficient to detect syndesmotic instability.
The Use of Long Acting Opioids to Prevent Rebound Pain Following Peripheral Nerve Blocks for Outpatient Foot and Ankle Surgery
Authors: Herzog Leah , Wilson Sylvia H. , Gross Christopher E.
Published: November 2020

Category:

Ankle; Bunion

Introduction/Purpose:

Peripheral nerve blocks have become an integral part of orthopedic surgery to assist with postoperative pain. However, 40% of patients who undergo a peripheral nerve block will experience rebound pain, which in turn, long-acting narcotics may be able to block. Unfortunately, this rebound pain can cancel out the potential benefits of decreased opioid medication use. Therefore, this study seeks to compare the difference in patient reported pain scores in those patients whom received long-acting opioid pain medication and those who did not.

Methods:

This is a retrospective review of patient-reported pain scores for 96 patients who underwent a peripheral nerve block for outpatient foot and ankle surgery. 48 patients either received three days of long-acting opioids or did not. Each patient was asked to fill out and return a pain diary as well as fill out a pain catastrophizing survey (PCS) at their postoperative appointment. The pain diary discussed their Visual Analogue Scale pain scores, amount of pain medication, and time they took the medicine. This data was then collected and compared via paired student t-tests for evaluation of significance.

Results:

Pain diaries were completed by 69 patients (72%). There were no significant differences between those comorbidities, types of procedures, age, or BMI between the groups. Mean postoperative pain scores did not differ between patients that did and did not receive postoperative extended release opioid medications (p = 0.226). Mean opioid consumption did not differ between groups (p = 0.945). There were no correlations between daily reported pain scores or the postoperative day with the highest pain score for those who received long acting opioid pain medication versus those who did not (r=0.336, p=0.550).

Conclusion:

Rebound pain is a difficult potential side effect of peripheral nerve blocks that currently does not have a preventative measure. This study was an attempted effort to help eliminate rebound pain, but there did not appear to be a significant benefit to adding long-acting opioid pain medication in addition to the peripheral nerve block and short-acting pain medication
A Comparative Study between Lateral Approach Alone and Combination of Medial and Lateral Approaches for Intra-Articular Calcaneal Fractures with Displaced Sustentaculum Fragment
Authors: Hio Naohiro , Taki Masanori
Published: November 2020

Category:

Hindfoot; Trauma

Introduction/Purpose:

In intra-articular calcaneal fractures, the sustentaculum fragment, which is the reference for reduction, often undergoes varus plantar flexion displacement and requires accurate reduction. Although the lateral approach is generally used as a surgical approach, it is considered that the use of the combination of medial and lateral approaches can achieve more accurate reduction. Here we report a comparative study of between the group with the lateral approach alone (L-group) and the group with the combination of the medial and lateral approaches (ML-group) for calcaneal fractures with displacement of sustentaculum fragment.

Methods:

L-group included 11 feet, six feet of which were categorized as Sanders classification type 2, four as type 3, one as type 4. ML-group included 14 feet, ten as type 2, two as type 3, two as type 4. In both groups, small incision such as sinus tarsi approach were used for lateral approach and screws and/or plates were used for fixation. We assessed Creighton-Nebraska scale, pre- and postoperative width and height of the calcaneal body, step of subtalar joint surface and inclination angle of the sustentaculum fragment.

Results:

The mean postoperative clinical evaluation for the L-group / ML-group was 90.5+-7.9 points / 87.2+-9.6 points respectively. The pre- and postoperative image assessments showed improvements in the mean width from 123.4+-15.3% to 110.3+-14.1% / 129.9+-23.1% to 109.9+-14.1%, in the mean height from 88.1+-5.2% to 98.1+-3.7% / 86.0+-9.6% to 95.4+-5.9%, in the step of subtalar joint surface from 9.0+-6.3mm to 0.9+-1.1mm / 10.0+-8.0mm to 0.7+-1.0mm, and in the inclination angle of sustentaculum fragment from 10.3+-5.1 ° to 5.5+-5.0 ° / 12.1+-7.5 ° to 0.5+-1.0 °, respectively. There was a significant difference between the two groups in the inclination angle of the sustentaculum fragment, but no significant difference was observed in the other assessments. Complications were more common with ML-group.

