bluuebunny/crossref_metadata_2025 huggingface dataset:
Total Sacrectomy for Low-Grade Malignant Peripheral Nerve Sheath Tumour: A Case Report
Authors: Kiatisevi Piya , Piyaskulkaew Chaiwat , Sukunthanak Bhasanan , Thanakit Voranuch , Bumrungchart Saraporn
Published: October 2016

We report on a 58-year-old woman who underwent total sacrectomy and spinopelvic reconstruction for a low-grade malignant peripheral nerve sheath tumour involving the sacrum. One week later, she developed deep wound infection, and the entire spinopelvic reconstruction was removed. At the 36-month follow-up, the patient had no pain and was able to walk with a walking frame. There was no sign of recurrence or metastasis.
Trauma-Induced Myelopathy in Patients with Retro-Odontoid Pseudotumour and Ossification of the Anterior Longitudinal Ligament: A Report of Two Cases
Authors: Tobari Yoshiko , Kimura Atsushi , Sasaki Satoru , Tajiri Yasuhito , Seichi Atsushi
Published: October 2016

We report 2 cases of acute, progressive myelopathy after a fall in elderly patients who had a retro-odontoid pseudotumour and extensive ossification of the anterior longitudinal ligament.
Leukocyte-Poor Platelet-Rich Plasma versus Bupivacaine for Recalcitrant Lateral Epicondylar Tendinopathy
Authors: Behera Prateek , Dhillon Mandeep , Aggarwal Sameer , Marwaha Neelam , Prakash Mahesh
Published: October 2016

Purpose.

To compare a single leukocyte-poor (type-4B) platelet-rich plasma (PRP) injection versus bupivacaine injection for recalcitrant lateral epicondylar tendinopathy (LET).

Methods.

25 patients aged 27 to 50 years with painful and recalcitrant LET of the humerus were randomised to receive leukocyte-poor (type-4B) PRP (n=15) or bupivacaine (n=10) injection. Outcome measures included visual analogue scale (VAS) for pain, modified Mayo clinic performance index for elbow (MMCPIE) for elbow function, and Nirschl score for activity-related pain at 1, 3, 6, and 12 months by a single assessor.

Results.

At baseline, the PRP and bupivacaine groups were comparable in terms of age, sex, duration of symptoms, VAS for pain, MMCPIE score, and Nirschl score. After one month, the percentage of improvement was less in the PRP than bupivacaine group in terms of the VAS for pain (17.7% vs. 26.5%), MMCPIE score (24.0% vs. 27.6%), and Nirschl score (20.7% vs. 31.1%). Nonetheless, improvement in the respective scores was greater in the PRP than bupivacaine group after 3 months (42.5% vs. 30.9%, 34.1% vs. 27.2%, and 50.7% vs. 39.6%), 6 months (67.3% vs. 20.1%, 40.6% vs. 16.3%, and 71.4% vs. 31.1%), and one year (83.2% vs. 45.6%, 47.0% vs. 21.7%, and 76.6% vs. 56.3%). The differences in scores between groups were significant at 6 months and one year only (p<0.001).

Conclusion.

Leukocyte-poor (type-4) PRP injection for recalcitrant LET enabled good improvement in pain and function.
Arthroscopic Resection of Humeroradial Synovial Plica for Persistent Lateral Elbow Pain
Authors: Rajeev Aysha , Pooley Joesph
Published: October 2016

Purpose.

To review the outcome of 121 patients who underwent arthroscopic resection of a humeroradial synovial plica for persistent lateral elbow pain.

Methods.

92 men and 29 women aged 24 to 56 (mean, 38) years with chronic lateral elbow pain underwent arthroscopic resection of a humeroradial synovial plica using a motorised soft tissue shaver, followed by intensive physiotherapy. The modified elbow score and range of motion were assessed, as were wound healing, infection, soft tissue swelling or effusion, tenderness, ligamentous instability, and motor strength.

Results.

No patient had any ligamentous instability. 80 patients were pain-free at 3 months; only 3 patients were taking pain medication at 6 months. All patients had full pronation and supination; the mean range of motion was 3° to 135° of flexion. The mean modified elbow score at 12 months was 93.2 (range, 72–100). The percentages of patients with excellent, good, fair, and poor score were 70%, 17%, 8%, and 5% at 3 months, 74%, 20%, 3%, and 3% at 6 months, and 76%, 18%, 3%, and 3% at 12 months, respectively.

Conclusion.

A humeroradial synovial plica is one of the causes of chronic lateral elbow pain. Arthroscopic resection of the synovial plica followed by intensive physiotherapy achieved good outcome.
Factors Associated with One-Year Outcome after Distal Radial Fracture Treatment
Authors: Cowie Jonathan , Anakwe Raymond , McQueen Margaret
Published: October 2016

Purpose.

To identify factors that affect functional outcome one year after distal radial fracture treatment.

Methods.

521 women and 121 men aged 16 to 92 (mean, 59) years with distal radial fractures underwent external fixation (n=123), open reduction and internal fixation (n=63), a combination of both (n=10), distal radial osteotomy for symptomatic malunion (n=90), or casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia. The indication for surgery (rather than casting) was metaphyseal instability. Radiographic evaluation (dorsal angulation, radial shortening, carpal malalignment, and malunion) was made before and after treatment and after fracture healing. Functional evaluation (range of movement, grip strength, and activities of daily living) was made at a mean of 16 (range, 6–54) months after injury.

Results.

