bluuebunny/crossref_metadata_2025 huggingface dataset:
Safety and Cost-Efficacy of Surgical Fixation of Isolated Ankle Fractures in a Free-Standing Ambulatory Surgical Center (ASC) vs. Hospital-Owned Outpatient Facility (HOPD)
Authors: Malik Azeem Tariq , Khan Safdar N , Quatman Carmen E , Ly Thuan V , Phieffer Laura
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Free-standing Ambulatory Surgical Centers (ASCs) typically provide uncomplicated surgical procedures in a non-hospital setting, and function as ‘focused factories’ that replicate the delivery of quality care while achieving lower costs as compared to hospital-owned outpatient facilities (HOPD). Despite an increasing interest towards outpatient foot and ankle surgery, few studies have compared the safety and cost-savings associated with surgical fixation of isolated ankle fractures in a free-standing ASC vs. a HOPD.

Methods:

The 2007-2014 Humana Administrative Claims (HAC) database was queried using Current Procedural Terminology codes to identify patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (27766, 27769, 27792), bi-malleolar (27814) and tri-malleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee or tibia were removed from the study to capture a relevant cohort of isolated ankle fracture patients. Location of surgery was identified using Service Location codes 22 (HOPD) and 24 (ASC). Propensity- score matching and multi-variate regression analyses were used to compare differences in 90-day complications, ED-visits and readmissions between the two groups. A 90-day cost comparison was also carried out to assess savings associated with surgery in an ASC vs. HOPD.

Results:

A total of 4,832 (80.1%) ankle fractures treated in a HOPD and 1,198 (19.9%) in a free-standing ASC were included in the study. Following propensity-score matching to account for differences in baseline demographics and clinical characteristics, each group consisted of 1,138 patients. Following multi-variate analyses, undergoing surgery in a free-standing ASC vs. a HOPD was not associated with a higher rate of 90-day complications (0.73 [95% CI 0.54 -1.00]; p=0.05), ED visits (OR 0.86 [95% CI 0.64- 1.16]; p=0.331) and readmissions (0.79 [95% CI 0.53 -1.18]; p=0.251). Furthermore, undergoing surgery in a free-standing ASC was associated with nearly $2500 cost-savings/case over the 90-day episode of care (ASC = $8,058 vs. HOPD = $10,619; p<0.001).

Conclusion:

Using national administrative claims of Commercial insurance beneficiaries, the results of the study show that performing surgical fixation of ankle fractures in a free-standing ASC is a safe and cost-effective option in a carefully selected patient population.
The Retrograde Drilling for Osteochondral Talar Lesion in Children
Authors: Minokawa So , Yoshimura Ichiro , Kanazawa Kazuki , Hagio Tomonobu , Yamamoto Takuaki
Published: October 2019

Category:

Ankle, Arthroscopy

Introduction/Purpose:

Osteochondral talar lesions (OCL) are infrequent in children, and little is known about the treatment and clinical outcome of these defects. Clinicians normally first attempt nonoperative treatment of these lesions, but if such treatment fails, surgical many treatments including retrograde drilling (RD), are attempted. RD is usually reserved for large OCLs with intact overlying cartilage. Good clinical outcomes have been reported in RD. However, the clinical outcomes of RD for OCL in children remains unclear. The purpose of this study was to evaluate the clinical and radiographic outcomes of RD in skeletally immature children.

Methods:

From January 2015 to April 2018, RD was performed on eight feet with OCL in six consecutive patients in skeletally immature children. Arthroscopic lateral ankle ligament repair was also performed in one of the eight feet, and one foot was excluded; therefore, we studied seven feet in five patients. The patients comprised three boys and two girls with a mean age at surgery of 11 (range, 9–12) years. All patients were followed for a minimum of 6 months postoperatively, the average follow-up was 19.1 (range, 8–39) months. All patients were grade 0, determined according to a modified Pritsch classification system. All patients were evaluated for Japanese Society for Surgery of the Foot (JSSF) scale and radiographic outcomes at preoperatively and postoperatively final follow up.

Results:

The average JSSF scale improved from 79.4 points (range, 69–90 points) to 100 points in all feet at final follow-up (p<0.01). The postoperative size of OCL using CT findings was improved than preoperative size. According to the postoperative computed tomography (CT) findings, four feet were good, three foot were fair. There were no incidences of postoperative complications.

Conclusion:

In our study, we suggest that RD for OCL in skeletally immature children is effective surgical treatment.
MRI Analysis for Clarification of Mechanism of Ankle Osteoarthritis: Prediction of Talar Lateral Process Impingement from X-Ray Findings
Authors: Mitsui Hiroyuki , Hirano Takaaki , Akiyama Yui , Endo Wataru , Karube Tomoko , Haraguchi Naoki , Niki Hisateru
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

We have previously elucidated the pathological condition of osteoarthritis (ankle OA) by MRI by examining the relationship between X-ray findings and bone marrow edema (BME) and found a relationship between talar lateral process impingement (TLPI) in the subtalar joint and the incidence of BME in the talocrural joint as well as found an association of these MRI findings with clinical symptoms. In the present study, we focus on the three talar movements inversion, dorsiflexion, and forward displacement to report on our survey of X-ray findings involved in occurrence of TLPI.