Conclusion:

Displacement of the sustentaculum fragment in calcaneal fractures can be more reduced accurately by using the combination of medial and lateral approaches, although there is no significant difference in clinical results.
Modified Ankle-Hindfoot Alignment Radiological Evaluation Method and Application in the Flatfeet
Authors: Hong-Mou Zhao
Published: November 2020

Category:

Hindfoot

Introduction/Purpose:

Based on a prospective study, a new method of photographing and measuring of hindfoot alignment based on X-ray was proposed, and its reliability is verified, as well as its application in flatfeet.

Methods:

This study included 28 patients (40 feet) with flatfeet and 20 volunteers (40 feet) from January to December in 2018. The shooting frame, designed by our team, has been used to take the hindfoot alignment view at 10°, 15°, 20°, 25°, 30° respectively. Our modified tibio-hindfoot angles (THA) at standard Saltzman position (shooting at 20°) were evaluated, and the consistency were compared with the van Dijk method and the modified van Dijk method, and compared with weight-bearing CT. The visibility of tibiotalar space were evaluated in all shooting angles. The consistency of the modified THA method at different projection angles were evaluated. The angle of hindfoot valgus of flatfoot patients was measured with use of the modified THA method, and compared in different shooting angles.

Results:

The mean THA in standard Saltzman view in normal people were significantly differences between the three evaluation methods (P < 0.001). The results of modified THA method were significantly larger than those of Van Dijk method (P < 0.001) and modified Van Dijk method (P < 0.001). There was no significant difference between the results of modified THA method and the weight-bearing CT (P=0.605), and the intra- and inter-group consistency was the best in modified THA group. The tibiotalar space in the normal group were visible in all cases at 10°, 15°, 20°; and visible in some cases at 25°; and invisible in all cases at 30°. In the flatfoot group, the tibiotalar space were visible in all cases at 10°; and in some cases at 15° and 20°; and invisible in all cases at 25° and 30°. In the normal group, the modified THA was 4.84±1.81° at 10°, 4.96±1.77° at 15°, 4.94±2.04° at 20°. No significant difference was found between the three groups (P=0.616). In the flat foot group, the modified THA of 18 feet, which was visible at 10°, 15° and 20°, was 13.58±3.57° at 10°, 13.62±3.83° at 15° and 13.38±4.06° at 20°. There was no significant difference between the three groups (P=0.425).

Conclusion:

The modified THA evaluation method is simple to use and has high intra- and inter-group consistency. It can be used to evaluate hindfoot alignment. For patients with flatfeet, the 10° position view and modified THA measurement can be used to evaluate the hindfoot valgus conditions.
Pathological Characters and Molecular Pathogenesis of Diabetic Neuropathic Osteoarthropathy Cartilages Damage
Authors: Hong-Mou Zhao
Published: November 2020

Category:

Basic Sciences/Biologics

Introduction/Purpose:

The aim of current study was to investigate the pathological characters and relative molecular pathogenesis of the cartilages damage in diabetic neuropathic osteoarthropathy (DNOAP) patients.

Methods:

The articular cartilages of ankle joint, subtalar joint and talonavicular joint of 8 patients with DNOAP from March 2017 to June 2018 were selected as DNOAP group. And the articular cartilage of matched joints from 8 amputation patients were selected as control group. Masson staining and safranine O/fixed green staining were used to observe the histopathological characteristics of cartilage, and the ultrastructural changes of chondrocytes were observed by electron microscopy. Chondrocyte culture was carried out in DNOAP group and control group. Western blot was used to detect the expression of RANKL, OPG, IL-1ß, IL-6, TNF-a, Aggrecan protein in chondrocyte. DCFH-DA probe was used to detect the level of reactive oxygen species in chondrocyte. Flow cytometry was used to detect the apoptotic rate of chondrocyte.

Results:

In DNOAP group, chondrocytes decreased, subchondral bone proliferated, structure disordered and osteoclasts formed in a large number in subchondral bone area. Under transmission electron microscopy, mitochondrial and endoplasmic reticulum swelling were observed in DNOAP chondrocytes. The chromatin was partially broken and concentrated at the edge of nuclear membrane. The ROS fluorescence intensity of chondrocyte in DNOAP group was higher than that in normal control group (28.1±2.3 VS 11.9±0.7, P<0.05). The relative expression of RANKL, TNF-a, IL-1ß and IL-6 protein in DNOAP group was higher than that in normal control group, while the relative expression of OPG and Aggrecan protein was lower than that in normal control group (both P < 0.05). Flow cytometry showed that the apoptotic rate of chondrocyte in DNOAP group was 3.3%±0.2%, which was higher than that in normal control group (1.2%±0.1%, P<0.05).