After multiple regression analysis, poorer functional score was associated with increasing age (p<0.001), dorsal angulation after healing (p<0.016), presence of volar comminution (p=0.005), and pain (p<0.001). Poorer grip strength was associated with non-dominant side injury, increasing age, dorsal angulation after healing, positive ulnar variance, comminution, and pain (all p<0.001). Predicted malunion showed colinearity with age ( r=0.657), dorsal comminution ( r=0.694), and dorsal angulation ( r=0.626).

Conclusion.

Understanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome.
Total Hip Arthroplasty Using a Short-Stem Prosthesis: Restoration of Hip Anatomy
Authors: Amenabar Tomas , Marimuthu Kanniraj , Hawdon Gabrielle , Gildone Alessandro , McMahon Stephen
Published: October 2016

Purpose.

To evaluate hip parameters such as vertical centre of rotation (VCR), horizontal centre of rotation (HCR), femoral offset, and leg length after total hip arthroplasty (THA) using the Nanos short-stem prosthesis.

Methods.

Medical records of 73 men and 74 women aged 25 to 92 (mean, 63) years who underwent THA using the Nanos short-stem prosthesis by a single surgeon were reviewed. Prior to the surgery, the optimal cup and stem size, head length, and level of the neck osteotomy were determined using radiographs. Intra-operatively, the leg length and femoral offset were checked, and the level of neck resection and head length were adjusted. VCR, HCR, femoral offset, and leg length of the operated and contralateral sides were compared. Functional outcomes were assessed using the Harris Hip Score (HHS).

Results.

Compared with the normal contralateral hips, the operated hips had a mean increase of 0.4 mm in VCR (p=0.032), a mean decrease of 1.4 mm in HCR (p=0.027), a mean increase of 0.6 mm in femoral offset (p=0.043), and a mean increase of 0.36 mm in leg length (p=0.035). For these respective parameters, the difference between the normal contralateral side and the operated side was within 5 mm in 89%, 80%, 71%, and 96% of patients. The HHS improved from a mean of 53 to 91 at one year (p<0.001).

Conclusion.

THA using the Nanos short-stem prosthesis enabled restoration of hip anatomy (VCR, HCR, femoral offset, and leg length).
Extensor Tendon Rupture of the Index Finger Secondary to Avascular Necrosis of the Scaphoid: A Case Report
Authors: Kohyama Sho , Nishiura Yasumasa , Hara Yuki , Ochiai Naoyuki
Published: October 2016

We report on a 74-year-old man with extensor indicis proprius (EIP) tendon rupture secondary to avascular necrosis and collapse of the scaphoid. The collapsed scaphoid was removed, followed by 4-corner fusion and tendon transfer of the extensor digiti minimi to the EIP. At the 3-year follow-up, the patient was pain-free and had full extension of his left index finger, with proper alignment of the carpal bones and union of the 4 bones.
Minimally Invasive Plate Osteosynthesis for Proximal Humeral Fractures
Authors: Koljonen Paul Aarne , Fang Christian , Lau Tak Wing , Leung Frankie , Cheung Nigel WK
Published: October 2016

Purpose.

To report the outcome after minimally invasive plate osteosynthesis (MIPO) through the deltoid-splitting approach for proximal humeral fractures.

Methods.

10 men and 30 women aged 37 to 88 years underwent MIPO through the deltoid-splitting approach using the Proximal Humerus Internal Locking System or the Locking Proximal Humerus Plate for 2-part (n=18), 3-part (n=20), and 4-part (n=2) proximal humeral fractures. The rehabilitation protocol was standardised.

Results.

All 40 patients were followed up at 3 months, 34 (85%) at 6 months, 30 (75%) at one year, and 13 (33%) at 2 years. Two patients had malunion. No patient had avascular necrosis, infection, nerve palsy, or nonunion. The mean Constant score at one year and 2 years was 75 and 87.5, respectively. The Constant score at 6 months correlated to that at one year ( r=0.926, p<0.0001) and at 2 years ( r=0.874, p=0.0001). In younger patients, improvement in the range of motion was faster. The early plateau group (those with no further improvement after 6 months) and the late plateau group (those with no further improvement after one year) did not differ significantly in age, fracture grade, or hand dominance.

Conclusion.

MIPO for fixation of proximal humeral fractures using a locking plate is safe and effective in enabling an early return of shoulder function.
Distal Femoral Fracture during Primary Total Knee Arthroplasty
Authors: Delasotta Lawrence A , Orozco Fabio , Miller Adam G , Post Zachary , Ong Alvin
Published: October 2016

Purpose.

To review 6 cases of periprosthetic distal femoral fracture during total knee arthroplasty (TKA).

Methods.

Of 778 women and 691 men who underwent primary TKAs using posterior-stabilised (n=1240), cruciate-retaining (n=165), or semi-constrained (n=64) implant, 5 women and one man with a mean age of 73.3 years and a mean body mass index of 31.6 kg/m2 sustained an intra-operative periprosthetic distal femoral fracture and were followed up for a mean of 12.8 (range, 2–39) months.

Results.

Respectively in patients with a posterior-stabilised, cruciate-retaining, or semi-constrained implant, the intra-operative fracture rates were 0.32%, 0%, and 3.13%. For women, the respective rates were 0.46%, 0%, and 5.10%. Intra-operative fracture was 9.69 times (p=0.03) more likely to occur in patients with a semi-constrained implant than those with a posterior-stabilised implant, and was 4.44 times (p=0.22) more likely to occur in women than in men. Half of the fractures occurred during the trial phase when the tibia was reduced onto the femur, and half during final prosthesis implantation.