Methods:

We examined MRI imaging for 70 feet of 68 cases, which has diagnosed ankle OA in our hospital. X-ray measurements of the movement of the talus regarding the TMM, TBM, TTA, LTMT, and LTC angles as well as the T-T ratio(refer to the figure) were obtained. The incidence of BME on MRI was calculated after dividing the talus, the subtalar joint, and Chopart’s joint into 22 regions; cases where BME was observed in the talar lateral process were defined as TLPI (+). For statistical analysis, the study sample was divided into two groups depending on the presence/absence of TLPI, which their respective incidences of BME and values of X-ray measurement were compared using a t-test. Furthermore, for values in which significant differences were observed, cut-off values were obtained from the ROC curve, and the factors that were most independently involved in the incidence of TLPI were identified using multivariate analysis.

Results:

On comparing the groups with the presence or absence of TLPI, the incidence of BME occurring at a region other than the lateral process was significantly higher in the TLPI (+) group, and significant differences were found for all values of X-ray measurement except for T-T Ratio. The multivariate logistic regression analysis with cut-off values at TMM = 46° or more, TBM = 77° or less, TTA = 4° or more, LTMT = 8° or more, and LTC = 35° or less demonstrated that LTC (odds ratio: 4.22, 95% CI: 1.28–14.0, p = 0.02) and TMM (odds ratio: 3.44, 95% CI: 1.12–10.6, p = 0.03) were significantly involved in the incidence of TLPI.

Conclusion:

Results of this study have led to the speculation that the incidence of TLPI is closely related to the positional relationship of the peripheral opening of the medial malleolus and the talocalcaneal bone as well as to the varus and dorsiflexion of the ankle joint. These new findings could be used as a new index to predict the incidence of TLPI.
Landmark Technique vs Ultrasound Guided Approach for Posterior Tibial Nerve Block in Cadaver Models
Authors: Morris Sara Elizabeth , McKissack Haley , Moraes Leonardo V. M. , Viner Gean C. , Jones James R. , Tedder Chandler , Kukreja Promil , Chinnakkannu Karthikeyan , Jha Aaradhana J. , Shah Ashish B.
Published: October 2019

Category:

Ankle, Basic Sciences/Biologics

Introduction/Purpose:

Until recently, many regional anesthetic blocks were performed without the assistance of ultrasound, relying on methods such as anatomical landmarks and nerve stimulation. The use of ultrasound for peripheral nerve blocks has proven extremely useful for improving the efficacy of many regional anesthetic techniques. There remain a few nerve blocks which have lagged in employing the assistance of ultrasound consistently, one of which is the ankle block. This block is commonly utilized for either surgical anesthesia or post-operative analgesia for a variety of foot and ankle procedures. In this study, we compared the accuracy of traditional landmark technique with an ultrasound guided approach for ankle block by assessing the spread of injectate (dye) along the posterior tibial nerve (PTN) in cadaver models.

Methods:

Ten below-knee cadaver specimens were used for this study. Five were randomly chosen to undergo landmark guided PTN blocks, and five were selected for ultrasound-guided PTN blocks. The landmark technique was performed by identifying the medial malleolus and Achilles tendon and inserting the needle (4 cm long, 21G Braun® Stimuplex) at the midpoint of the two structures, aiming toward the medial malleolus and advancing until bone was contacted. 2 cc of blue acrylic dye was injected at this location. The ultrasound technique was performed with a linear probe identifying the medial malleolus and the PTN. The needle was advanced in-plane with a posterior to anterior trajectory until the tip of the needle was adjacent to the nerve. 2 cc of blue acrylic dye was injected surrounding the nerve. The extremities were then dissected to determine which nerves had been coated with dye.

Results:

100% of the ultrasound guided blocks resulted in completely stained PTN with dye. In the landmark group, only 40% of the landmark technique blocks resulted in completely stained PTN with dye. Of the nerves not stained with dye, 2 were noted to have had dye injected posterior to the nerve and 1 was noted to have had dye injected into the flexor digitorum longus tendon.

Conclusion:

The base of evidence has dramatically increased in recent years in support of the use of ultrasound in regional anesthesia. This study substantiates the superiority of ultrasound guidance for ankle block by demonstrating a 100% success rate amongst the ultrasound guided group.
Fixation Technique Using PLLA Pins Gives Good Clinical Results Regardless of Bone Condition in Osteochondral Lesion of Talar Dome
Authors: Nakasa Tomoyuki , Ikuta Yasunari , Tsuyuguchi Yusuke , Ota Yuki , Kanemitsu Munekazu , Adachi Nobuo
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Osteochondral lesion of the talus (OLT) has various treatment options which are chosen depending on the stage, size and cartilage condition. The fixation technique can restore the natural congruency with the hyaline cartilage. However, it is not clear whether a bone condition such as the disruption of the subchondral bone plate will affect the clinical results after the fixation of the osteochondral fragment. We hypothesized that even if the subchondral bone plate were disrupted, if the articular cartilage condition in the osteochondral fragment were good, then the clinical results of the fixation technique would be good. The aim of this study was to explore whether the fragment’s bone condition affects clinical outcomes including second look arthroscopy.