Conclusion:

Serious destruction of chondrocytes and organelles structure was the pathological characteristics of DNOAP. Inflammation plays a role in promoting the pathogenesis of DNOAP.
Patient Characteristics and Comorbidities in Patients Attending Specialist Foot and Ankle Outpatient Clinics in the UK: A Report of 2000 Patients
Authors: Houchen-Wolloff Linzy , Tomlinson Clare , White Alice E. , Venturini Sara , Best Alistair J. , Allen Patricia , Mangwani Jitendra
Published: November 2020

Category:

Ankle; Midfoot/Forefoot

Introduction/Purpose:

For integrated care and appropraite referral pathways, it is important to understand the patient demographics, pathologies and comorbidities of patients with foot and ankle pain. We are aware of the burden of foot and ankle problems in UK primary care, with a large number of referrals to outpatient orthopaedic clinics (Ferguson et al. Br J Gen Pract, e422, June 2019). With increasing demands on secondary and tertiary care settings, it is important to think of innovative solutions. To our knowledge there is no large patient case series looking at these aspects of care in foot and ankle patients attending outpatient clinics in the UK.

Methods:

Therefore the aims of this study were to: 1. To gain a better understanding of the demographics and pathologies of patients attending a specialist foot and ankle clinic. 2.To develop our existing knowledge of the types and prevalence of comorbidities within this population. Data was collected prospectively. All new patients attending a specialist foot and ankle clinic in one centre in the UK were asked to complete a proforma at their first assessment (figure 1). Information was collected on gender, age, occupation, hobbies, location of ankle pain, previous injuries, compensation issues, presence of comorbidities and medications. A descriptive analysis of the data was conducted using SPSS (version 19, IBM).

Results:

Data from 2001 patients was collected. The mean (SD) age was 52.9 (16.9) years with 76% being female. Nine percent of patients had diabetes (though others may have been seen in diabetic/ vascular clinics and not captured here) and 16% were current smokers. Thirty-three percent of patients had a previous history of injury to the foot and/or ankle. The right foot was affected in 49% and the left in 51%. Location of pain was in the forefoot (52%), midfoot (21%) and hindfoot (27%). Compensation issues were reported in 3%. The proportion of patients in work was 64.4% meaning 35.6% were unemployed (including those who had retired).

Conclusion:

This large study demonstrates that more women attend specialist foot/ ankle clinics in the UK. Both feet are equally affected; the forefoot was the most common site of pathology. The prevalence of diabetes and smoking are in line with the general UK population (reported as 9% and 15%). A small proportion of patients had compensation issues, with the majority of patients working. This data can be used to help streamline referral pathways and to establish innovative ways of working (e.g. virtual clinics). In turn, this may reduce the burden on outpatient clinics, the health economy and improve patient satisfaction.
Arthroscopic Findings During Routine Ankle ORIF: What is Being Missed?
Authors: Howard Shain , Hoang Victor C. , Watson Troy S. , Brady Candice L. , Eudy Adam
Published: November 2020

Category:

Ankle; Arthroscopy; Trauma

Introduction/Purpose:

Ankle fractures are among the most common operatively treated injuries by orthopedic surgeons. However, up to 20% of patients will have continued pain and poor patient reported outcomes despite good/excellent radiographic results. Ankle fractures typically occur with varying degrees of intra-articular and soft tissue injury which can include ligamentous injury, loose bodies, and chondral lesions. The aim of study is to document intra-articular findings with ankle arthroscopy prior to ankle open reduction internal fixation (ORIF) and to contribute to the growing body of literature that shows this to be a safe adjunct to fracture fixation.

Methods:

IRB approval was obtained prior to chart review. This is a retrospective review of ankle fractures that were treated with arthroscopy and ORIF by a single surgeon. Between August 2016 and July 2018 Operative reports, office notes, and images were reviewed to identify intra-articular pathology and fracture type. Analysis was performed with regard to fracture type, presence and location of osteochondral lesions, presence of loose-body, syndesmotic injury, and deltoid injury.

Results:

Fifty-seven ankle fractures were identified that met inclusion criteria. 84.2% of the fractures had intra-articular pathology, most commonly a syndesmotic injury followed by loose joint body and osteochondral defect.

