bluuebunny/crossref_metadata_2025 huggingface dataset:
Quality of Cementation in Conventional versus Minimally Invasive Total Knee Arthroplasty
Authors: Ang Chia-Liang , Yeo Seng-Jin
Published: October 2016

Purpose.

To review the immediate postoperative radiographs of 108 patients following conventional or minimally invasive total knee arthroplasty (TKA) to assess the quality of cementation in terms of cement voids and retained cement.

Methods.

Records of 20 male and 88 female consecutive patients aged 50 to 83 (mean, 67.5) years who underwent conventional TKA (n=56) or computer-assisted minimally invasive TKA (n=52) for osteoarthritis by a single senior surgeon were reviewed. Immediate postoperative radiographs were assessed by a single blinded assessor for the quality of cementation in terms of cement void and retained cement in different zones of the femoral, tibial, and patellar components along the prosthesis-bone interface using the Knee Society total knee arthroplasty roentgenographic evaluation and scoring system.

Results.

The 2 groups were comparable in terms of baseline demographics as well as cement void and retained cement on the femoral, tibial, and patellar components, except that in the minimally invasive group, cement void beneath the anterior flange of the femoral component was wider (0.32 vs. 0 mm, p=0.001), and retained cement in the posterior or lateral aspects of the tibial component was more common (50.0% vs. 28.6%, p=0.018).

Conclusion.

Minimally invasive TKA resulted in a wider cement void beneath the anterior flange of the femoral component and a higher rate of retained cement around the tibial component.
Standard Preoperative Analgesia with or without Fascia Iliaca Compartment Block for Femoral Neck Fractures
Authors: Williams Huw , Paringe Vishal , Shenoy Shrisha , Michaels Phil , Ramesh Balasundaram
Published: October 2016

Purpose.

To compare the visual analogue score (VAS) for pain in patients with femoral neck fracture who received standard preoperative analgesia with or without fascia iliaca compartment block (FICB).

Methods.

In patients with femoral neck fracture, 69 patients who received standard preoperative analgesia (regular paracetamol 1g 4 times a day, codeine 60 mg 4 times a day, and opioid 10 mg 2 hourly as required) were compared with 50 patients who received standard preoperative analgesia plus FICB. VAS for pain at rest and on movement (hip flexion) was assessed before FICB and 15 minutes, 2 and 8 hours after FICB. The amount of additional opioid required and the incidence of opioid overdose (necessitating administration of naloxone) were determined.

Results.

VAS for pain was significantly lower after standard analgesia plus FICB than standard analgesia alone (p=0.001). The analgesic effect (pre-score minus post-score) of standard analgesia plus FICB did not differ between genders (p=0.57) or fracture patterns (p=0.79). 19 (38%) patients with standard analgesia plus FICB required no additional opioid analgesia. Compared with standard analgesia alone, addition of FICB reduced the mean dose of opioid from 6.2 to 2.0 (p=0.001) and the number of opioid overdose from 7.2% to 0% (p=0.001). No patient had any complication following FICB.

Conclusion.

In patients with femoral neck fracture, FICB reduced the need for additional opioid analgesia and avoided the risk of opioid overdose and respiratory depression.
Morbidity and In-Hospital Mortality after Hip Fracture Surgery on Weekends versus Weekdays
Authors: Kent Steven John , Adie Sam , Stackpool Gregory
Published: October 2016

Purpose.

To compare morbidity and in-hospital mortality in patients who underwent surgery for femoral neck fracture on weekends versus on weekdays.

Methods.

Records of 90 men and 225 women (mean age, 80.5 years) who underwent surgery for femoral neck fractures on weekends or public holidays (n=110) or on weekdays (n=205) were retrospectively reviewed. The morbidity and in-hospital mortality of the 2 groups were compared.

Results.

The 2 groups were comparable in terms of age, sex, and time to surgery, but more hemiarthroplasties were performed on weekdays (35.0% vs. 25.0%, p=0.036). Compared with surgery on weekdays, surgery on weekends was associated with increased in-hospital mortality (3.4% vs. 9.1%, p=0.04). None of the potential confounders (age, type of surgery, presenting hospital, and time to surgery) had a significant effect on in-hospital mortality.

Conclusion.

In patients with femoral neck fractures, surgery on weekends was associated with increased in-hospital mortality but not with increased morbidity after adjusting for confounders, compared with surgery on weekdays.
Screw Fixation versus Arthroplasty versus Plate Fixation for 3-Part Radial Head Fractures
Authors: Wu Pang Hung , Shen Liang , Chee Yu Han
Published: October 2016

Purpose.

To compare the outcome following headless compression screw fixation versus radial head arthroplasty versus plate fixation for 3-part Mason types III or IV radial head fracture.

Methods.