Methods:

Eighteen ankles in 17 patients, which had undergone the fixation technique using poly-L-lactide (PLLA) pins, were included. The mean follow-up period was 18.8±8.9 months. They consisted of 10 males and 7 females, with a mean age of 20.1±10.1 years. Based on the fragment’s bone condition on preoperative CT, ankles were divided into 3 groups; normal, segmentation, and absorption groups. The American Orthopaedic Foot & Ankle Society (AOFAS) score were evaluated both pre and post surgery. On MRI, the BME area was measured, and stability, incorporation, subsidence, and the surface of the articular cartilage of the fragment were evaluated. Second look arthroscopic findings were evaluated in 13 ankles. The repair of OLT was assessed according to the criteria of the ICRS which are allocated for the degree of filling defect by repair tissue, integration, and surface appearance of the repair site.

Results:

The AOFAS score before surgery significantly improved from 72.1±2.8 points to 98.6±3.3 points at the final follow-up in all ankles. In each group, the AOFAS score improved and there were no significant differences in AOFAS score among the 3 groups at final follow-up. MRI at 1 year showed good incorporation and cartilage surface in all groups, but the bone marrow lesion in the absorption group was significantly larger than that in the other groups. In the second look arthroscopic findings, the ICRS scale for the normal, segmentation, and absorption groups produced 10.6±1.7 points, 9.8±1.9 points, and 10.7±1.2 points, respectively.

Conclusion:

Good clinical results including those of second look arthroscopy for osteochondral fragment fixation using PLLA pins in OLT were obtained, even in the case of disruption of the subchondral bone plate. Since the fixation procedure can restore the native contour of the articular cartilage surface, this surgical procedure is a viable option for large OLT lesions regardless of bone condition in the osteochondral fragment.
New Model Foot and Ankle Service Pathway: Pilot Results 2 Years
Authors: Nicolas Andrea Pujol , Ramaskandhan Jayasree Ramas , Siddique Malik
Published: October 2019

Category:

Service improvement

Introduction/Purpose:

The foot and ankle services at NUTH incorporates both elective and trauma services. The elective service carries out on average 10,500- 11,000 review appointments/ year and 4000-4500 new patient appointments/year. The waiting times for new out-patient appointments were 8-14 weeks. A new pathway was designed with the aim to improve 18 week national target compliance, improve departmental efficiency, and improve patient satisfaction.

Methods:

A new initial assessment clinic pathways was designed were all new patients are seen in a one hour slot one stop clinic by a dedicated Extended Scope Practitioner. History and clinical examination are taken as well as initial Proms questionnaire, x-ray assessment followed by gate analysis including pain map, treadmill assessment and plantar pressure analysis. A consultant led MDT review of the finding is performed the same week where plan for treatment or further investigations is formulated.

Results:

A total of 1792 patients had the initial assessment through the new clinic pathway between March 2016 and March 2018. The average waiting time for the initial assessment has been gradually reduced from 14 to 3 weeks. We obtained over 96% patient satisfaction in enhancing patient experience.

Conclusion:

Our new clinic model has shown to improve efficiency, patient satisfaction and reduce waiting times.
An Anatomic Approach for Intramedullary Screw Fixation of Fifth Metatarsal Fracture: A Clinical and Radiographic Study
Authors: Niu Shuo , Mirza Faris , Schwartz Andrew , Labib Sameh
Published: October 2019

Category:

Ankle, Sports, Trauma

Introduction/Purpose:

Intramedullary screw fixation is the most common surgical intervention for treating Jones fractures and diaphyseal stress fractures of the fifth metatarsal. Proper screw placement is paramount to surgical success. There have been studies describing more traditional antegrade and retrograde approaches, dependent upon fluoroscopy and guidewires. However, we propose a novel, more efficient surgical approach that utilizes anatomical landmarks and plantarflexion angle during screw fixation. The purpose of this study was to evaluate screw position and radiographic healing parameters, return to sport, and patient-reported outcome measures after utilization of our technique for screw fixation of the fifth metatarsal fracture.

Methods:

This is a retrospective review from 2007 to 2017 of clinical records and radiographs of 31 consecutive patients who had fifth metatarsal fracture open reduction internal fixation using anatomical landmarks and plantarflexion angle (Johnson, Labib and Fowler 2004). The classification of the fracture, surgery time, time to union, and post-operative complications were collected. Return to sport, Tegner score, the Foot and Angle Disability Index (FADI) Sports Module, and the Short Form 12 Physical and Mental Health Composite Scale (SF-PCS/MCS) were obtained through phone interview. Post-operative X-ray analysis, including screw position and bone healing percentage, were evaluated. Post-operative screw position was described as either center-center, oblique, or cortical breach on anteroposterior, lateral or oblique view. Fisher’s exact test was used to determine the difference among frequencies of each screw position. P<0.05 was considered significant.

Results:

Patient and surgical information were shown in Table 1. Average post-operative follow-up was 98 (36-227) days. Screws were well center-center positioned at all three views on post-op X-ray in most cases (all p<0.001). No case showed the screw protruding into tarsometatarsal joint or cuboid impingement. Average phone interview follow-up was 5.4 (1.0-11.1) years. Tegner scores showed no difference (p=0.58) when compared between pre-injury (6.4) and current level (6.1). At the terminal follow-up, average FADI-sports was 87.2 (37.5-100), SF-PCS was 50.7 (27.3-55.6), and SF-MCS was 59.7 (52.9-67.2). In addition, 12 of 15 (80%) the college or professional athletes (1 lost to follow-up) returned to the same level sports after the surgery.