Conclusion:

Arthroscopic evaluation during ankle fracture ORIF, particularly pronation external rotation and supination external rotation patterns give a more detailed examination of associated pathology. Arthroscopy at the time of ankle fracture fixation is a safe adjunct and should be considered a potential compliment to routine ORIF of ankle fractures.
Outcomes after Minimally Invasive Chevron/Akin Procedure and Strategies to Optimize Outcomes
Authors: Hussaini Syed H. , Neufeld Steven K. , Dean Daniel M. , Lockey Stephen D.
Published: November 2020

Category:

Midfoot/Forefoot; Bunion

Introduction/Purpose:

Minimally invasive surgery (MIS) is being increasingly used for bunion deformity correction. New third generation minimally invasive chevron/akin (MICA) techniques are used but limited data on patient outcomes have been reported. The goal of this IRB-approved study was to look at outcomes of percutaneous, extra-articular distal metatarsal osteotomies for mild to moderate bunion deformity, including the degree of deformity correction obtained, patient pain control, and complication rates. We also describe strategies for avoiding the intra-operative and post-operative complications that may arise with MIS bunion surgery.

Methods:

The participants were the treating surgeon’s first 75 consecutive patients 18 years and older who were treated with MICA procedures. Via retrospective chart review, outcome measures including pre and final post-operative intermetatarsal angles (IMA), hallux valgus angles (HVA), visual analogue scale (VAS) score, and complication rates were assessed. Statistical analysis was done utilizing student’s t-test for continuous variables and chi square test for categorical variables.

Results:

Average follow-up was 105.0 days. VAS scores dropped one week post-operatively, from 5.4 pre-operatively to 2.5 (p< 0.05). IMA angles improved from 12.7 degrees (range 6.1-18.1) pre-op to 6.1 (range 1.2-12.5) at final follow-up (p< 0.05). HVA angles improved from 27.2 degrees (range 9.7-43.4) to 10.4 (range 1.3-25.9) (p<0.05). A major infectious complication occurred in one patient, requiring operative irrigation/debridement and hardware removal. Another patient had a DVT treated successfully with medication. Minor complications included intra-operative fracture (3 patients), persistant paresthesias (3), cellulitis (1), minor loss of reduction (2), hardware prominence/backout (3) and medial prominence pain (3). One patient had surgical removal of a prominent screw head one year after surgery. Complication rates were similar between the first and second half of patients chronologically.

Conclusion:

Our data suggests that MICA osteotomies are associated with rapid, significant improvement in pain scores, significant deformity correction, and low frequency of major complications. While there is a learning curve, MICA is a reproducible technique, is safe, and allows immediate post-operative weightbearing. All osteotomies achieved union, and there were no tendon injuries. Only two patients required a second surgery. We also present strategies to avoid and limit pitfalls and complications encountered with the procedure. Although our data is exciting, additional studies looking at long-term outcomes, larger sample sizes, and more physicians should be conducted.
Safety Profile of Artelon Use for Soft Tissue Reconstruction in Foot and Ankle Surgery
Authors: Hussaini Syed H. , Dean Daniel M. , Kelly Michael , Cuttica Daniel J.
Published: November 2020

Category:

Basic Sciences/Biologics; Ankle; Hindfoot; Midfoot/Forefoot; Sports

Introduction/Purpose:

Artelon is a synthetic degradable polyurethaneurea graft which has been investigated and utilized for soft tissue reconstruction in a variety of orthopaedic settings. However, in the field of foot and ankle surgery, there is very limited reported clinical data on outcomes of surgery utilizing Artelon. The goal of this study was look at outcomes of foot and ankle surgery in which Artelon is used, including post-op VAS scores and complications including adverse foreign body reaction, infection, repeat surgery, and implant failure. Our hypothesis was that soft tissue reconstruction procedures utilizing artelon will have a low complication rate, similar to established complication rates for other soft tissue reconstruction procedures such as those utilizing allograft, autograft, or other synthetic tissue.

Methods:

The treating surgeon’s first 55 consecutive patients 18 years and older who were treated with artelon graft as part of a foot and ankle surgery are being included in this IRB-approved study. Through retrospective chart review, outcome measures including the procedure for which artelon was utilized, pre and post-op Visual Analogue Scale (VAS) scores, and complications including repeat surgery for graft failure, foreign body reaction, wound healing issues, infection, and osteolysis were assessed. Statistical analysis was done utilizing Student’s t-test for continuous variables and chi square test for categorical variables.