Records of 25 men and 16 women aged 21 to 80 (mean, 43.3) years who underwent fixation using 2 to 3 2-mm cannulated headless compression screws (n=16), radial head arthroplasty (n=13), or fixation with a 2-mm Synthes plate (n=12) for 3-part Mason types III or IV radial head and neck fracture were reviewed. Treatment option was decided by the surgeon based on the presence of associated injury, neurovascular deficit, and the Mason classification. Bone union, callus formation, and complications (such as heterotopic ossification, malunion, and nonunion) were assessed by an independent registrar or consultant using radiographs. The Mayo Elbow Performance Score and range of motion were assessed by an independent physiotherapist.

Results.

The median age of the 3 groups were comparable. Associated injuries were most common in patients with arthroplasty, followed by screw fixation and plate fixation (61.5% vs. 50% vs. 33%, p=0.54). The median time to bone union was shorter after screw fixation than plate fixation (55 vs. 86 days, p=0.05). No patient with screw fixation had nonunion, but 4 patients with plate fixation had nonunion. The 3 groups were comparable in terms of the mean Mayo Elbow Performance Score (p=0.56) and the mean range of motion (p=0.45). The complication rate was highest after plate fixation, followed by screw fixation and arthroplasty (50% vs. 18.8% vs. 15.4%, p=0.048). Excluding 20 patients with associated injuries (8 in screw fixation, 8 in arthroplasty, and 4 in plate fixation), the 3 groups were comparable in terms of the median time to bone union (p=0.109), mean Mayo Elbow Performance Score (p=0.260), mean range of motion (p=0.162), and complication rate (p=0.096).

Conclusion.

Headless compression screw fixation is a viable option for 3-part radial head fracture. It achieves earlier bone union with fewer complications.
Platelet-Rich Plasma versus Steroid Injection for Subacromial Impingement Syndrome
Authors: Say Ferhat , Gürler Deniz , Bülbül Murat
Published: October 2016

Purpose.

To compare the 6-week and 6-month outcome in 60 patients who received a single-dose injection of platelet-rich plasma (PRP) or steroid for subacromial impingement syndrome (SIS).

Methods.

22 men and 38 women (mean age, 49.7 years) opted to receive a single-dose injection of PRP (n=30) or steroid (n=30) for SIS that had not responded to conservative treatment for >3 months. The PRP or a mixture of 1 ml 40 mg methylprednisolone and 8 ml prilocaine was administered via a dorsolateral approach through the interval just beneath the dorsal acromial edge. Both groups were instructed to perform standard rotator cuff stretching and strengthening exercises for 6 weeks. The use of non-steroid anti-inflammatory drugs was prohibited. Patients were evaluated before and 6 weeks and 6 months after treatment using the Constant score, visual analogue scale (VAS) for pain, and range of motion (ROM) of the shoulder.

Results.

No local or systemic complication occurred. Improvement in the Constant score and VAS for pain at week 6 and month 6 was significantly better following steroid than PRP injection. The difference in the Constant score was greater than the mean clinically important difference of 10.4. Nonetheless, the 2 groups were comparable for improvement in ROM of the shoulder.

Conclusion.

Steroid injection was more effective than PRP injection for treatment of SIS in terms of the Constant score and VAS for pain at 6 weeks and 6 months.
Single versus Double Blade Technique for Skin Incision and Deep Dissection in Surgery for Closed Fracture: A Prospective Randomised Control Study
Authors: Trikha Vivek , Saini Pramod , Mathur Purva , Agarwal Abhinav , Kumar Senthil V , Choudhary Budhhadev
Published: October 2016

Purpose.

To compare blade cultures in surgery for closed fracture using a single or double blade technique to determine whether the current practice of double blade technique is justified.

Methods.

155 men and 29 women aged 20 to 60 (mean, 35) years who underwent surgery for closed fracture with healthy skin at the incision site were included. Patients were block randomised to the single (n=92) or double (n=92) blade technique. Blades were sent for bacteriological analysis. Outcome measures were early surgical site infection (SSI) within 30 days and cultures from the blades.

Results.

The 2 groups were comparable in baseline characteristics. In the single blade group, 6 surgical blades and 2 control blades showed positive cultures; 4 patients developed SSI, but only one had a positive culture from the surgical blade (with different organism isolated from the wound culture). In the double blade group, 6 skin blades, 7 deep blades, and 0 control blade showed positive culture; only 2 patients had the same bacteria grown from both skin and deep blade. Five patients developed SSI, but only one patient had a positive culture from the deep blade (with different organism isolated from the wound culture). The difference in incidence of culture-positive blade or SSI between the 2 groups was not significant. The relative risk of SSI in the single blade group was 0.8. Positive blade culture was not associated with SSI in the single or double blade group.