Conclusion:

This study quantified the benefit of a novel technique for intramedullary screw fixation of fifth metatarsal fracture that was reliable and reproducible. It facilitated accurate screw positioning, dependable union, and accompanying positive return to sport and patient-reported outcome measures.
A New Minimally Invasive Technique for Achilles Tendon Repair in the Supine Position
Authors: O’Donnell Seth , Velasco Brian , Whitehouse Brianna , Kwon John Y. , Miller Christopher P.
Published: October 2019

Category:

Tendon

Introduction/Purpose:

Achilles tendon repairs are a common procedure that, historically have been plagued by complications. Recent advanced in both operative and non-operative techniques have changed the landscape for this procedure. Minimally invasive approaches have become far more common which have improved outcomes by decreasing the risk of wound complications. However, a further limiting factor is the traditional need to place the patient prone. This requires higher levels of anesthesia and careful positioning of the extremities. We present a technique that eliminates the need for prone position while maintaining the advantages of a minimally invasive approach.

Methods:

The authors present a novel surgical technique to repair the Achilles tendon. The patient is maintained in the supine position on the pre-operative stretcher. The leg is externally rotated. A direct medial incision is made at the rupture site and the tendon is repaired by passing suture percutaneously through the eyelets of a bent ring forcep and delivered into the wound. This is performed proximally and distally and then the sutures are tied together to complete the repair. Clinical case time, wound complications and short term outcomes will be reported.

Results:

6 patients results will be presented including operative case times which average 57 minutes from the time the patient enters the room until they exit the room and arrive in PACU. This represents a decrease of nearly 30 minutes of OR time required for intubation and prone positioning. 4/6 of the patients received only MAC anesthesia and a nerve block with no tourniquet. The first two patients had general anesthesia with an LMA. 6 month PROMIS and FAAM scores will be obtained but are not available at the time of abstract submission.

Conclusion:

We present a novel technique to repair an Achilles tendon with the patient in the supine position. The technique is reliable and can be performed with a minimal learning curve. The operative case times are faster as the patient is kept on their recovery stretcher and do not need to be positioned prone. This decreases the amount of anesthesia required for the surgery as well. The authors believe that eliminating prone positioning will be both safer for the patient and results in a faster surgery without compromising outcomes.
Effectiveness of the Saline Load Test in Diagnosis of Traumatic Ankle Arthrotomies in Varying Arthrotomy Locations
Authors: Ohliger Erin , Miniaci-Coxhead Sara Lyn
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

The purpose of this study was to investigate the amount of fluid required and the sensitivity of the saline load test to identify an intra-articular arthrotomy of the ankle. Limited prior studies have been conducted in arthroscopic models with proposed volumes ranging from 30 ml to 60 ml. Due to this range it was inferred that volume needed to detect arthrotomy would vary based on site of arthrotomy. Using cadavers without prior ankle trauma or surgeries we aim to assess volume needed to detect ankle arthrotomies at varying arthrotomy locations.

Methods:

A cadaveric study was conducted using 20 thawed, fresh-frozen below knee amputations. Cadavers were randomly divided into four groups of five and an ankle arthrotomy was made using a 4 mm trochar at standard ankle portal sites; anteromedial, anterolateral, posteromedial, and posterolateral. To confirm intra-articular location, a scope was inserted for direct visualization. A 18-gauge needle was then inserted into the anteromedial portal, except for the anteromedial arthrotomy where the needle was inserted into the anterolateral portal, and saline mixed with methylene blue was loaded into joint. During the injection, the known arthrotomy site was viewed for extravasation. Amount of saline required to diagnose arthrotomy was recorded. All injections were confirmed as intra-articular by demonstrating methylene blue staining of the anterior joint by open exploration.

Results:

The saline volume required to achieve extravasation ranged from 3 mL to 11 mL. The median saline volume required to achieve extravasation was 5.3 mL. A total of 8 mL was required to achieve 90% sensitivity, 10 mL for 95% sensitivity and 11 mL for 99% sensitivity. For the anterolateral, anteromedial, posteromedial, and posterolateral arthrotomy sites the median saline volume needed to detect a traumatic arthrotomy was 5.2 ml, 6.2 ml, 5 ml, and 4.8 ml respectively. There was no statistically significant difference in volume needed to detect arthrotomies across all four locations.

Conclusion:

A minimum injection of 10 mL is recommended to identify 95% of traumatic arthrotomies approximately 4 mm in size. Prior studies performed in arthroscopic models with prior ankle pathology may overestimate volume needed to detect arthrotomies. No difference in volume needed to detect extravasation was found across all four arthrotomy locations.
Tibiotalar Joint Contact Mechanics Following Syndesmosis Fixation with Screws Versus a Flexible Fixation Device (TightRope™)
Authors: Pang Eric , Bedigrew Katherine , Behn Anthony , Chou Loretta , Hunt Kenneth , Palanca Ariel
Published: October 2019

Category:

Ankle, Arthroscopy, Trauma

Introduction/Purpose:

Background: A shift and increase in mean tibiotalar contact pressure has been demonstrated in simulated syndesmotic injuries. The effect of screw fixation and/or suspensory fixation on restoration of pressure mechanics in the setting of a syndesmotic injury remains largely unknown.

Hypothesis/Purpose:

The purpose of this study is to examine the contact mechanics of the tibiotalar joint following syndesmosis fixation with screws versus a flexible fixation device for complete syndesmotic injury.