Results:

Average follow-up time was 246.5 days. The majority of patients had artelon placed for spring ligament reconstruction, brostrom procedures, or achilles tendon reconstruction. VAS scores dropped significantly from before surgery to 3 weeks post- operatively (5.6 to 3.2, p<0.05). VAS scores stabilized after 3 weeks, with final follow-up score at 2.9. There were no reports of osteolysis in the area of the graft placement, adverse foreign body reaction, or episodes of graft failure. There were two major complications involving artelon surgical sites: one patient required a free flap for wound coverage, and another required an operative debridement with hardware and artelon removal, antibiotic spacer placement, and subsequent hindfoot fusion. Other minor complications not requiring operative intervention included cellulitis (3 patients) and delayed wound healing (5).

Conclusion:

Artelon is a safe and effective implant that can be utilized for soft tissue reconstruction in the foot and ankle, with similar post-operative pain recovery and wound complication rates compared to established historical data for these procedures. Additional studies must be done looking at long-term patient outcomes with utilization of artelon, and direct comparative studies with other soft tissue reconstruction techniques and materials in the foot and ankle.
Fractures of the Talar Head: A Series of 16 Patients
Authors: Ibrahim Ishaq , Kwon John Y. , Miller Christopher P. , Smith Jeremy T.
Published: November 2020

Category:

Hindfoot; Trauma

Introduction/Purpose:

Fractures of the talar head are very rare accounting for just 5-10% of talus fractures and fewer than 1% of all fractures. As such, limited clinical literature is available to guide management of these injuries. We present the largest clinical series on talar head fractures to date.

Methods:

We performed a retrospective review of all patients presenting to three level-1 trauma centers with major fractures of the talus (fractures of the neck, body or head) over a 14-year period. From this cohort of patients, we identified patients presenting with fractures of the talar head with available computed-tomographic (CT) imaging of the foot allow proper fracture evaluation and characterization. In total, 258 patients with major fractures of the talus were identified. Sixteen patients (6.2%) with talar head fractures met inclusion criteria.

Results:

Most injuries were due to falls from height and only 4 were isolated. The navicular was fractured in 7 patients (43.8%). Six patients (37.5%) exhibited comminuted fracture patterns, while the remaining demonstrated simpler shear or impaction injuries. Four patients underwent fixation of the talar head, 3 were treated with primary stabilization or fusion of the talonavicular joint, and two patients were treated with head fragment excision. The talar head was managed in a closed fashion in the remaining seven patients, five of which presented with comminuted fracture patterns. Eight patients showed radiographic evidence of post- traumatic arthritis (PTA) at mean follow-up of 15.5 months. In all instances of PTA, the patient had sustained a comminuted talar fracture, an associated navicular fracture or both.

Conclusion:

Talar head fractures are extremely rare injuries with sparse literature to guide clinical management. Simple shearing or impaction fractures may be amenable to surgical fixation with favorable radiographic outcomes. Comminuted fractures and/or concomitant navicular trauma at the time of injury may be associated with increased incidence of talonavicular arthrosis.
Quantitative Analysis of the Deltoid Ligament Degradation in Chronic Ankle Instability Patients using the CT Value
Authors: Ikuta Yasunari , Nakasa Tomoyuki , Sumii Junichi , Nekomoto Akinori , Adachi Nobuo
Published: November 2020

Category:

Ankle; Other

Introduction/Purpose:

Chronic lateral ankle instability (CLAI) that is developed after multiple lateral ankle ligament injury lead to ankle osteoarthritis. Although isolated deltoid ligament injury is rare compared to lateral ankle ligament injury, deltoid ligament tear, especially deep posterior tibiotalar ligament (PTT) can be observed arthroscopically in CLAI patients. Unphysiological loading of the ankle joint with CLAI might cause degradation of the deltoid ligament. This study aimed to investigate image findings of the deltoid ligament using computed tomography (CT) value for quantitative analysis of degenerative ligament changes in CLAI patients.

Methods:

Among the enrolled patients who underwent ankle magnetic resonance imaging (MRI) and CT scans of the ankle, this retrospective analysis included 24 ankles without ankle osteoarthritis, osteochondral lesion of the talus (OLT), flatfoot and ankle fractures (14 males and 10 females; mean age, 42.8 years) as a control group, and 14 CLAI ankles without OLT (7 males and 7 females; mean age, 31.1 years) as CLAI group. The CT scans were performed using a 64-slice multidetector row CT. Deep PTT was detected on coronal T2-weighted MR images. Both the coronal MR and CT images were matched for analysis, then average CT values were measured using the region of interest that was applied to the detected area of deep PTT on the CT images. Spearman’s correlation coefficient was used to evaluate the correlation between age and CT value in the control group.