Conclusion.

Distal femoral fracture during primary TKA is rare and associated with the use of a semi-constrained implant. Preserving as much bone in the distal femur is advised.
Lateral Plantar Nerve Release with or without Calcaneal Drilling for Resistant Plantar Fasciitis
Authors: Sadek Ahmed Fathy , Fouly Ezzat Hassan , Elian Mostafa Mohammed
Published: October 2016

Purpose.

To compare the outcome following lateral plantar nerve release with or without calcaneal drilling for resistant plantar fasciitis.

Methods.

30 women and 3 men aged 30 to 60 (mean, 45) years with resistant plantar fasciitis were randomised to undergo release of the first branch of the lateral plantar nerve with (group 1, n=18) or without (group 2, n=15) calcaneal drilling.

Results.

Patients were followed up for a mean of 27 months. According to the modified Mayo scoring system for plantar fasciotomy, group 1 was superior to group 2 in terms of score (93.9±6.97 vs. 83±8.2, p<0.001) and grading (15 excellent, 2 good, and one fair vs. 6 excellent, 4 good, and 5 fair; p=0.031). Three patients in group one and one patient in group 2 (16.7% vs. 6.6%, p=0.381) developed complications of heel numbness, foot oedema, and 2 cases of superficial wound infection, respectively.

Conclusion.

Adding calcaneal drilling to release of the first branch of the lateral plantar nerve achieves better outcome than release alone in patients with resistant plantar fasciitis.
Recurrence of Cervical Myelopathy Secondary to a Strut Graft Fracture 20 Years after Anterior Decompression and Fusion: A Case Report
Authors: Kida Kazunobu , Takaya Shogo , Tadokoro Nobuaki , Kumon Masashi , Kiyasu Katsuhito , Kato Tomonari , Takemasa Ryuichi , Ikeuchi Masahiko , Tani Toshikazu
Published: October 2016

This study reports on a 70-year-old man with recurrent cervical myelopathy 20 years after anterior decompression and fusion of C4–7 using a free vascularised strut graft. The recurrent myelopathy was secondary to a kyphotic deformity of a fractured graft and residual ossification of the posterior longitudinal ligament with stenosis at C3/4. Intra-operative spinal cord–evoked potentials indicated that spinal cord traction secondary to progressive kyphosis of the cervical spine after the graft fracture was the cause. The patient underwent laminoplasty at C3 and laminectomy at C4 to decompress the stenosis at C3/4 as well as posterior cervical spinal fusion at C3–7 with pedicle screws and a lateral mass screw and a bone graft to prevent further progression of the kyphosis. At postoperative 18 months, the patient's Japanese Orthopaedic Association score had improved to 14 from 8, and he could walk without support.
Spondylodiscitis Concurrent with Infectious Aortic Aneurysm Caused by Candida Tropicalis: A Case Report
Authors: Oichi Takeshi , Sasaki Satoru , Tajiri Yasuhito
Published: October 2016

We report a case of spondylodiscitis concurrent with infectious aortic aneurysm caused by Candida tropicalis in a 79-year-old immunocompromised man. The patient underwent percutaneous drainage of the abscess and endoluminal exclusion of the aneurysm using a bifurcated stent graft. Micafungin was administered intravenously for 8 weeks, followed by a prolonged course of oral fluconazole. At the one-year follow-up, no recurrence was noted, and the patient could walk with a cane without low back pain.
Intra-Articular Tranexamic Acid Wash during Bilateral Total Knee Arthroplasty
Authors: Zhu Meng , Chen Jerry Yongqiang , Yew Andy Khye Soon , Chia Shi-Lu , Lo Ngai Nung , Yeo Seng Jin
Published: October 2016

Purpose.

To compare the outcome after simultaneous bilateral total knee arthroplasty (TKA) with or without an intra-articular tranexamic acid (TXA) wash in terms of blood loss, haemoglobin change, and transfusion requirement.

Methods.

35 women and 10 men (mean age, 67.5 years) who underwent primary simultaneous bilateral TKA by a single senior surgeon were compared with 45 matched controls. In the TXA group, 1500 mg of TXA diluted in 100 ml of 0.9% sodium chloride was administered as a wash after cementing of implant and before closure of the retinaculum. At least 5 minutes of contact time was allowed before wound closure and tourniquet deflation. No drain was used.

Results.

No patients had thromboembolic complication. Compared with controls, the TXA group had lower perioperative blood loss (920 vs. 657 ml, p=0.001), total blood loss (997 vs. 679 ml, p<0.001), blood transfusion rate (60% vs. 37.8%, p=0.035), percentage of patients requiring more than one blood unit (24.4% vs. 8.9%, p=0.048), and length of hospitalisation (6 vs. 4 days, p<0.001). Nonetheless, the 2 groups were comparable in blood units and volume transfused.

Conclusion.

An intra-articular TXA wash during simultaneous bilateral TXA reduced total blood loss and resulted in a difference of 22.2% in blood transfusion rate and a 2-day reduction in the length of hospital stay.
Radiography versus Multidetector Computed Tomography in Assessing Graft Integration after Acetabular Reconstruction
Authors: Fernandez-Valencia Jenaro Ángel , Gallart Xavier , Tomás Xavier , Piñeros Daniel , García Sebastián , Riba Josep
Published: October 2016

Purpose.

To compare radiography with multidetector computed tomography (MDCT) in the evaluation of graft integration following acetabular reconstruction for failed total hip arthroplasty (THA).

Methods.