Methods:

Six matched pairs of cadaveric below knee specimens were randomly assigned fixation with either two 3.5 mm cortical screws or two TightRopes™ (Arthrex). Motion capture trackers were fixed to the tibia, fibula, and talus and a pressure sensor was placed in the tibiotalar joint. Each specimen was first tested intact with an axial compressive load followed by external rotation torque while maintaining axial compression. The syndesmosic ligaments were then completely sectioned and subsequently repaired with either two TightRopes™ or two screws and the protocol was repeated. Mean contact pressure (MCP), peak pressure (PP), reduction in contact area (CA), translation of the center of pressure (COP), and relative talar and fibular motion were calculated. Specimens were then cyclically loaded in external rotation to failure. Comparisons were made using paired t-tests and/or Welch’s t-tests.

Results:

No differences in MCP, PP, or CA were observed between the intact and instrumented states during AL alone for either group. MCP relative to intact testing was increased in the screw group at 5 Nm (4.8±4.1 MPa vs 3.6±0.8 MPa, p=0.033) and 7.5 Nm torque (6.2±1.4 MPa vs 4.2±1.2 MPa, p=0.024). Likewise, PP was increased in TightRope™ group at 7.5 Nm torque (14.4±3.1 MPa vs 10.8±1.6 MPa, p=0.046). There was no change in COP in the TightRope™ group at any threshold; however, at every threshold tested there was significant medial and anterior COP translation in the screw group relative to the intact state.

Conclusion:

Either screws or TightRope™ fixation is adequate with AL alone. With lower amounts of torque, the TightRope™ group exhibits contact and pressure mechanics that more closely match native mechanics.
A Suspicious Atypical Fracture of 5th Metatarsal Bone: A Case Report
Authors: Park Byeong-Seop , Koo Seungbum , Park Won-keun , Kwon Ki-bum , Lee Kyoung Min
Published: October 2019

Category:

Trauma

Introduction/Purpose:

Long-term usage of bisphosphonate can severely suppress bone turnover and alter bone mechanical properties, thereby resulting in atypical fractures that mainly occur at the femur.We present a rare case of suspicious atypical fracture of the metatarsal bone.

Methods:

A 63-year-old woman presented to our clinic with a primary complain of a one-week history of pain in her right foot. The patient had no history of trauma to the right foot and denied any strenuous activity. She experienced lateral foot pain while walking within her home. She was on alendronate therapy for osteoporosis for a decade. X ray and CT examination revealed a fifth metatarsal fracture whose features were compatible with those of atypical femoral fractures (Figure 1).

Results:

The patient was advised to discontinue alendronate and underwent percutaneous surgical fixation of the fracture via a proximal approach using a 4.0-mm half-threaded cannulated screw. Postoperatively, a short leg cast was created and the patients performed non-weight bearing ambulation until the cast was removed at the sixth postoperative week. Radiography in the sixth postoperative week revealed callus formation.

Conclusion:

Our findings suggest that physicians must keep in mind that atypical fractures could possibly occur at bones other than the femur.
Opposite Association Between Radiographic Lateral Ankle Instability and Osteochondral Lesions of the Talus in Patients with Ankle Inversion Injuries
Authors: Park Byeong-Seop , Koo Seungbum , Park Won-keun , Kwon Ki-bum , Lee Kyoung Min
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Insufficient bony coverage surrounding the talus could cause considerable mechanical ankle instability, whereas excessive bony coverage could cause bone contusion at the time of injury and subsequent osteochondral lesions of the talus (OLT). This study aimed to investigate the relationship between radiographic lateral ankle instability and OLT in patients that sustained ankle inversion injuries.

Methods:

One-hundred-ninety-five patients (113 men and 83 women; mean age, 38.7 years; standard deviation, 8.8 years) with a history of ankle inversion injuries were included. All patients underwent ankle magnetic resonance imaging (MRI) and stress X-ray (varus stress and anterior drawer) examination. The tibiotalar tilt angle on varus stress X-ray, anterior translation of the talus on anterior-drawer lateral X-rays, bimalleolar tilt angle, and fibular position were radiographically determined. The anatomical grade of the lateral ankle ligament injury and the presence of OLTs were determined from MRI findings.

Results:

A greater lateral ankle ligament grade tends to increase the tibiotalar tilt angle (p=0.074), significantly affecting the anterior translation of the talus (p=0.036). The presence of radiographic lateral ankle instability (tibiotalar tilt angle =10°) showed opposite associations with the presence of OLT in the chi-square test (p=0.003). OLT was a negative significant factor (p=0.011) affecting the tibiotalar tilt angle in the multiple regression analysis (Table 1) and was negatively affected by the tibiotalar tilt angle (p=0.016) in the binary logistic regression analysis.

Conclusion:

This study showed an opposite association between lateral ankle instability and the development of OLT following ankle inversion injury. The role of bony predisposition in the development of sports injuries in the ankle should be considered and investigated further.
The Assessment of Reduction Status Using Radiographic Parameters and Ideal Trans-Fixation Technique for Unstable Syndesmotic Injury with Ankle Fracture
Authors: Park Chul-Hyun , Song Kwang-Soon , Kim Beom-Soo , Choi Jung-Hoon , Kwon Hyuk-Jun , Hee Son-Young
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Anatomical restoration of distal tibiofibular syndesmosis is essential in ankle fractures with syndesmotic injury. However, intraoperative reference line of penetrating angle and evaluation of reduction status remains without consensus. The purpose of this study is to analyze the reduction status of syndesmotic injury using radiographic parameters and to find ideal fixation angle treated with trans-fixation in unstable syndesmotic injury.