Results:

The strong negative correlation was identified between age and CT value in the control group (Spearman ρ= -0.88; p < 0.001). The CT value of the deep PTT are degraded with aging. Mean CT value of deep PTT in participants under 60 years old were 79.9 HU (95% CI, 75.1-84.8) in the control group (18 ankles), and 66.5 HU (95% CI, 58.6-74.5) in the CLAI group (14 ankles) (Welch’s t test; p = 0.005).

Conclusion:

MRI techniques and protocols recently have been developed, however, some limitations remain such as a quantitative evaluation of the ligament. Our findings suggest that the CLAI can lead to degradation of the deltoid ligament via an overloading of medial ankle structures. Additionally, CT values should be useful for quantitatively evaluating ligament status including degenerative changes.
Combined Internal and External Fixation for Charcot Neuroarthropathy: A Learning Curve
Authors: Iqbal Muhammed H. , Qasim Sultan N. , Chambers Simon
Published: November 2020

Category:

Diabetes; Trauma

Introduction/Purpose:

Management of complex foot and ankle deformities secondary to charcot neuroathropathy represents a significant challenge. This is a consequence of medical co-morbidities, vascular disease, peripheral neuropathy, and immune compromise with the surgical challenges of progressive bony defomity and bone resorption. To combat these challenges ‘superconstructs’ have been developed to improve fixation. These aim for fusion beyond the zone of injury with adequate deformity correction all whilst maintaining viability of the soft tissue envelope and mechanical function. This can be achieved with internal fixation using indication specific plates and beaming techniques, external fixation with a circular frame or a combination of the two. The aim of this study was to evaluate of a tertiary referral hospital in the operative management of charcot neuroarthopathy.

Methods:

This is a retrospective two surgeon case series with all cases jointly operated upon. Cases were identified from a locally held diabetic patient registry as those undergoing charcot foot and ankle reconstruction from 2017 to 2019. No exclusion criteria were outlined. Patient demographics and co-morbidities were collected, pre-op radiological markers (meary’s angle) measured and repeated at 6 weeks and one year. Pre-op radiographs were classifed accroding to brodsky classification. Patient outcomes were recorded of amputation, mortality, ulcer recurrence, reported pain, stable heel, ability to ambulate, need for revision surgery, need for prolonged antibiotics, fusion and surgical complications. PROMS were requested and still awaited at time of submission.

Results:

Eleven Cases were identified from ten patients, all were included for analysis. Three patients had internal fixation, two had external fixation and six had combined internal with external fixation. Eight patients were Brodsky 1, two patients were Brodsky 3 and one patient was Brodsky 2. Limb salvage was 100% with nil amputations, mortality 0%, ulcer recurrence 0%, 100% improved pain score, and 100% with a stable heel. Meary’s angle improved by a mean of 14o from -16o to -2o at 1 year. Fusion rate determined clinically and radiologically with X-ray was 100% with mean of 129 days and range of (360 - 52). Mean follow-up 454 days and range (547-417). Complications of 2 tibial fractures and 1 deep infection with delayed wound healing.

Conclusion:

The outcomes of using all three methods is positive with 100% limb salvage, 100% fusion rate, 100% ulcer free and maintenace of Meary’s angle at 1 year post op. We believe that combined internal and external fixation, not widely reported in the literature, is a good option in these cases. The complications reported here were in the first three patients undergoing said technique and represent a learning curve.
Return to Sport and Activity after Total Ankle Arthroplasty and Arthrodesis: A Systematic Review
Authors: Johns William L. , Sowers Christopher , Walley Kempland C. , Jackson J. Ben , Thordarson David B. , Gonzalez Tyler A.
Published: November 2020

Category:

Ankle Arthritis; Ankle; Other

Introduction/Purpose:

There is no consensus regarding participation in sports and recreational activities following total ankle replacement (TAR) and ankle arthrodesis (AA). Better understanding on this topic will allow orthopaedic foot and ankle surgeons to set evidence-based goals and expectations with their patients in regards to postoperative activity recommendations and quality of life. We aimed to summarize the evidence on return to sport and activity after surgical management with either TAR or AA for ankle osteoarthritis (OA).

