bluuebunny/crossref_metadata_2025 huggingface dataset:
Reliability of Hindfoot Alignment Using Weightbearing CT Semi Automatic Software
Authors: Lintz Francois , Welck Matthew , Bernasconi Alessio , Thornton James , Cullen Nicholas , Singh Dishan , Goldberg Andrew
Published: September 2017

Category:

Ankle, Hindfoot, Imaging

Introduction/Purpose:

Hindfoot Alignment (HA) on 2D radiographs presents anatomical and operator-related bias. In this study, weightbearing CT (WBCT) was used to measure HA using a semi-automatic software which gives HA as a value of Foot Ankle Offset (FAO) after selecting four landmarks (weight bearing points of first and fifth Metatarsals, Calcaneus and center of the ankle joint). We assessed the intra and interobserver reproducibility and the distribution of FAO values in a series of datasets from clinically normal, varus and valgus cases. We hypothesized that reproducibility would be excellent. Furthermore, FAO in normals should have a Gaussian distribution and be significantly different to the varus and valgus groups.

Methods:

In this level 3, retrospective comparative study, WBCT (PedCAT ®, CurveBeam LLC, Warrington, PA, USA) datasets were obtained from an existing database. The 135 feet were assessed by a senior foot and ankle surgeon as normal, varus or valgus (57, 38 and 40 respectively). Two surgeon investigators (one senior and one trainee) independently analyzed each case using a semi-automatic HA measurement tool (TALAS ™, CurveBeam LLC, Warrington, PA, USA). A third, independent investigator conducted the statistical analysis using Stata® Software.

Results:

The overall intraoberver and interobserver reliability were 0.99 ± 0.002 and 0.97 ± 0.02 respectively. In normal cases, mean value for FAO was 2.38% ± 2.96, whereas in varus and valgus cases mean was -11.67% ± 6.90 and 11.47% ± 5.79, respectively (p<0.001). The normal population had a Gaussian distribution with a Kolmogorov-Smirnov test > 0.8

Conclusion:

This study reports excellent reliability and discriminative power of a semi-automatic 3D measurement tool for Hindfoot Alignment in WBCT.
Subchondral Bone Degradation Following Bone Marrow Stimulation -An MRI Analysis-
Authors: Shimozono Yoshiharu , Yasui Youichi , Megill Robin , Kennedy John
Published: September 2017

Category:

Ankle

Introduction/Purpose:

Microfracture is the most common operative procedure for the treatment of osteochondral lesions of the talus (OLT). The role of the subchondral bone (SCB)/plate (SCBP) is recognized as one of the most significant factors providing joint-loading support to the ankle. Greater attention has recently been paid to the SCBP and its effects on overlying hyaline and fibrocartilage function. However, damage to the SCB and SCBP during microfracture may irreversibly change the joint loading support of the ankle, leading to reparative cartilage degradation. The purpose of this study is to investigate the morphological change in the SCB and SCBP after microfracture for OLT by developing a novel magnetic resonance imaging (MRI) scoring system specifically for evaluating SCB and SCBP.

Methods:

Twenty patients who underwent microfracture for OLT and had at least a one year follow-up 3-Tesla MRI between 2008 and 2011 were selected. A SCB Health scoring system was developed to assess the condition of the SCB using 3-Tesla MRI. The SCB Health score is based on the amount of edema, subchondral cyst diameter, qualitative change in SCBP morphology and thickness change of the SCBP (Table 1). Nine of the twenty patients had two follow-up MRIs, and differences in their scores were calculated. The clinical evaluation was assessed using the Foot and Ankle Outcome Scores (FAOS) preoperatively and at final follow-up.

Results:

At first follow-up MRI, 65% of patients had mild or greater edema, 40% had subchondral cysts, 65% had irregularity or collapse of their SCBP and 85% had a >25% change in SCBP thickness. The overall SCB Health score of 90% of patients were abnormal. Of the nine patients who had a subsequent follow-up MRIs, the mean time between the first and second study was 22±6 months. The scores between the two time points were not statistically significant (p=0.347, p=0.559, p=0.169, p=0.347 p=0.154 for edema, subchondral cyst diameter, qualitative SCBP measurements, SCBP thickness change and overall SCB Health score, respectively). The mean FAOS score improved significantly from 55.5±16.8 preoperatively to 76.0±12.3 at final follow-up (p<0.05).

Conclusion:

The SCB and SCBP were not completely healed in 90% of patients at a mean 18 months follow-up following microfracture of the talus. Subsequently, morphological changes were not restored at a mean 43 months at second follow-up in a smaller subset of patients. Most previous studies have focused on the degeneration of the articular cartilage layer, and its effect on clinical outcomes. The authors of current study believe that looking at the changes in the SCB may provide additional information as to why BMS procedures fail in the long-term.
The Osteochondral Lesions of Talus in the Subtalar Joint following the Intra-articular Calcaneal Fractures
Authors: Angthong Chayanin , Nangnual Suebsagul
Published: September 2017

Category:

Hindfoot, Trauma

Introduction/Purpose:

The cartilage delamination was frequently associated at the posterior articular facet of calcaneus following displaced intra-articular calcaneus fractures. However, little is known about the osteochondral lesion of the posterior facet of talus (OLPT) following an intraarticular calcaneal fracture. This study is to report the prevalence and characteristics of these lesions.