Records of 5 men and 6 women aged 60 to 78 (mean, 71.8) years who underwent acetabular reconstruction using structural allografts for severe acetabular deficiency secondary to aseptic loosening (n=9) or septic loosening (n=2) were reviewed. The mean survival time of the THA was 136.4 (range, 12–360) months. Acetabular defects were classified as IIC (n=2), IIIA (n=3), or IIIB (n=6). Structural allografts were fixed with impaction followed by a reinforcement ring (n=10), an antiprotrusio cage (n=2), and/or an oblong cup (n=1) with gentamicine-loaded cement. Cup loosening, graft integration, and graft resorption were evaluated using radiography. In addition, graft integration was evaluated using MDCT.

Results.

At a mean follow-up of 4.2 (range, 2–11) years, the survival of the acetabular reconstruction was 90.9%. No patient had any signs of infection. One patient underwent reoperation 22 months later for dislocation secondary to abductor deficiency caused by nonunion of the trochanteric fracture. According to radiography, all patients had graft integration. One patient had definitive and another had possible cup loosening. Four patients had minor graft resorption. According to MDCT, graft integration was complete in only one patient, partial >50% in 3, partial <50% in 4, and absent in 2.

Conclusion.

MDCT is more accurate than radiography in evaluating graft integration following acetabular reconstruction.
Posterior Condylar Cartilage Thickness and Posterior Condylar Offset of the Femur: A Magnetic Resonance Imaging Study
Authors: Wernecke Gregory C , Seeto Bradley G , Chen Darren B , MacDessi Samuel J
Published: October 2016

Purpose.

To measure the femoral posterior condylar cartilage (PCC) thickness and the posterior condylar offset (PCO) and determine the correlation between the 2 parameters in 530 normal subjects using magnetic resonance imaging (MRI).

Methods.

Records of 287 male and 243 female patients (mean age, 40.7 years) who underwent MRI for traumatic soft tissue knee injuries not involving the femoral PCC and did not have symptomatic knee arthritis were reviewed.

Results.

The PCC thickness was comparable in the lateral and medial sides (2.04 vs. 1.99 mm, p=0.13). Males had thicker PCC in the medial (2.05 vs. 1.92 mm, p=0.0006) and lateral (2.16 vs. 1.86, p<0.0001) sides than females. Age did not correlate with PCC thickness. The bony PCO was larger in the medial than lateral side (25.8 vs. 22.6 mm, p<0.0001). Males had a larger PCO than females in the medial side only (26.1 vs. 25.5 mm, p = 0.0195). The bony PCO did not correlate with PCC thickness.

Conclusion.

Femoral PCC thickness was comparable in the medial and lateral sides. Males had thicker PCC in the medial and lateral sides than females.
Midterm Outcome of Total Hip Arthroplasty for Rapidly Destructive Coxarthrosis
Authors: Yuasa Takahito , Maezawa Katsuhiko , Nozawa Masahiko , Kaneko Kazuo
Published: October 2016

Purpose.

To compare the midterm outcome in 12 women who underwent total hip arthroplasty (THA) for rapidly destructive coxarthrosis (RDC) and in 12 controls who underwent THA for osteoarthritis.

Methods.

Records of 12 women aged 50 to 80 (mean, 72.3) years who underwent THA for RDC after a mean of 9 (range, 4–11) months since symptom onset were reviewed. They were compared with 12 age-and sex-matched controls who underwent THA for primary or secondary osteoarthritis. Acetabular bone deficiency of the 12 RDC patients was classified as type I (n=7), type II (n=4), or type III (n=1). Type I was treated with cementless THA, and types II and III were treated with THA with a cemented acetabular component. The femoral component was cementless. Pre- and post-operative Harris Hip Score was assessed. Radiographs of the hip were evaluated for implant migration, osteolysis, and periprosthetic radiolucency in the acetabulum and proximal femur.

Results.

The 12 women who underwent THA for RDC and the 12 controls who underwent THA for osteoarthritis were comparable in terms of pre-, intra-, and post-operative parameters. After a mean follow-up of 9.3 years, the mean Harris Hip Score improved from 38.3 to 81.1 in RDC patients and from 43.6 to 84.2 in controls (p=0.13). One RDC patient had dislocation but did not require revision surgery. One RDC patient developed a radiolucent line <2 mm in zones 1 and 7 of the femoral component, but no migration occurred. No patient had progression of bony destruction, loosening, osteolysis, migration, or radiolucency of the acetabular component.

Conclusion.

Despite the rapid destruction of the acetabulum and femoral head in RDC patients, cemented or cementless THA achieved a good midterm outcome comparable to that for patients with primary or secondary osteoarthritis.
Bone-Peg Grafting for Osteochondritis Dissecans of the Humeral Capitellum
Authors: Maruyama Masahiro , Harada Mikio , Satake Hiroshi , Uno Tomohiro , Takagi Michiaki , Takahara Masatoshi
Published: October 2016

Purpose.

To review the outcome of bone-peg grafting for osteochondritis dissecans (OCD) grade II lesions of the humeral capitellum.

Methods.

Records of 10 male adolescent baseball players aged 10 to 15 (mean, 12.3) years who underwent bone-peg grafting for OCD grade II lesions of the humeral capitellum of the dominant arm were reviewed. The mean time from symptom onset to presentation was 11 (range, 1–36) months. The mean duration of conservative treatment was 5 (range, 1–25) months. The mean time from symptom onset to surgery was 17 (range, 3–39) months; it was >6 months in 6 patients. The mean size of the lesions was 13×14 mm. Patients were assessed for elbow pain, range of elbow and forearm motion, Timmerman-Andrews elbow score, return to sports activity level, and radiographic evidence of healing, osteoarthritic changes, and radial head hypertrophy.