Methods:

Twenty-six patients with ankle fractures with syndesmotic injury that underwent preoperative and postoperative bilateral computed tomography (CT) scans were enrolled. A multi-center study was performed in two tertiary medical centers. All patients were treated with tibiofibular trans-fixation screw or tight rope® fixation. The axial sections of bilateral CT scans were reviewed to measure Fibular Diastasis (FD) and Surface Area of Syndesmosis (SAS) at the level of 1.0 cm above ankle joint. Reduction status was measured by calculating the ratio of postoperative and intact side using radiologic parameters. The trans-fixation angles between the perpendicular line of incisura and distal trans-fixation material was measured. Patients were classified by trans-fixation angle into three groups, as showing 0 -1 degree (A), 1-5 degree (B), 5 or more degree (C) in absolute value.

Results:

The mean value of reduction status ratio was 1.13 in FD and 1.27 in SAS. The absolute mean value of trans-fixation angle was 4.11°. Trans-fixation angle and reduction status had positive correlation in FD (R = 0.522, p = 0.006) and SAS ratio (R = 0.695, p = 0.000). The absolute mean value of trans-fixation angle in group A, B, C was 0.56° (7 cases), 3.01° (12 cases), and 8.90° (7 cases). The mean value of FD ratio in group A, B, C was 1.01, 1.03 and 1.41. FD and SAS ratio had no difference between group A and B but had significant difference between group A, B and C (p < 0.05).

Conclusion:

Inappropriate trans-fixation technique had correlated with the loss of reduction after treatment of unstable ankle fracture associated with syndesmotic injury. An angle of 5° from the perpendicular line of the incisura is considered as the ideal trans-fixation angle to maintain the reduction status.
Survivorship and Long-term Results of Consecutive Series of 118 Hintegra Total Ankle Arthroplasties
Authors: Park Jae Han , Hwang Yeok Gu , Kwon Jae Bum , Shim Dong Woo , Park Kwang Hwan , Han Seung Hwan , Lee Jin Woo
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

Total ankle arthroplasty (TAA) has been more suggested to patients with end-stage ankle osteoarthritis. However, there were few studies which had investigated long-term clinical outcomes with mobile bearing system. The purpose of this study is to evaluate the long-term outcomes of total ankle arthroplasty with use of the Hintegra prosthesis and to identify prognostic factors that affect the outcome.

Methods:

Between September 2004 and December 2009, 118 ankles underwent total ankle arthroplasty with Hintegra prosthesis. Clinical outcomes were assessed annually after operation using visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) scores, plain radiographs and re-operation. Kaplan-Meier survival plot showed survival outcomes of TAA in long-term follow-up.

Results:

The mean follow-up period was 10.9 years (range 9.0-14.3). The mean change from baseline to final follow-up was -6.7 ± 4.3 points for VAS, and 26.1 ± 10.3 points for the AOFAS score. Three (2.5%) of the ankles required metal component revision at a mean of 2.9 ± 1.8 years (range, 0.5 to 5.8 years) after primary surgery. Five (4.2%) ankles underwent conversion to arthrodesis. Cystic osteolysis that needed surgery was 19 (16.1%) cases, most frequent lesion was posterior aspect of distal tibia. 65 ankles (55.1%) showed heterotopic ossifications but the degree of heterotopic ossification was not significantly correlated with VAS and AOFAS score. Revision with metal component as the end point of prosthesis was 86% at 10 years of follow up.

Conclusion:

Long term outcomes were satisfactory after mobile-bearing total ankle arthroplasty. Further study to elucidate possible reasons for osteolysis and subjective pain after TAA is warranted.
Increasing Values of the Lateral Talar-First Metatarsal Angle Preoperatively Predict Spring Ligament Attenuation in Adult Acquired Flat Foot Deformity
Authors: Pate Matthew , Hall Jacob , Albright Patrick , Bohay Donald , Anderson John , Roberts Justin
Published: October 2019

Category:

Ankle, Hindfoot, Trauma

Introduction/Purpose:

Adult acquired flat foot deformity (AAFD) is responsible for numerous adult foot and ankle deformities, and spring ligament damage has been implicated in the pathology of AAFD. Treatment of AAFD may involve attempts to address spring ligament incompetency, and preoperative knowledge of spring ligament integrity would be valuable in planning for such procedures. To our knowledge, there have been no attempts to correlate preoperative radiographs with direct intraoperative evaluation of spring ligament competency. This study aims to examine the relationship between preoperative radiographic measures specific to flatfoot deformity and intraoperative competency of the spring ligament during flatfoot reconstruction in order to find radiographic measures predicting spring ligament attenuation.

Methods:

The operative reports of 3 fellowship trained orthopaedic foot and ankle surgeons were searched over a 5-year period from 2012-2017. Patients with pre-operative standing AP and lateral radiographs along with an operative report directly visualizing and commenting on spring ligament integrity were included in the study. Investigators reviewed operative reports to identify patients with spring ligament tears and evaluated pre-operative radiographs. Five common radiographic parameters were measured: lateral talar-first metatarsal angle, AP talar-first metatarsal angle, talonavicular coverage angle, talonavicular coverage percentage, and calcaneal pitch. Chi-square and logistic regression analysis were used to evaluate the five radiographic parameters for association with spring ligament tear.