Methods:

This study retrospectively reviewed 34 patients who had the intraarticular calcaneal fractures. The CT scan was used to preoperatively evaluate the fracture type, the presence, area of lesion, and severity of OLPT following the intraarticular calcaneal fracture. These data were recorded in accordance with Akiyama mapping system, Sanders, and Ferkel classification.

Results:

The OLPT was found as 94.1% from a total of 34 patients. The most common area of OLPT was anterocentral part (26.5%) of posterior facet of talar surface in accordance with Akiyama mapping system. The most common fracture type was Sanders IV (44.1%). The most common severity of OLPT was Ferkel grade I (82.4%). The OLPT was predominantly associated in Sanders type IV fractures (46.9%; p = 0.412).

Conclusion:

This study demonstrated the high prevalence of OLPT following the intra-articular calcaneal fracture. Most lesions were mild severity; however, there was a tendency of the association of lesion occurrence with higher grade of fracture severity. The OLPT may play an important role in the formation of post-traumatic osteoarthritis of subtalar joint which can be found following the intraarticular calcaneal fracture. The preoperative evaluation of this lesion is recommended via CT. The lesion treatment may be encouraged to be performed during calcaneal fracture fixation for the reduction of post-traumatic osteoarthritis formation.
The relationships between patient-reported outcome, quality of life, and gait characteristics using a wearable foot inertial-sensor assessment in patients with foot and ankle conditions
Authors: Angthong Chayanin
Published: September 2017

Category:

Gait analysis

Introduction/Purpose:

The purpose of this study was to report the relationships between validated patient-reported outcome, health-related quality of life, and gait characteristics using a wearable foot inertial-sensor assessment in patients with foot-ankle conditions. In addition, the inter-metrics correlations were analyzed to determine the relationships between each spatiotemporal or gait parameter.

Methods:

Fifty-three patients with foot-ankle conditions (38 female/15 male, aged 21–75 years) were collected for this study. Clinical assessments, including evaluations with validated patient-reported outcomes using the visual analogue scale foot and ankle (VAS-FA) score, health-related quality of life using the validated Short Form-36 (SF-36)9, and gait characteristics assessment using a wearable foot inertial-sensor device, were performed and recorded in each patient.

Results:

Negative correlation between physical component summary (PCS) and maximal cadence only showed a significant value at Pearson’s correlation coefficient (r) = –0.308, P = 0.025. Positive correlations (r) were found between mean walking speed and mean cadence (r = 0.776, P < 0.001) and between maximal walking speed and mean step length (r = 0.498, P < 0.001). Negative correlations (r) were found between mean cadence and mean step length (r = –0.491, P < 0.001) and between maximal cadence and mean step length (r = –0.355, P = 0.009).

Conclusion:

Regarding relationships among several spatiotemporal parameters and patient-reported outcome measures, cadence is the only parameter that was significantly negatively related with PCS in health-related quality of life. Based on inter-metrics relationships, increased cadence might be used to maintain walking speed as a compensatory mechanism in patients with foot- ankle conditions.
Radiography in in SER II - IV Ankle Fractures
Authors: Baecker Henrik
Published: September 2017

Category:

Ankle, Sports, Trauma

Introduction/Purpose:

SER lateral malleolar fractures are common. The assessment of the stability of the ankle fracture is crucial for decision making of treatment which is associated with the integrity of the deltoid ligament (SERII-III). Slight talar shift can lead to extensive decrease of tibio-talar contact area (Ramsey 1999). Several clinical tests have been proposed of which static weightbearing radiography is used to measure the lateral talar shift with the medial clear space to detect medial instability (SERIV). However, the correlation of a stable ankle joint under weightbearing load with the structural integrity of the deltoid ligament has not been shown yet which we want to investigate.

Methods:

17 patients with lateral malleolar fractures were investigated who underwent an MRI and weightbearing radiography examination. In the MRI, the deep deltoid ligament was assessed as intact, partial und complete rupture. The medial clear space was measured - distance between the lateral border of the medial malleolus and the medial border of the talus at the level of the talar dome (millimeter).

Results:

7 patients suffered from deep deltoid ligament rupture (4 partial; 3 complete).The medial clear space in patients with intact deep deltoid ligament was 2.96+0.41 mm in mean, in partial rupture 2.8+0.38 mm, in complete rupture 3.43+0.23 mm. When counting the complete and partial ruptures together the mean was 3.07+0.45 mm and in partial ruptures plus the intact ones 2.91+0.40 mm.

Conclusion:

Our results show no significant correlation between the medial clear space and the integrity of the deep deltoid ligament (figure1). A negative weightbearing radiograph does not exclude deep deltoid ligament rupture. This fact might indicate the importance of the intrinsic stability provided by the osseous contour of the highly congruent ankle joint. In our opinion, malleolar fracture with deep deltoid ligament rupture (SERIV) can therefore be treated conservatively as long as ankle stability is provided under physiological load.
Single-Surgeon Experience with Supramalleolar Osteotomy
Authors: Barg Alexej , Saltzman Charles
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Supramalleolar osteotomy is a joint-preserving option for patients with asymmetric ankle osteoarthritis. However, it remains unclear whether tibiotalar tilt can be effectively corrected by this procedure. The objective of this prospective study was to evaluate the short-term clinical and radiographic outcomes in patients who underwent a supramalleolar osteotomy procedure performed by one surgeon.