Results.

The mean follow-up period was 25 (range, 10–52) months. Postoperatively, elbow pain was absent in 6, mild in 2, and moderate in 2 patients. The mean range of elbow motion changed from 136° to 139° (p=0.80). The mean Timmerman-Andrews elbow score improved from 163 to 189 (p=0.014); it was excellent in 7, good in 2, and fair in one patient. The mean extent of lesion healing was 71% (range, 33–100%). Five patients achieved complete healing after a mean of 5.2 (range, 5–6) months and returned to sports at a competitive level. The other 5 achieved partial healing of 33 to 56% (mean, 41%) that occurred laterally but not medially. Two of them returned to sports at a competitive level: one changed the throwing side and another had radial head hypertrophy. The remaining 3 underwent arthroscopic debridement of the unhealed lesion at 5, 10, and 15 months. One patient developed secondary osteoarthritis and further underwent costal osteochondral autografting 10 months later. None of the 5 patients with partial healing versus 4 of the 5 patients with complete healing underwent surgery within 6 months of symptom onset. All 3 patients with a dot at the interface versus 2 of the 6 patients with a line at the interface between the fragment and the lesion on MRI had complete healing.

Conclusion.

Bone-peg grafting is a viable option for OCD grade II lesions of the humeral capitellum when performed within 6 months of symptom onset and when the interface between the fragment and the lesion appears as a dot (rather than a line) on MRI.
Time-Varying Distortions of Binaural Information by Bilateral Hearing Aids
Authors: Brown Andrew D. , Rodriguez Francisco A. , Portnuff Cory D. F. , Goupell Matthew J. , Tollin Daniel J.
Published: October 2016

In patients with bilateral hearing loss, the use of two hearing aids (HAs) offers the potential to restore the benefits of binaural hearing, including sound source localization and segregation. However, existing evidence suggests that bilateral HA users’ access to binaural information, namely interaural time and level differences (ITDs and ILDs), can be compromised by device processing. Our objective was to characterize the nature and magnitude of binaural distortions caused by modern digital behind-the-ear HAs using a variety of stimuli and HA program settings. Of particular interest was a common frequency-lowering algorithm known as nonlinear frequency compression, which has not previously been assessed for its effects on binaural information. A binaural beamforming algorithm was also assessed. Wide dynamic range compression was enabled in all programs. HAs were placed on a binaural manikin, and stimuli were presented from an arc of loudspeakers inside an anechoic chamber. Stimuli were broadband noise bursts, 10-Hz sinusoidally amplitude-modulated noise bursts, or consonant–vowel–consonant speech tokens. Binaural information was analyzed in terms of ITDs, ILDs, and interaural coherence, both for whole stimuli and in a time-varying sense (i.e., within a running temporal window) across four different frequency bands (1, 2, 4, and 6 kHz). Key findings were: (a) Nonlinear frequency compression caused distortions of high-frequency envelope ITDs and significantly reduced interaural coherence. (b) For modulated stimuli, all programs caused time-varying distortion of ILDs. (c) HAs altered the relationship between ITDs and ILDs, introducing large ITD–ILD conflicts in some cases. Potential perceptual consequences of measured distortions are discussed.
The Tarsal Navicular Stress Fracture Revisited
Authors: Torg Joseph S. , Pavlov Helene , Roberts Matthew M. , Eremus Joseph , Drakos Mark C. , Arnoczky Steven P.
Published: October 2016

Category:

Sports.

Introduction/Purpose:

The purpose of this paper is to both refute and condemn the current practice of open reduction and internal fixation in the treatment of both uncomplicated partial and complete tarsal navicular stress fractures. It will deal with issues that have violated the basic principals of clinical based evidence and resulted in unnecessary surgery, patient injury, and excessive costs.

Methods:

Ten cases managed by the senor author as well as a meta-analysis 250 cases in 19 published reports in the peer reviewed literature will be reported vis-a- vis surgical vs. conservative management. Management of the dorsal transverse fragment will be discussed, The large cost disparity between operative and non-operative management will be emphasized. The vascular and biomechanical factors will be presented.

Results:

The 10 cases of TNSF reported & treated by the senior author successfully healed by non-surgical, non-weight management. The meta-analysis of 250 reported cases treated conservatively had 96% successful outcomes. Conversely, those cases treated surgically with screw fixation had a 19% to 26% failure / major complication rates with repeat surgery and some with years of disability,

Conclusion:

Surgical management of TNSFs has resulted in a 19% to 26% non-union +/or morbidity rate, a marked increase in costs and is contra-indicated in the management of all non-displaced lesions. Non-weight bearing immobilization is indicated for both partial and complete sagittal fractures. Treatment should be based on established evidence based data and not on economic or remuneration factors. Orthopedic surgeons should subscribe to the concept of self regulation in dealing with this situation.
Functional Parameters of Gait Following Total Ankle Arthroplasty
Authors: Kane Justin M. , Brodsky James W. , Daoud Yahya , Coleman Scott C.
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Numerous studies have attempted to study outcomes after total ankle arthroplasty (TAA). The majority of these studies are clinical in nature. There have been some reports that rheumatoid patients have better outcomes after TAA although there are papers that are contradictory. Objective outcome studies of gait after TAA usually measure outcome against a control group or ankle arthrodesis. No studies have attempted to measure objective outcomes of TAA based upon the preoperative diagnosis. Without objectively studying outcomes for patients with osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis, it is unclear whether a difference exists in outcomes after TAA. This study aims to answer the question: Is preoperative diagnosis predictive of outcome after total ankle arthroplasty?