Results:

The study enrolled 58 patients with 29 patients having confirmed spring ligament tears and 29 patients having an intact spring ligament. Increasing values for each of the 5 radiographic measures were statistically significant predictors for spring ligament tear on univariate analysis (p=0.001) with the lateral talar-first metatarsal angle being the most significant predictor for spring ligament tear (p<0.001). On logistic regression analaysis, LT-1st angle was a significant predictor of spring ligament tear (p<0.001). A lateral talar-first metatarsal angle =30 degrees had a sensitivity and specificity of 65% and 100% for spring ligament attenuation. The positive predictive value of spring ligament tear with a lateral talar-first metatarsal angle =30 degrees was 100% and the negative predictive value was 74%.

Conclusion:

This study is the first to correlate preoperative radiographs with direct visualization and evaluation of spring ligament competency. Increasing severity of common radiographic measures of flat foot deformity, particularly the lateral talar-first metatarsal angle, correlate significantly with spring ligament tear and may assist surgeons in planning appropriate preoperative interventions.
Radiographic Outcomes of Plate vs Screw Constructs in Open Reduction and Internal Fixation of Calcaneus Fractures via the Sinus Tarsi Approach
Authors: Pitts Charles , Almaguer Adam , Wilson Jack , Johnson Michael
Published: October 2019

Category:

Hindfoot, Trauma

Introduction/Purpose:

Intra-articular fractures of the calcaneus are a common injury to the hindfoot following high energy trauma to the lower extremity. Treatment of these fractures has evolved. Due to the concern of wound complications associated with extensile open treatments, smaller incision techniques, such as the sinus tarsi approach, are increasing in popularity. A number of fixation strategies are utilized with this approach, and it is unknown which most accurately restores radiographic alignment. The purpose of this study is to compare the postoperative radiographic outcomes of a plate and screw construct versus a cannulated screw construct when using the sinus tarsi approach for open reduction and internal fixation (ORIF) of calcaneus fractures.

Methods:

After IRB approval, records for all patients treated surgically at our institution for calcaneus fractures from 2012 to 2017 were reviewed. Inclusion criteria were intra-articular calcaneus fractures, patients aged 18 years or older, and use of the sinus tarsi approach. Exclusion criteria were open fractures and clinical follow up less than 6 weeks. A total of 51 fractures underwent ORIF using cannulated screws alone (Group 1), and 23 fractures underwent ORIF using a sinus tarsi plate (Group 2). The primary outcomes of interest included pre- and postoperative Bohler and Gissane angles, wound complications, and unplanned return to OR.

Results:

There was no statistically significant difference between preoperative Bohler angles for Group 1 (14.5 degrees) versus Group 2 (12.3 degrees) (p=0.35), nor was there a significant difference between postoperative Bohler angles between Group 1 (30.1 degrees) and Group 2 (27.0 degrees) (p=0.09). Similarly, preoperative Gissane angles for Group 1 (128.4 degrees) and Group 2 (134.5 degrees) (p=0.17) and postoperative Gissane angles for Group 1 (116.7 degrees) and Group 2 (118.8 degrees) (p=0.44) showed no statistically significant difference. There were a total of 3 wound complications in Group 1 versus 2 wound complications in Group 2 (p=0.76). There was no statistically significant difference in operative duration (p=0.97) or the number of unplanned returns to the OR between the two groups (p=0.77).

Conclusion:

When comparing the cannulated screw and plate and screw fixation techniques, there was no difference in restoration of the Bohler and Gissane angles. Both techniques had similar rates of postoperative complications and return to the OR. Our data suggests that fixation using cannulated screws alone versus sinus tarsi plate provide similar radiographic outcomes and risk of complications. The two techniques are also similar in terms of implant costs. Our results indicate that either technique effectively improves radiographic parameters.
The Prevalence and Clinical Significance of FHL Tears in Athletes with Posterior Ankle Impingement Surgery
Authors: Porter David A , Rund Angela , Kulwin Robert , Walrod Madison
Published: October 2019

Category:

Ankle, Hindfoot, Sports

Introduction/Purpose:

Posterior ankle pain in the athlete is common and thought to be caused by Flexor Hallucis Longus (FHL) tendon tear/tendinopathy or Os trigonum syndrome. The association of flexor hallucis longus (FHL) pathology in conjunction with PAIS has not been described. The purpose of this study is to report the prevalence of FHL tears in athletes who undergo surgical treatment for PAIS. We also report the outcome of 36 athletes treated with FHL repair with PAIS surgery and compare them to 122 athletes undergoing PAIS surgery without FHL tears. The utility of advanced imaging, standardized outcome scores at standard post-operative time intervals, return to sport (RTS) and time to RTS were all evaluated in the 158 athletes.

Methods:

Our clinical database was searched for appropriate surgical codes, and patients from 1996 through March 2016 were retrospectively collected. Inclusion criteria included surgical treatment of PAIS, age between ten and 50, and participation in recreational or competitive athletics. Exclusion criteria included other injuries that could affect return to sport or recovery process. 158 patients met these criteria, (36 dancers, 122 non-dancers). Pre-operative imaging, operative records, dorsiflexion range of motion at six weeks and one year postoperatively, and time to return to sport are reported. AAOS Foot & Ankle, and Lower Limb Core Module (FALLC) scores were obtained (six weeks, three months, and one year post-operatively). Questionnaire data and functionality scores were compared between the two groups using two-sample Student t-tests. Categorical data outcomes were compared using chi-square tests or Fisher’s exact tests.