Methods:

A total of 16 patients with asymmetric ankle osteoarthritis and a concomitant supramalleolar deformity were included in this prospective study: 7 patients with valgus (medial closing wedge osteotomy) and 9 patients with varus deformity (medial opening wedge osteotomy). There were 11 male and 5 female patients with a mean age of 41.6 ± 10.9 years. Intraoperative and postoperative complications were recorded and analyzed. Clinical and radiographic outcomes were assessed after a mean follow- up of 3.6 ± 1.1 years. The clinical assessment included pain assessment (VAS), functional assessment (range of motion and AOFAS hindfoot score), and quality of life (SF-36). The radiographic assessment included alignment measurements (medial distal tibial angle, tibiotalar tilt, calcaneal moment arm) and osteoarthritis degree assessment in the tibiotalar joint. Outcomes were compared between both patient groups: valgus vs. varus ankle osteoarthritis.

Results:

In 10 of 16 patients, removal of hardware was performed. There was significant pain relief from 5.8 ± 0.8 to 2.4 ± 0.8. The AOFAS score increased significantly from 36 ± 12 to 84 ± 10. The average range of motion increased from 31 ± 5 to 33 ± 4. All categories of the SF-36 score showed significant improvement. Preoperatively, tibiotalar tilt was 4.8 ± 2.4 in the varus group and 1.8 ± 2.4 in the valgus group. Postoperatively, tibiotalar tilt improved significantly in both groups, however, there was significant difference between both groups with 2.3 ± 1.6 (varus) vs. 0.2 ± 0.5 (valgus) (p=0.005). Postoperative clinical outcomes were comparable in both groups. One patient showed progressive ankle osteoarthritis requiring ankle arthrodesis.

Conclusion:

Our prospective study demonstrated encouraging short-term results in patients with asymmetric ankle osteoarthritis who underwent supramalleolar osteotomy. A significant clinical and radiographic improvement can be expected. However, especially in patients with varus osteoarthritis, tibiotalar tilt cannot be fully corrected.
Early Postoperative Results of Endoscopic Transfer of Flexor Hallucis Longus for Chronic Achilles Rupture
Authors: Baumfeld Daniel , Raduan Fernando , Nery Caio , Macedo Benjamim , Silva Thiago , Baumfeld Tiago
Published: September 2017

Category:

Ankle, Arthroscopy, Hindfoot

Introduction/Purpose:

Background Achilles tendon chronic rupture lead to proximal retraction of the tendon and have a greater tendency to show poorer functional outcomes than acute ruptures. Numerous surgical procedures have been described to treat this pathology. The transfer of the flexor hallucis longus is a well-established treatment option, usually performed as an open procedure. The aim of this paper is to report a case series of six patients with chronic Achilles tendon rupture treated with endoscopic transfer of FHL.

Methods:

Six patients with Achilles tendon chronic injuries or re-ruptures were treated with endoscopic FHL transfer. There were four man and two women, average of 50 years, with four left and two right tendons involved, and no bilateral cases. All lesions were at zone 2 (between 2-6 cm proximal to insertion). We describe the surgical technique and report our results at an average of a nine-month follow-up.

Results:

The average follow-up of the series was 9 months (range, 5–12 months). Three patients had an associate procedure at the Achilles tendon to repair the pre-existent gap, using a minimally invasive technique. On average, we expend 56 minutes to perform the surgery, ranging from 45 to 70 minutes. All patients had a major increase in ATRS score values postoperatively, with an average of 17.8 preoperatively and 83,3 postoperatively No major complications or wound healing problems were noted. Tiptoe stance was possible for all patients without limitation. None of the patients noticed functional weakness of the hallux during daily life activity.

Conclusion:

Endoscopic FLH transfer is a reliable option for patients with higher skin risk and soft tissue complications. Other studies are needed to compare this technique with the open procedure, gold standard by now, to ensure its safety and efficacy.
Plate Fixation of Metatarsal Shaft and Neck fractures has high union rates and low rates of hardware removal
Authors: Beck David , Raikin Steven , Bryant Tony , Pedowitz David
Published: September 2017

Category:

Midfoot/Forefoot, Trauma

Introduction/Purpose:

Despite large numbers of traumatic 1st,2nd,3 rd, and 4th (1-4 MT) metatarsal shaft and neck fractures, there have be very few outcome studies related to their treatment. K- wire fixation of metatarsal fractures has been shown to lead to poor outcomes when residual displacement and angulation occurs. In order to maintain anatomic alignment, some surgeons use plates for fixation of metatarsal fractures. To the best of our knowledge, this is the first study to report the healing rates, fracture angulation and need for hardware removal of operatively treated 1-4 MT shaft and neck fractures with plate fixation.

Methods:

In this retrospective cohort study, we reviewed the medical records of all metatarsal fractures at our institution from October 1, 2006 – December 31, 2014 to identify all 1-4 MT shaft and neck fractures. All tarsometatarsal joint factures, isolated 5th metatarsal fractures, fractures treated at outside facilities, skeletally immature patients and fractures treated non operatively were excluded. Final available x-rays with a minimum of one year follow-up from the date of surgery were reviewed. Medical records and x-rays were reviewed for evidence of union, sagittal and coronal fracture angulation (degrees), time to full weight bearing, plate size, fracture location (neck vs shaft) and number of screws on each side of the fracture. Patients were also called to see if the plates were bothersome, if the plates had been removed, or if they desired to have the plate removed. Multiple linear regression analysis was used to make calculations of statistical significance.