Methods:

A retrospective review of 75 patients who underwent isolated TAA with a minimum one-year follow-up, including patient demographics, pre-operative diagnosis, and pre and postoperative gait studies was conducted. Gait function was evaluated for postoperative improvement using multivariate analysis to determine the influence of patient variables on parameters of gait. ANOVA was conducted to compare improvement in gait based on preoperative diagnosis. P-values of < 0.05 were considered statisticallysignificant.

Results:

Outcomes/p-values are listed in table 1. While not reaching statistical significance, a meaningful clinically important difference was seen across numerous parameters. Temporal Spatial Parameters Patients with RA had the slowest preoperative cadence the fastest postoperative cadence. They also had the greatest improvement in walking speed. Patients with osteoarthritis had the greatest increase in walking speed. KinematicParameters Patients with RA had the greatest improvement in maximum plantarflexion and the least improvement in maximum dorsiflexion. Patients with osteoarthritis had the least improvement in maximum plantarflexion and the most improvement in mean maximum dorsiflexion. Patients with osteoarthritis had the greatest improvement in total ROM. Kinetic Parameters Patients with RA had the greatest improvement in peak ankle power while patients with osteoarthritis had the greatest post-operative power.

Conclusion:

There is a lack of data supporting the optimal candidate for TAA. While statistical significance was not reached across a number of the parameters of gait analysis, a number approached statistical significance. Given the relatively small sample size, it is possible that a larger cohort would reach statistical significance. Patients with osteoarthritis generally had superior preoperative and postoperative parameters of gait while patients with RA had the greatest improvement in parameters of gait. Patients with post-traumatic arthritis consistently had less improvement than patients with either osteoarthritis or RA.
Is the Canadian Orthopaedic Foot and Ankle Society Ankle Arthritis Score (COFAS AAS) Associated with the Need for Revision Surgery?
Authors: Wing Kevin , Croft Stephen , Daniels Timothy R. , Glazebrook Mark A. , Dryden Peter , Younger Alastair S. , Penner Murray J. , Sutherland Jason M.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

There has been limited evidence to support the effective use of a patient reported outcome measure (PROM) for patients that have undergone surgical treatment for end-stage ankle arthritis (ESAA). This study used longitudinally collected patient-data from a cohort of patients in the Canadian Orthopaedic Foot and Ankle Society (COFAS) ankle arthritis study to evaluate whether the post-operative COFAS Ankle Arthritis Score (COFAS AAS), a patient-reported outcome (PROs), was associated with need for revision surgery.

Methods:

Between 2001 and 2010, a cohort of 623 patients and 653 ankles undergoing total ankle replacement or ankle arthrodesis were enrolled in a multicenter prospective ankle reconstruction study. At pre-surgical baseline, key patient level variables were collected including demographics, body mass index, and comorbidities. The COFAS AAS, a patient-reported outcome measure was collected at baseline and annually post-surgically. Time to revision surgery was modeled using a proportional hazards model which controlled for age, sex, BMI, diabetic status, smoking status, inflammatory arthritis, and surgery on the right or left side and time varying PROs.

Results:

531 ankles in 509 patients with complete pre and post-operative data were included. Seventy of the cohort underwent metal component revision procedures during the follow up time period . The remaining 461 unrevised ankles had a minimum 2 year follow up (average of 3.4 years). Baseline COFAS AAS, age, sex, side, BMI, diabetic status, smoking status, and inflammatory arthritis were not statistically associated with the need for revision surgery. However, revision surgery was found to be associated with a higher post-operative COFAS AAS, and with a longer follow-up. The hazard ratio for the COFAS AAS indicates that for every one-point increase in the score, the rate of revision surgery was one percentage point higher at each post-operative time point.

Conclusion:

This study demonstrated that patients who reported higher levels of post-operative functional impairment, as indicated by a higher COFAS AAS, were more likely to undergo a revision surgery. This finding is also based on duration of follow-up, with the risk of revision surgery rising with length of follow up. This study provides further evidence for the utility of the COFAS AAS in the clinical setting. Further investigation is warranted to better understand the COFAS AAS’s ability to measure clinically meaningful change in an individual patient not requiring revision surgery.
Predictors of Long-Term Functional Outcome in Operative Ankle Fractures
Authors: Dean Daniel M. , Ho Bryant S. , Lin Albert B. , Fuchs Daniel , Ochenjele George , Kelikian Armen , Kadakia Anish R.
Published: October 2016

Category:

Trauma

Introduction/Purpose:

Risk factors associated with short-term functional outcomes in patients with operative ankle fractures have been established. However, no previous studies have reported on the association between these risk factors and long-term functional outcomes. Using the Patient Reported Outcomes Measurement System (PROMIS) physical function (PF) and pain interference (PI) measures, we attempt to identify predictors of long-term functional outcome in patients with operative ankle fractures.