Results:

74/158 patients had magnetic resonance imaging (MRI) pre-operatively. 5/14 patients with an FHL tear had positive MRI suggesting an FHL tear, 9/14 patients with FHL tear had negative MRI (sensitivity of 0.26). FHL tears occurred in 36/158 (23%) of athletes with PAIS, 16/36 (44.4%) of dancers and 20/122 (16.4%) non-dancers. RTS did not differ between athletes with and without FHL tears, but time until RTS increased-average of 13.5 days (67.5 versus 81) with FHL repairs. Dancers with FHL tears reported increased foot pain and lower foot and ankle function at 3 months relative to those without tears. Scores were similar at one year.

Conclusion:

FHL tears in athletes undergoing surgical treatment for PAIS is 23% and in dancers can be as high as 44%. Pre- operative MRI has a poor sensitivity for FHL tears in this population. Concomitant FHL tear with repair during PAIS surgery does not decrease the rate of RTS or long term overall outcome. Overall, dancers have a higher rate of FHL tear at time of PAIS than non-dancers. FHL results in only a mild delay in RTS time. This is the first study to note FHL tear rate in association with PAI surgery.
Biomechanical Comparison of the Influences of Two Proximal Metatarsal Osteotomies on First Ray Articular Contact Characteristics
Authors: Reddy Sudheer C. , Li Jihui , Cuttica Daniel J. , Theiss Mark
Published: October 2019

Category:

Bunion

Introduction/Purpose:

Proximal metatarsal osteotomies are commonly employed to treat moderate to severe hallux valgus deformities. An understudied area with respect to these procedures is the effect on articular contact properties following the surgeries. Potential long-term risks include altered joint mechanics and possible arthritic progression. A biomechanical comparison of articular characteristics of the proximal opening wedge and Ludloff osteotomies was performed in this study. It is hypothesized that the proximal opening wedge osteotomy (POWO) would lead to greater alterations in articular contact properties along the first ray.

Methods:

Seven paired fresh-frozen below-knee cadaveric limbs with hallux valgus deformity were selected. The first ray inclusive of the navicular-medial cuneiform articulation was dissected and potted in resin. Specimens in each pair were tested in the intact state and then randomized to receive either a Ludloff or POWO. A 4 mm opening wedge osteotomy was used in all cases. The FHL was dissected and isolated. Testing was conducted in a customized apparatus with the cuneiform pinned to the apparatus and positioned at 10 degrees of declination. Loading of the FHL was conducted to 100 N utilizing an instrumented tensioner. A 28 N load was added at the distal phalanx to simulate the ground reaction force(Fig.1). First MTP and TMT articular properties were recorded simultaneously using two pressure sensors. For each state, a pressure map was generated and contact area, peak pressure and center of pressure were calculated.

Results:

Average peak pressure was noted to be elevated at the MTP (4.6 mPa vs 6.9 mPa, P = 0.08) and TMT (3.3 mPa vs 5.1 mPa, P = 0.16) joints when comparing the Ludloff and the POWO respectively, but was not significant. Contact area was also noted to be lower in the POWO vs Ludloff states for the MTP (86. 6mm2 vs 69.1mm2, P = 0.15) but not the TMT joints (89.1 mm2 vs 88.5mm2, P = 0.96). A trend towards decreased contact force within the TMT joint was noted following opening wedge osteotomy relative to the intact state (103.8 N vs 113.9 N, P = 0.31), while forces were elevated at the MTP joint (104.3 N vs. 96.0 N, P = 0.63), although not statistically significant.

Conclusion:

POWO can potentially change articular contact characteristics along the TMT and MTP articulations of the first ray. This could possibly lead to altered loading patterns and possible long-term arthritic progression versus other osteotomies. However, it is unlikely that the changes observed with the sizes of the osteotomy commonly used would lead to long term significant consequences.
Risk of Complications with the Total Contact Cast in Diabetic Foot Disorders
Authors: Riopelle Alexandria , LeDuc Ryan , Pinzur Michael S. , Schiff Adam P.
Published: October 2019

Category:

Diabetes

Introduction/Purpose:

The total contact cast is an important component of the clinical treatment algorithm for diabetic foot ulcers and Charcot Foot Arthropathy. Few studies have reported on the complications associated with this treatment modality.

Methods:

Over a ten year period, 2265 total contact casts were placed on 384 patients during their treatment for diabetic foot disorders. All of the casts were applied by a Certified Orthopaedic Technologist under the supervision of a University Faculty member. Complications were grouped as: (1) development of a new ulcer or wound, (2) new or increasing odor or drainage, (3) wound infection, (4) gangrene, (5) newly identified osteomyelitis, and (6) pain or discomfort necessitating cast change / removal. Complications were then associated with Hemoglobin A1C levels at the time of treatment.

Results:

Using this very stringent definition of a complication, ten percent of patients had some form of a complication. Most complications resolved following cast change or cast removal.

Conclusion:

The total contact cast has been demonstrated to be a valuable tool in the treatment of diabetic foot disorders. This retrospective chart review should serve as a valuable reference to assist clinicians when counseling patients during treatment for diabetic foot disorders.