Results:

45 patients with 75 metatarsal fractures treated with plate fixation were included. All fractures went to union and full weight bearing. Average time to union and full weight bearing was 10.9 and 7.5 weeks respectively. The average coronal and sagittal plane angulation was 3.9 degrees and 2.2 degrees. No demographic variable showed statistical significance with regards to sagittal and coronal angulation. Fractures located in the neck were found to have higher coronal plane angulation malunion compared to fractures in the shaft (P=0.019). No variable was related to final sagittal plane angulation. 28/45 patients responded to our telephone interview with an average follow-up of 4.4 years. 10 stated the plate bothered them. No plates had been removed and 27/28 patients did not want the plate removed.

Conclusion:

Metatarsal fractures fixed with plates show high rates of union and low final fracture angulation. Patients did not report symptomatic hardware and did not desire to have plates removed. No patient included in this study underwent hardware removal.
Supramalleolar Osteotomy combined with Intra-articular Osteotomy for the Reconstruction of Malunited Supination-Adduction Ankle Fractures
Authors: Changjun Guo , Xu Xiangyang
Published: September 2017

Category:

Ankle Arthritis, Trauma

Introduction/Purpose:

The supination-adduction ankle fractures often showed vertical impaction of the tibial medial plafond. The malunion of these fractures cause the varus ankle deformity and secondary ankle arthritis. This retrospective control study looked at the use of supramalleolar osteotomy combined with intra-articular osteotomy in patients with malunited supination- adduction ankle fractures.

Methods:

Twelve patients were treated with malunited supination-adduction ankle fractures between January 2013 and December 2014. All of these patients had the varus ankle deformity and secondary ankle arthritis. Supramalleolar osteotomy combined with intra-articular osteotomy were underwent for the reconstruction surgery. The visual analog scale (VAS) score for pain during daily activities, Olerud and Molander Scale scores, subjective satisfaction survey rating and the modified Takakura classification stage were obtained. Ten patients were available for follow-up at a mean of 35.4 months (range, 28 to 40 months).

Results:

Average postoperative Olerud and Molander Scale score 24 months after surgery was 83±10 compared with 60±14 preoperatively. The mean VAS score decreased from 7±2 preoperatively to 2±2 at the latest follow-up. Six patients rated their result as excellent, 3 as good and 1 as fair. No significant difference in the modified Takakura classification stage was observed between the preoperative and the last follow-up.

Conclusion:

The use of supramalleolar osteotomy combined with intra-articular osteotomy was an effective option for the treatment of malunited supination-adduction ankle fractures.
Is a Flatfoot Associated with a Hallux Valgus Deformity?
Authors: Cheney Nicholas , Rockwell Kyle , Long Joseph , Weis John , Lewis Dylan , Law Timothy , Carr Adam
Published: September 2017

Category:

Bunion

Introduction/Purpose:

An arch collapse model has been described for a multitude of foot and ankle problems that is based on a gastrocnemius equinus contracture producing a predictable collapse that has been described in five distinct phases. Previous studies have evaluated the presence of pes planovlagus in hallux valgus patients and concluded that this is a rare occurance. The Grand Rapids arch collapse model reviews adult foot pathology and believes there is a link between bunions and flatfeet. We wanted to evaluate patients with flatfeet and determine if they had an associated bunion deformity. Based upon the arch collapse model, there should be a significant number of flatfeet with an associated bunion deformity and our goal was to see if this proved to be true.

Methods:

We retrospectively reviewed the radiographs of patients diagnosed with a flatfoot based upon their ICD 9 and 10 codes in the senior author’s practice. For each patient, we used standard anteroposterior and lateral foot radiographs obtained on all new patients. Initially, we had 254 feet but had to exclude 93 feet due to inadequate radiographs, normal radiographs (normal meary’s angle and talonavicular coverage angle) or in patients who already had surgical procedures to the foot. This left 161 feet radiographs for review. We then measured the Meary’s angle on the lateral images and the talonavicular coverage angle, hallux valgus angle, intermetatarsal angle and sesamoid position on the anteroposterior radiographs.

Results:

Of the 161 feet that remained in the study, only 6 feet (3.7%) had no radiographic evidence of a bunion based upon sesamoid position, hallux valgus angle or the intermetatarsal angle. We did find a correlation with the severity of the flatfoot based upon the Meary’s angle and the talonavicular coverage angle with the severity of the bunion deformity defined by the sesamoid position, hallux valgus angle and the intermetatarsal angle. As the flatfoot got worse, the bunion did so as well.