Methods:

We retrospectively reviewed a multicenter cohort of patients aged ≥18 years old who underwent operative management of a closed ankle fracture from 2001-2013 with a minimum of 2 years follow-up. Patients with posterior pilon variants, Maisonneuve fractures, prior ankle surgery, and chronic ankle fractures were excluded from the study. Patients meeting inclusion criteria were contacted and evaluated using the PROMIS PF and PI computerized adaptive tests. PROMIS scores are standardized to a US population with a mean of 50 and a standard deviation of 10. Higher PF scores represent increased physical function, while increased PI scores are indicative of higher pain. Patient risk factors including sex, age, diabetes, smoking, ASA class, BMI, education level, ankle dislocation, energy of injury, and fracture pattern were obtained through a retrospective chart review. Univariate and multivariate regression models were developed to determine independent predictors of physical function and pain at long-term follow up.

Results:

In total, 199 patients met inclusion criteria. Of those, 142 patients (64 females, 78 males) with a mean age of 52.7 years (SD=14.7) averaging 6.3 years of follow-up (range 2 – 14) participated. Patients had a mean PF score of 51.9 (SD=10.0) and a mean PI score of 47.8 (SD=8.45). Multivariate analysis demonstrated that independent predictors of decreased PF score included higher age (B=0.16, p=0.03), higher ASA class (B =10.3, p < 0.01) and higher BMI (B=0.44, p < 0.01). Predictors of decreased PI score included higher ASA class (B=11.5, p < 0.01) and lower BMI (B=0.41, p < 0.01). Sex, presence of diabetes, smoking status, education level, presence of ankle dislocation, energy of injury mechanism, and fracture pattern did not independently impact long- term pain or functional outcomes.

Conclusion:

At long-term follow-up of operative ankle fractures, increased ASA class, increased BMI, and higher age at time of surgery are independently predictive of decreased physical function. Factors that are associated with increased pain at long-term follow-up include lower BMI and higher ASA class. ASA class had the strongest effect on both physical function and pain.
Radiographic Evaluation of Medial Arch Correction of the Flexible Flatfoot Using the Cotton Osteotomy
Authors: Aiyer Amiethab , Dall Graham , Shub Jeffrey , Myerson Mark S.
Published: October 2016

Category:

Midfoot/Forefoot

Introduction/Purpose:

The opening wedge cuneiform (Cotton osteotomy) has been used to correct forefoot supination in flexible flatfoot deformity reconstruction. The purpose of this study was to identify the radiographic effects of the Cotton osteotomy on the medial column joints, the 1st tarsometatarsal (TMT) and naviculocuneiform (NC) joints).

Methods:

We retrospectively analysed 67 patients who underwent a Cotton osteotomy as part of a routine flatfoot reconstructive procedure which included a calcaneus osteotomy, peroneus brevis to longus transfer, flexor digitorum longus transfer and gastrconemius recession. The indications for use of the Cotton osteotomy included fixed forefoot varus after operative hindfoot correction, in the absence of severe medial column instability or midfoot arthritis where an arthrodesis would have been selected. We evaluated 12 radiographic parameters including the articular surface angles of the foot, Meary’s angle and a newly defined Medial Arch Sag Angle (MASA), (Fig 1). A matched cohort of 28 patients of patients who underwent a similar flatfoot reconstruction but did not undergo a Cotton osteotomy were compared to the Cotton osteotomy study group patients to identify the effects of the osteotomy.

Results:

In all patients who underwent a Cotton osteotomy, there were statistically significant changes in the articular surface angles and medial arch height (p < 0.05). No radiographic secondary sag of the medial column was seen at final follow up. Compared to 28 matched controls, the use of the Cotton osteotomy did not statistically significantly alter the postoperative Meary’s angle but it did significantly improve the MASA by 6.5 degrees (p=0.002) . Sag of the medial arch was improved via plantarflexion through the TMT and NC joints. Arch height was also improved with use of the Cotton osteotomy, but this was not statistically significant.

Conclusion:

The data indicates that the MASA is a useful radiographic measurement for assessing midfoot collapse, in the setting of pes planovalgus. The current study demonstrated the corrective capacity of the Cotton osteotomy on the MASA, with increased plantar flexion through both the NC and 1st TMT joints, although the effect was more noticeable at the 1st TMT joint. The current study demonstrates that either a TMT or NC arthrodesis may not be routinely warranted for medial column stabilization in the setting of flatfoot reconstruction.
Are Hindfoot Procedures More Painful than Forefoot – A Prospective Cohort Study in Foot and Ankle Reconstructive Surgery?
Authors: Qasim Sultan N. , Gulati Ash , Alcorn Edward G. , Venturini Sara , Gaur Atul , Mangwani Jitendra
Published: October 2016

Category:

Other

Introduction/Purpose:

Several variables are thought to have an effect on the post-operative pain relief after reconstructive foot and ankle surgery. In the past decade, the role of regional nerve blocks in the management of post-operative pain has become established. The technique(s) of regional blocks varies between centers and the published literature on this subject is inconsistent. More recently, image guided regional nerve blocks for post-op pain relief in F&A surgery have gained popularity. Traditionally, hindfoot reconstructive procedures are deemed to be more painful than the surgery involving the rest of the foot. This prospective study was carried out to examine this question.

Methods:

143 patients undergoing elective foot and ankle surgery were prospectively studied. In addition to the demographics, the details of the anaesthetic used were also recorded. 70 patients received peripheral nerve blockade with guidance either by a nerve stimulator or ultrasonography. The procedures were categorised into those belonging to the forefoot, midfoot, hindfoot or combined. The magnitude of pain was recorded immediately post-operatively, at 6 hours and at 24 hours after the surgery, using the visual analog scale (VAS, 0 as ‘no pain’ and 10 as ‘ the worst possible pain’). All adverse effects were recorded. The patients’ satisfaction at two weeks after surgery was also assessed. Kruskal-Wallis test was used to perform non-parametric analysis between the groups. For categorical data, Pearson’s Chi-square test was used. Significant difference was demonstrated by a p-value < 0.05.