Methods:

A literature search of PubMed, MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in January 2020. The bibliographies of all relevant publications were searched for further applicable studies. Included studies were required to report sport and activity outcomes in patients undergoing TAR and AA, with primary outcomes being percentage of sport participation and level of sport participation. Excluded studies were non-English and did not assess level of sport activity after TAR or AA.

Results:

Twelve studies met inclusion criteria for analysis. There were 1,270 ankle procedures, of which 923 TAR and 347 AA were performed. Mean reported patient age was 59.2 years old and mean BMI was 28 kg/m2. Mean follow-up was 43 months. Fifty-four percent of patients were active in sports preoperatively compared to 63.7% postoperatively (Figure 1). Mean preoperative activity participation rate was 41% in the TAR cohort, but improved to 59% after TAR, whereas preoperative activity participation rate of 73% was similar to postoperative rate of 70% in the AA cohort. The most common sports in TAR and AA groups were swimming, hiking, cycling, and skiing.

Conclusion:

Participation in sports activity is nearly 10% improved after surgical management of ankle OA. The existing literature demonstrated a large improvement in pre-to postoperative activity levels after TAR, with minimal change in activity after AA, however, AA patients were more active at baseline. The most frequent postoperative sports activities after surgical management of ankle OA are: swimming, hiking, cycling, and skiing. Despite preoperative participation in high-impact sports such as tennis, soccer, and running, these were consistently limited after surgery. This review of the literature will equip patients and physicians with the knowledge to appropriately establish realistic expectations for postoperative physical activity and return to sport goals. [Table: see text]
Total Ankle Arthoplasty as a Day Case Surgery: How Safe and Effective it is?
Authors: Kayum Shahin , Daniels Timothy R. , Khan Ryan M.
Published: November 2020

Category:

Ankle Arthritis

Introduction/Purpose:

Outpatient total joint arthroplasty (OTJA) allows for a safe, cost effective pathway for appropriately selected patients. Total ankle arthroplasty (TAA) is a surgical procedure commonly used for patients with painful arthritis. As the number of TAA procedures increase, so does the associated economic burden. The purpose of this study was to evaluate patients undergoing total ankle arthroplasty, who were discharged on the same day as undergoing surgery. These patients have stayed in the hospital for <12 hours, and are referred to as ‘‘outpatients.’’ Outpatients were evaluated with regard to the following outcomes: (1) postoperative pain; (2) perioperative complications and healthcare provider visits (readmission). We also assessed patients’ satisfaction regarding discharge on the same day as surgery.

Methods:

The medical records of 46 consecutive TAA outpatients from July 2018 to June 2019 with a minimum 1 month post- operative follow-up, were reviewed. All patients received an Integra Cadence TAA. Prior to surgery, all patients received popliteal blocks. Patients were discharged home with a popliteal catheter, which they were to remove themselves after 48 hours. After removal of the catheter, patients were prescribed oral pain medication to help with any pain or discomfort. The following data was collected: demographics, comorbidities, (ASA) class, and perioperative complications, including wound breakdown, infection, revision and non-revision surgeries. At their 1-month post-operative visit, patients completed a questionnaire regarding their satisfaction post-surgery, which consisted of six questions.

Results:

There were no readmissions for pain control, no signs of wound infection among the 46 outpatients. All patients were ‘very satisfied’ with the surgical procedure and with recommend methods of pain control. The majority of patients were also very satisfied with discharge on the same day as surgery with the exception of patients who would have liked to stay overnight. When asked if they would recommend the care they experienced to a friend with the same condition, 46 patients said that they would definitely recommend this process to a friend. In terms of rating their pain on a scale of 0-10 (0 being no pain, 10 being worst pain imaginable), the average score for the 46 patients was 2.03.

Conclusion:

Our study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory outpatient experience and no readmissions for pain control.
Validity of the Paper Pull Test for Strength in Patients with Hallux Valgus
Authors: Hutchison Marcey Keefer , Houck Jeff , Kau Jaymee , Omohundro Kristen E. , Hughes Alex , Oshiro Kara , Eckel Taylor
Published: November 2020

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

The purpose of this study was to explore validity of the paper pull test (PPT) to assess hallux flexion strength and function in persons with hallux valgus (HV). The following hypotheses were tested: 1) The PPT is valid for inferring 1st MTP flexion strength and heel rise (HR) performance (e.g. heel height). 2) A specified threshold of force during the PPT can be identified that discriminates patients with HV. 3) Muscle activity (abductor hallucis [AH], flexor hallucis brevis [FHB]), in patients with HV will be distinct from controls across three tasks: 1) PPT, 2) lowering phase of a HR, and 3) rising phase of a HR.