Conclusion:

Our findings would seem to fit with the Grand Rapids arch collapse model. The hypermobility of the first ray that creates the bunion deformity then allows the arch to ultimately collapse. It also does not seem to contradict what has been found previously. Earlier studies showed a low association between patients with bunions who also had flatfeet. This would make sense as the deformity may not have progressed to the flatfoot yet. However, in our study the deformity has already progressed to a flatfoot and almost all have some radiographic evidence of a bunion.
Clinical Outcomes of the Modified Broström Procedure Using Distal Fibular Periosteal Flap Augmentation for Chronic Lateral Ankle Instability
Authors: Choi Hongjoon , Kim Daewook , Park Chul-Hyun , Cho Jaeho , Chun Dong-Il , Kang Yeong Hun
Published: September 2017

Category:

Sports

Introduction/Purpose:

Modified Broström procedure (MBP) is the most widely accepted primary operative treatment for the operative treatment of chronic lateral ankle instability (CLAI). However, in cases of generalized ligament laxity, severe attenuation of the soft tissue, previous failed surgery, high demand activity, and obesity, unsatisfied results of the MBP have been reported. We hypothesized that if the soft tissue can be augmented enough to support body activity, the clinical outcomes are comparable with those of the anatomical reconstruction. The purpose of this study is to compare the clinical results between the MBP using a distal fibular periosteal flap augmentation and anatomical reconstruction using free tendon allograft for CLAI in cases of concerning poor outcome by MBP.

Methods:

Thirty-eight patients [(39 ankles), (25 men, 13 women) (mean age: 27.6 years)] who underwent both procedures were retrospectively analyzed. The mean symptom duration before surgery was 31.7 months and the mean follow up duration was 21.6 months. The indications for operation were: (1) severe subjective ankle instability feeling and objective ankle instability, (2) previous failed MBP, (3) generalized joint laxity, (4) obesity, (5) severe attenuation of the ligament. The patients were divided into 2 groups: a group of anatomical lateral ligament reconstruction (reconstruction group, 17 ankles) and a group of MBP using distal fibular periosteal flap augmentation (augmentation group, 22 ankles). Radiographic assessments were made with weightbearing anteroposterior, lateral radiographs of the ankle, hindfoot alignment radiographs, and stress radiographs using a Telos device. Clinical evaluations were performed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Karlsson-Peterson score.

Results:

The mean AOFAS score significantly improved from 54.65 to 92.94 in the reconstruction group and from 60.14 to 94.86 in the augmentation group. (p=0.000, p=0.000) The mean Karlsson score also significantly improved from 46.41 to 92.65 in the reconstruction group and from 52.64 to 94.09 in the augmentation group. (p=0.000, p=0.000) There were no significant differences in the postoperative mean AOFAS and Karlsson score between the groups. (p=0.214, p=0.299)

Conclusion:

If satisfied results can be expected with both procedures, we believe that surgeons will prefer the MBP using periosteal augmentation, which is more familiar and less invasive. The MBP using distal fibular periosteal flap augmentation is an alternative surgical option for CLAI in cases of generalized ligament laxity, severe attenuation of the soft tissue, previous failed surgery, high demand activity, and obesity.
Stress Radiographs Under Anesthesia for Painful Chronic Lateral Ankle Instability
Authors: Choi Jun Young , Suh Jin Soo
Published: September 2017

Category:

Ankle

Introduction/Purpose:

Anterior drawer and varus stress radiographs are commonly used for chronic lateral ankle instability. We compared pre-operative stress radiographs to intra-operative ones under anesthesia to figure out the accuracy and efficacy of stress radiographs at outpatient clinic.

Methods:

Data was collected from the patients underwent Modified Broström operation for painful chronic unilateral lateral ankle instability from January, 2014 to June, 2016. Subjects were divided by three groups (complete tear, partial tear and instability without rupture) according to the status of preoperative MRI findings of anterior talofibular ligament.

Results:

Ninety six patients were enrolled with a mean age of 29.63±12.04 (male: female=65: 31). Complete, partial tear and instability without rupture were 39, 46 and 11 respectively. On anterior drawer and varus stress radiographs on the affected limb, talar translation and tilting were increased significantly (2.57 mm and 2.01o). The differences between the unaffected limbs were increased by 2.47 mm and 1.32 o. Despite the stress radiographs were performed under anesthesia, the results often showed relatively small value which was not matched to the diagnostic value, even for complete tear group.

Conclusion:

Stress radiographs for chronic painful unilateral lateral ankle instability performed at outpatient clinic would be inaccurate. Therefore, additional diagnostic tools such as, ultrasonography or MRI are highly necessary.
Comparison of Total Ankle Replacement and Ankle Arthrodesis During the Recovery Period
Authors: Colanese Justin , McCormick Jeremy J. , Johnson Jeffrey , Klein Sandra
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Two reliable surgical alternatives exist for end-stage ankle arthritis, ankle arthrodesis and total ankle replacement. Several comparative studies have shown similar clinical results between the two procedures at intermediate-term follow-up (2 to 6 years). Despite this comparative literature, no studies have been dedicated to determining which of the two procedures allows better function and pain during the recovery period (the first 6 months following the procedure). This information is especially beneficial to patients for whom a more difficult and longer recovery is particularly adverse, such as elderly patients or patients with medical comorbidities. It is also unclear if pain or dysfunction during the recovery period correlates with intermediate-term complications such as nonunion or prosthetic loosening.