Results:

There was no difference in post-operative, 6 hours or 24 hours VAS in the patients having the hindfoot surgery or those having surgery involving the rest of the foot. Although patients who underwent peripheral nerve block had a satisfactory initial pain relief, they experienced significantly more pain at 24 hours than those who did not have a block (Table 1). There was no significant difference in the hospital stay or patient satisfaction at two weeks. In total, 94% patients were satisfied with their anaesthetic and would not mind having it again.

Conclusion:

This study provides evidence that contrary to the popular belief, hindfoot surgery is not more painful than the surgery involving the rest of the foot. Our results showed that patients who received peripheral nerve block probably had rebound pain at 24 hours after the surgery. Further studies are needed to explore this relationship. The detailed information provided by this study about the mean (and SD) VAS at various time points after surgery can be used to predict post-operative pain based on various pre-operative surgical and anaesthetic parameters.
Minimally Invasive Lateral Ligaments Reconstruction With Autograft in Patients With Chronic Ankle Instability
Authors: Maccario Camilla , Grassi Miriam , Usuelli Federico G. , Manzi Luigi
Published: October 2016

Category:

Sports

Introduction/Purpose:

Persistent instability following an acute lateral ankle sprain has been reported to vary in incidence from 15% to 48. Many surgical procedures have been described to reestablish lateral ankle stability, varying from direct in situ repair of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) to augmented reconstructions with either autograft or allograft tissue. Anatomic reconstructions for lateral ankle instability utilizing tissue augmentation have gained recent popularity. The purpose of this retrospective study was to assess the results of a novel surgical percutaneous technique for the treatment of chronic lateral ankle instability using a free semitendinosus tendon transfer to reconstruct anatomically the anterior talofibular and calcaneofibular ligaments.

Methods:

Between November 2011 and January 2014, 18 patients (18 ankles) underwent an anatomic reconstruction of the lateral ankle ligaments for chronic ankle instability. Patients were clinically assessed preoperatively and at 6 and 12 months postoperatively and annualy there after (range, 12-49 months). Radiographic examination included pre-operative MRI and weight- bearing plain radiographs and post-operative weight-bearing plain radiographs scan obtained 3 months after surgery. Outcomes were assessed by comparison of preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, the Sf-12 score and visual analog pain score.

Results:

Eighteen patients (18 ankles) (100%) returned for final evaluation. Good or excellent outcome was noted on physical examination, radiographs, visual anlog pain score, SF-12 score and AOFAS score at final follow-up in all patients. Ankle range of motion was not affected by lateral ankle reconstruction.

Conclusion:

In the present study, lateral ankle reconstruction with a free semitendinosus tendon graft augmentation performed percutaneously resulted in a high percentage of successful results, excellent ankle stability with a minimal loss of ankle or hindfoot motion, and marked reduction of pain at a minimum follow-up of 12 months.
The Use of Calcaneus Osteotomy for Treatment of Symptomatic Muller Weiss Disease
Authors: Li ShuYuan , Myerson Mark S. , Monteagudo Manuel , Maceira Ernesto
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

Muller Weiss disease (MWD) is characterized by lateral navicular necrosis which is associated with a varus alignment of the subtalar joint, a short 1st metatarsal, varying degrees of arthritis of the talonavicular-cuneiform joints and a paradoxical flatfoot deformity in advanced cases. The literature is replete with various methods of arthrodesis of the hindfoot for treatment of refractory painful deformity. We present the results of a unique, previously unreported, method of treatment using a calcaneus osteotomy incorporating a wedge and lateral translation.

Methods:

Fourteen patients with MWD who were treated with a calcaneus osteotomy were retrospectively reviewed. There were seven females and seven males with an average age of 56 years (range 33-79). Using Maceira’s grading we found the following: one grade 5, five grade 4, four grade 3 and four grade 2 patients. Patients had been symptomatic for an average of eleven years (range 1-14), and all underwent initial conservative treatment with an orthotic support that posted the heel into valgus. The primary indication for surgery was a limited but positive response to the use of the orthotic support, and a desire to avoid an arthrodesis of the hindfoot. Other than the described calcaneus osteotomy, no additional procedures were performed.

Results:

Patients were followed for an average of three years following the procedure (range 1 – 7 years). Patients rated their pain on a visual analogue pain scale as an average of 8 (range 6-9) prior to surgery and an average of 2 postoperatively (range 0-4). The AOFAS scores improved from a mean of 29 (range 25 – 35) preoperatively to a mean of 79 (range 75-88) postoperatively. Hindfoot range of motion remained unchanged, so too the extent of arthritis of the navicular complex. One patient experienced ipsilateral knee pain for 6 months postoperatively which resolved following physical therapy. One patient experienced intermittent midfoot pain and felt that the surgery was not successful. No patient has since required an arthrodesis.

Conclusion:

While the traditional treatment of Muller Weiss disease has been various types of hindfoot arthrodesis, it has been our experience that these procedures are not ideal unless the heel varus is simultaneously corrected. Since the majority of MWD patients respond to an orthotic support which changes the load of the hindfoot and forefoot, we believed that selected patients would respond positively to a calcaneal osteotomy as an alternative treatment. Although the follow up in this series is relatively short, the patients responded remarkably well to the use of a calcaneus osteotomy, however we cannot predict if an arthrodesis will be necessary in the future.