Methods:

Participants (24 controls, 22 with HV) performed: 1st MTP flexion, PPT, and heel rise. A force transducer in a jig assessed 1st MTP flexion. The same transducer recorded force during the PPT. Electromyography (EMG) was used to record FHB/AH muscle activity during 1st MTP flexion, PPT, and heel rising. 3D movement analysis was used to measure heel height and divide the HR into an up (HR-Up) and down (HR-Dwn) phase. One practice and 3 maximum 1st MTP flexion efforts were recorded. Manchester Scale of hallux deformity was used; 63.6% were classified as C or D. Validity was assessed with Pearson correlation’s between force during the PPT and 1st MTP flexion and PPT and HR height. Assessment of a threshold value for discriminating participants with HV from controls was determined using receiver operator curve (ROC) analysis. A two-way ANOVA for muscle groups and tasks were used to assess muscle activation.

Results:

The correlation between PPT force and maximum 1st MTP force was high (r=0.87, p<0.01) and the correlation with HR height was significant (r=-0.41, p<0.01). The ROC analysis yielded a high area under the curve (0.88(0.05)) for discriminating HV participants. Participants with HV that were below a threshold of 4.5% BW (44.1 N for a 100 kg person) on the PPT showed an 88% specificity/80% sensitivity in distinguishing HV participants from control participants (control average 64.1(37.3) N) versus HV (average 21.8 (16.4) N). Muscle activity was significantly higher across tasks for the AH (p=0.02) but was similar for the FHB (p=0.22).

Conclusion:

This data validates the PPT as simple, effective, clinical evaluation of 1st MTP flexion strength in patients with HV. This data also documents that patients with HV (surgery or not) may avoid using 1st MTP flexion explaining their significant weakness. The importance of this weakness on function is supported by the correlation with the heel rise test. The abnormal EMG findings suggests altered muscle control contributes to a lower PPT. The threshold of 1st MTP strength may assist with clinical decisions regarding whether rehabilitation or advice on increasing physical activity might benefit patients with various degrees of HV.
Household Items-Based Personalized Video Rehabilitation amidst the COVID-19 Pandemic: Handouts We All Wish We Had
Authors: Khan Irfan , Martin Kevin D. , Quatman Carmen E. , Groth Adam T. , Rodriguez Rudy
Published: November 2020

Category:

Ankle; Sports

Introduction/Purpose:

Rehabilitation is vital in the recovery of countless foot and ankle injuries and operations.1With our attention directed to providing care on the frontlines of the COVID-19 pandemic, rehabilitation has fallen by the wayside with poor consequences. Access to outpatient rehabilitation services and their specialized exercise equipment has significantly decreased,2 leaving patients feeling abandoned and surgeons looking for help on how to guide patients’ postoperative rehabilitation. This poster serves to introduce household items-based personalized video rehabilitation (PVR).

Methods:

Rehabilitation exercise videos were produced by a board-certified athletic trainer and board-certified orthopaedic foot and ankle surgeon. The videos showed how to perform rehabilitation exercises with common household items (Figure 3).The videos were produced in a structured order, explaining the purpose of the exercise, showing what household items are needed, and demonstrating the proper technique of the exercise. Following recording of the videos, they were assembled into injury/scenario-specific infographics (Figure 1).

Results:

34 rehabilitation exercise videos were recorded, with an average length of two minutes, 11 seconds.11 injury/scenario- specific infographics were assembled, with each page of an infographic containing seven exercises (Figure 1), with specific information and access for each exercise (Figure 2).Patients can access the videos by clicking on the hyperlink, or by scanning the QR code. When giving infographics, healthcare professionals can guide patients on which exercises to perform.

Conclusion:

Household items-based PVR provides patients with an interactive infographic that gives access to concise videos of rehabilitation exercises, especially during a time of reduced rehabilitation accessibility. Healthcare professionals can assign patient- specific exercises on the infographic that are appropriate for a patients’ phase of rehabilitation. Not meant to replace the current rehabilitation model, household item-based PVR is a paradigm shift that will allow physicians to bridge gaps in care.