Methods:

This is a single site retrospective case-control study. Patient-Reported Outcomes Measurement Information System (PROMIS) scores have been completed by patients at the orthopedic foot and ankle clinic at each visit since October 2014. Patients who have undergone either a total ankle replacement or an ankle arthrodesis during that timeframe were evaluated to determine their level of pain, function, anxiety and depression at a given interval (from preoperative to 6 months) during their recovery. Data acquisition was via chart review. Exclusion criteria included Charcot neuroarthropathy and inadequate data.

Results:

138 procedures (58 total ankle replacements, 80 ankle arthrodeses) were performed at our institution during the study period. Chart review of patients meeting inclusion criteria is currently being conducted to record PROMIS scores, adjuvant procedures, complications, return to work and post-operative protocol during the first 6 months following the procedure. Data analysis will be undertaken, to detect a minimally important difference between PROMIS scores, with a 95% confidence interval and power of 0.8, the minimal sample size was calculated to be 44 subjects in each group. For patients who developed a complication from surgery (non-union, implant loosening, infection, etc.), scores will be reviewed to determine if abnormal PROMIS scores early on in the recovery period correlate with future complications.

Conclusion:

Patient pain and function during the first 6 months following surgery is an important consideration for those contemplating both ankle arthrodesis and replacement as options. Data collected from this study to be completed by Spring 2017 will help to clarify if differences between the two procedures exist.
The role of bone marrow edema on autologous matrix induced chondrogenesis for the treatment of osteochondral lesions of the talus
Authors: D’Ambrosi Riccardo , Maccario Camilla , Usuelli Federico Giuseppe
Published: September 2017

Category:

Ankle, Arthroscopy, Basic Sciences/Biologics

Introduction/Purpose:

to assess the functional and radiological outcomes after AT-AMIC® (arthroscopic talus autologous matrix induced chondrogenesis) in 2 groups: patients with and without bone marrow edema (BME).

Methods:

Thirty-seven patients of which 24 without edema (GNE) and 13 with edema (GE) were evaluated. All patients were treated with AT-AMIC® repair for osteochondral talar lesion. MRI and CT-scan evaluations, as well as clinical evaluations measured by the VAS score for pain, AOFAS and SF-12 were performed preoperatively (T0) and at 6 (T1), 12 (T2), and 24 (T3) months postoperatively.

Results:

GNE consisted of 24 patients while GE consisted of 13 patients. In both groups we found a significant difference for clinical and radiological parameters with ANOVA for repeated measures through four time points(p<0.001). In GNE, AOFAS improved significantly at each follow-up(p<0.05); while CT and MRI showed a significant decrease between T1 and T2 and T2 and T3(p<0.05). In GE, AOFAS improved significantly between T0 and T1 and T2 and T3(p<0.05); CT decreased between T1 and T2(p<0.05), while MRI showed a reduction at each follow-up(p<0.05). Lesion size was significantly higher both in MRI and CT in GE in respect to GNE(p<0.05). In the GNE no patients presented edema at T3, while in GE only 23.08% of the patients presented edema at T3.

Conclusion:

The study revealed that osteochondral lesions of the talus were characterized by bigger size both in MRI and CT in patients with edema. We conclude that AT-AMIC® can be considered a safe and reliable procedure that allows effective healing, regardless of edema and more than half of patients did not present edema six months after surgery.
Effectiveness of Lateral Soft Tissue Release of the 1st Metatarsophalangeal Joint Through a Medial Transarticular Approach – A Cadaver Study
Authors: de Cesar Netto Cesar , Shah Ashish , Hudson Parke , Sahranavard Bahman , Cone Brent , Araoye Ibukunoluwa , Lee Sung , Bergstresser Shelby , Johnson Michael , Johannesmeyer David , Jones Caleb
Published: September 2017

Category:

Bunion

Introduction/Purpose:

First metatarsophalangeal joint lateral soft tissue release is frequently performed during corrective surgery for hallux valgus deformity. Surgical approaches include an open dorsal approach as well as a medial transarticular approach. The medial transarticular approach avoids the need for a second incision while also attenuating the risk of avascular necrosis of the first metatarsal head. However, this method is limited by the poor visualization of the lateral structures through the joint. The objective of this study was to evaluate the effectiveness of the medial transarticular approach for lateral soft tissue release in the 1st metatarsophalangeal joint.

Methods:

Ten below-the-knee fresh-frozen cadaveric specimens were used (6 females, 4 males). The mean age was 73.4 years. Two specimens had moderate hallux valgus deformity. None of the samples had considerable degenerative changes of the first metatarsophalangeal joint. Lateral soft tissue release was performed using a single 2.5 cm medial incision. Lateral soft tissue release targeted the lateral collateral ligament, lateral capsule, adductor hallucis muscle tendon and lateral metatarsosesamoid suspensory ligament. A single surgeon performed all procedures. An extended lateral dissection of the 1st intermetatarsal space was carried out to examine the accuracy of the technique. Successful release of each targeted structure (4 total) was recorded for each specimen. Thus, the percentage of successful release was computed for each specimen. Injuries to important non-targeted structures were also registered.

Results:

All four targeted structures were successfully released (100%) in seven of the ten cadavers. Three out of four structures were released (75%) in one cadaver, while two of the four and one of the four targeted structures were successfully released in the other two cadavers (50% and 25% success respectively). Lateral collateral ligament was successfully released in all cadavers. Lateral joint capsule, adductor hallucis muscle tendon, and lateral metatarsosesamoid suspensory ligament were released in 80% of the specimens. 1st metatarsal head chondral and unintended release of lateral head of the flexor hallucis brevis occurred respectively in 40% and 50% of the procedures. No injuries to the flexor hallucis longus tendon, neurovascular bundle, deep transverse metatarsal ligament or chondral damage to the proximal phalanx were recorded.

Conclusion:

Lateral soft tissue release of the first metatarsophalangeal joint can be successfully performed through a medial transarticular approach. Inadvertent release of the lateral head of the flexor hallux brevis and chondral damage of the 1st metatarsal head are complications to be considered.
Efficacy of Particulated Juvenile Cartilage Allograft Transplantation for Osteochondral Lesions of the Talus
Authors: Dekker Travis , Hamid Kamran , Easley Mark , Steele John , Adams Samuel
Published: September 2017

Category:

Ankle, Arthroscopy, Basic Sciences/Biologics, Sports

Introduction/Purpose:

Symptomatic osteochondral lesions of the talus (OLTs) are difficult to treat. As such, a broad array of cartilage treatment options exist. Despite the various techniques, many patients require multiple procedures due to persistent pain, failure of cartilage adherence, or persistent mechanical symptoms. The cartilage replacement technique, particulated juvenile cartilage allograft transplantation (PJCAT), is a novel treatment option supported by the benefits of ease of application, no need for perpendicular access to the OLT, and the delivery of viable hyaline cartilage. However, there is minimal clinical data to support this treatment option. The purpose of this study was to determine the efficacy of PJCAT.

Methods:

After obtaining IRB approval, we conducted a retrospective review of patients that underwent PJCAT for the treatment of OLTs at a single academic institution. From 2012 to 2015, 18 patients were identified. However, one patient died of an unrelated cause and two patients were lost to follow-up leaving 15 patients (7 males and 8 females) whom had a minimum of 12 months of follow up (mean 34.6, range, 12-51 months). The mean age of this cohort was 32.7 years (15-48) at time of surgery with BMI average 29.9 (18.8-40.2). The primary outcome was failure of the procedure defined as: recurrent or worsening symptoms with corresponding imaging demonstrating delamination, and/or the need for a secondary cartilage restoration procedure. Variables studied included: size of lesion denoted by MRI, intraoperative size, etiology (traumatic versus atraumatic), location of lesion, sex, age, and history of prior surgery.

Results:

Failure of primary procedure as defined by continued pain with corresponding imaging and/or necessity of secondary cartilage procedure after use of PJCAT was 40% (6/15). Preoperative MRI size (188.7 +/- 81.7mm2 vs. 113.5 +/- 50.5mm2, p<0.05) was significant predictors of PJCAT failure. Furthermore, male sex was predictive of failure(p<0.05). Age, BMI, etiology, technique (open versus arthroscopic), history of prior surgery nor location were predictors of failure. Lastly, patients with lesions greater than 125mm2 area were at a statistically significant increased risk of clinical failure. Functional outcome scores were significantly better at final follow-up in the patients who had undergone successful treatment versus those who did not: AOFAS score (89.4 +/- 8.4 vs. 65.8 +/- 26.7) and FAOS total (77.9 +/- 13.2 vs. 47.9 +/- 24.8).

Conclusion:

These findings demonstrate the association of preoperative MRI lesion size, intraoperative lesion size and male sex as risk factors for failure of PJCAT setting of an already difficult to treat pathology.
Financial Impact of MRI in Treatment of Foot and Ankle Osteomyelitis
Authors: Divi Srikanth , Hynes Kelly , Dirschl Douglas , Lee Cody
Published: September 2017

Category:

Ankle, Diabetes, Hindfoot, Lesser Toes, Midfoot/Forefoot, Infection

Introduction/Purpose:

Osteomyelitis of the foot and ankle is a common condition with a high economic burden in the United States, particularly in the context of diabetes mellitus. The timely and accurate diagnosis of osteomyelitis is important to initiate treatment and possibly reduce overall healthcare costs. Plain radiographs are the initial study of choice given their widespread availability and low cost. Magnetic resonance imaging (MRI) is generally considered the most sensitive imaging modality for detecting osteomyelitis, however it is associated with significant cost and may not change overall treatment as compared to plain radiographs. The purpose of our retrospective study is to determine whether the use of MRI at our institution changed clinical decision making and calculate the financial impact in patients with foot and ankle osteomyelitis.

Methods:

We retrospectively identified patients at our tertiary care, academic center treated for a diagnosis of osteomyelitis using ICD-9 codes 730.07, 730.17, and 730.27. Demographic data including age, sex, race and ethnicity and patient comorbidities was collected. The use of plain radiographs, MRI, and any operative procedures up to 2 years after the index encounter for each patient were identified. An impact MRI was defined as an MRI that led to an operative procedure within the same admission encounter. The cost of an impact MRI was estimated using the equation: (average MRI cost)*(total MRIs/impact MRIs). Chi- squared test was used to statistically compare patients that underwent procedures in the MRI group vs. those in non-MRI group.

Results:

619 patients undergoing osteomyelitis treatment between January 2009 and September 2015 at our institution were identified, of which 40.4% were female and 59.6% were male. 151 patients had a total of 227 MRIs of the lower extremity performed vs. 468 patients that did not have MRIs performed. Of the MRI cohort, 104/151 patients (68.9%) had subsequent operative procedures, whereas in the non-MRI cohort 299/468 patients (63.9%) had subsequent operative procedures (p = 0.26). Of the 227 MRIs performed, 85 were deemed impactful MRIs and 142 were deemed non-impactful MRIs. Average MRI cost at our institution for the lower extremity with and without contrast was $5069.75. Using our previous definition, the cost of an impact MRI was calculated to be effectively $13,539.21.

Conclusion:

MRI can be an effective modality in aiding the clinical diagnosis of osteomyelitis, however, it can be an unnecessary cost when not used to guide treatment. In our study, we did not find a significant difference in the operative rate between patients undergoing MRIs vs. those that did not. We also found that the effective cost of an MRI that led to a change in treatment was $13,539, almost 2.7 times higher than the average cost of an MRI at our institution.
Midfoot Charcot Reconstruction with Intramedullary Beaming
Authors: Ford Samuel , Jones Carroll P. , Davis W. Hodges , Cohen Bruce
Published: September 2017

Category:

Diabetes, Midfoot/Forefoot, Charcot

Introduction/Purpose:

Midfoot Charcot osteoarthropathy is characterized by non-infectious osteolysis that often leads to midfoot collapse and resultant ulceration. Deformity and ulceration often lead to deep infection and amputation. Midfoot reconstruction with intramedullary screws (beams) is a recently described technique that provides deformity correction and a stable construct without the extensive exposure required for plate fixation. The purpose of this study is to examine the clinical outcomes and complications of patients with midfoot Charcot managed with midfoot osteotomy, realignment arthrodesis, and stabilization using intramedullary beams.

Methods:

A surgical database query of a tertiary-care foot and ankle center was performed from January 2013 to July 2016 to identify patients with midfoot Charcot who underwent corrective osteotomy with internal beam fixation. 24 patients were identified and included in the final analysis. Patients with minimum one-year follow-up were evaluated with physical examination, weight-bearing radiographs, and patient-reported outcome measures (FAAM and VR-12). The primary outcome measure was defined as restoration of a stable, plantigrade, ulcer-free foot. Secondary outcome measures include quantitative angular correction, rates of reoperation, postoperative infection, and amputation.

Results:

Median age was 60 years, median BMI was 32.5, and 79% were diabetic. The lateral Meary’s angle median improved from -29° preoperatively to -20° on final postoperative radiographs (p=0.007). 39% of midfoot osteotomies were united on final radiographs. An ulcer-free, stable, plantigrade foot was obtained in 83% of patients. Deep infection developed in six (25%) patients. The presence of a preoperative ulcer was found to be predictive of postoperative infection (p=0.05); all six deep infections occurred in patients with preoperative ulceration. 62.5% of patients required reoperation. Three (12.5%) patients progressed to amputation at a median nine postoperative months. The final postoperative median FAAM scores was 19. The VR-12 median score was also 19 with the following breakdown: Physical Component – 30, Mental Component – 67.

Conclusion:

Results from the FAAM indicate that patients with midfoot Charcot are severely disabled overall, moderately disabled with activities of daily living, and mostly unable to participate in sport. Results from the VR-12 indicate that patients continue to have poor healthcare quality of life, even following Charcot reconstruction. Midfoot Charcot reconstruction with intramedullary beaming allows for restoration of an ulcer-free, plantigrade foot in most patients, but the complication rates are high, especially in patients with pre-operative ulceration. Despite a low bony union rate, improvement in the lateral Meary’s angle and clinical success is often obtainable with a relatively low amputation rate.
Total Ankle Arthroplasty
Authors: Francis Ara , Flavin Robert , Mohammed Khalid Merghani Saleh , Aljabi Yasser
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Total Ankle Arthroplasty has been introduced relatively late in the modern era in comparison to hip and knee replacement. it suffered from poor outcomes initially leading to abandonment of the procedure in favour of ankle arthrodesis. The reasons for failure have been debated in the literature. The development of second generation implants, consisting of a three component design, has heralded a new era for Total Ankle Arthoplasty. The purpose of this study was to perform a biomechanical analysis of three commercially available Total Ankle Arthroplasty implants and a literature review to shed light on mechanisms of failure.

Methods:

Three commercially available ankle arthroplasty (STAR, Hintegra, Mobility) implants were tested using a specifically designed ankle simulator which replicated plantarflexion/ dorsiflexion and inversion/eversion movements. Different loads were applied to the implants which were put through 50,000 cycles at a rate of 1.4 Hz and bearings were removed for inspection. The followoing were conducted before, during and after testing - Visual inspection, Weight of implant, Optical Profile Projector and Scanning Electron Microscopy. A literature review was also performed to compare and contrast results seen elsewhere.

Results:

Biomechanical analysis revealed loss of congruency and wear of the polymer bearing surfaces with varying degrees across the three implants - STAR 7%, Hintegra 10% and Mobility 4%. This is supported by evidence in the literature that STAR and Hintegra implants suffer considerably from flattening of the polymer bearing surfaces and subsequent decrease in height.

Conclusion:

The above biomechanical analysis and literature review of these implants supports our senior author’s clinical experience that the main reason for failure is medial insufficiency and tibialis posterior dysfuction that cause increased demand on the implants ultimately leading to implant failure.