Conclusion.

The practice of changing blade following skin incision has no effect on reducing early SSI in surgery for closed fracture in healthy patients with healthy skin.
Transfibular Ankle Arthrodesis Using Burring, Curettage, Multiple Drilling, and Fixation with Two Retrograde Screws through a Single Lateral Incision
Authors: Lee Hyun-Joo , Min Woo-Kie , Kim Ji-Su , Yoon Seong-Dae , Kim Dong-Hyun
Published: October 2016

Purpose.

To review the outcome of 23 ankle arthrodeses using burring, curettage, multiple drilling, and fixation with 2 retrograde screws through a single lateral incision.

Methods.

Records of 22 consecutive patients aged 39 to 79 (mean, 62.4) years who underwent 23 ankle arthrodeses for end-stage ankle arthritis were reviewed. Through a single lateral incision, articular cartilage was removed using burring and curettage, and multiple holes were drilled using a Kirschner wire, followed by fixation with 2 retrograde screws. The resected distal fibula was fixed to the distal part of the talus and tibia. The position of the ankle and subtalar joint arthrosis was assessed by 2 orthopaedic specialists. Pre- and post-operative American Orthopaedic Foot and Ankle Society (AOFAS) scores were evaluated.

Results.

The mean operating time was 122 minutes. The mean follow-up period was 41 months. The mean postoperative ankle alignment was suboptimal: 2.7° varus, 6.7° plantar flexion, and 2.9° internal rotation. The mean AOFAS score improved from 30 to 71 (p<0.01). The postoperative varus ankle alignment was not associated with the AOFAS score ( r= −0.13, p=0.569). Of the 23 cases, one was nonunion and 22 achieved bone union after a mean of 5.4 (range, 2–16) months; 3 of them were delayed union. Despite bone union, 7 patients complained of persistent pain; 4 of them had progressive arthrosis of the adjacent subtalar joints (n=2) or subtalar and talonavicular joints (n=2).

Conclusion.

Ankle arthrodesis using burring, curettage, multiple drilling, and fixation with 2 retrograde screws achieved a high union rate and acceptable functional score without serious complications.
Total Knee Arthroplasty with Extra- or Intra-Articular Correction Technique for Arthritic Knees with Extra-Articular Deformity of the Femur or Tibia: A Report of Three Cases
Authors: Rattanaprichavej Piti , Laoruengthana Artit
Published: October 2016

This study reports 3 patients who underwent total knee arthroplasty combined with extra- or intra-articular correction technique for arthritic knees with extra-articular deformity of the femur or tibia.
Rapid Release From Listening Effort Resulting From Semantic Context, and Effects of Spectral Degradation and Cochlear Implants
Authors: Winn Matthew B.
Published: October 2016

People with hearing impairment are thought to rely heavily on context to compensate for reduced audibility. Here, we explore the resulting cost of this compensatory behavior, in terms of effort and the efficiency of ongoing predictive language processing. The listening task featured predictable or unpredictable sentences, and participants included people with cochlear implants as well as people with normal hearing who heard full-spectrum/unprocessed or vocoded speech. The crucial metric was the growth of the pupillary response and the reduction of this response for predictable versus unpredictable sentences, which would suggest reduced cognitive load resulting from predictive processing. Semantic context led to rapid reduction of listening effort for people with normal hearing; the reductions were observed well before the offset of the stimuli. Effort reduction was slightly delayed for people with cochlear implants and considerably more delayed for normal-hearing listeners exposed to spectrally degraded noise-vocoded signals; this pattern of results was maintained even when intelligibility was perfect. Results suggest that speed of sentence processing can still be disrupted, and exertion of effort can be elevated, even when intelligibility remains high. We discuss implications for experimental and clinical assessment of speech recognition, in which good performance can arise because of cognitive processes that occur after a stimulus, during a period of silence. Because silent gaps are not common in continuous flowing speech, the cognitive/linguistic restorative processes observed after sentences in such studies might not be available to listeners in everyday conversations, meaning that speech recognition in conventional tests might overestimate sentence-processing capability.
3-D CT Analysis of Screw and Suture-Button Fixation for Syndesmosis Repair
Authors: Schon Jason M. , Williams Brady T. , Venderley Melanie B. , Backus Jonathon D. , Dornan Grant J. , Turnbull Travis L. , Laprade Robert , Clanton Thomas O.
Published: October 2016

Category:

Sports.

Introduction/Purpose:

Historically, unstable injuries to the distal tibiofibular syndesmosis have been repaired with syndesmotic screws. However, newer repair techniques with inherently flexible implants, including suture-button constructs, may be less susceptible to malreduction and more reliably restore the native anatomy. The purpose of this study was to compare the anatomic accuracy of reduction between a syndesmotic screw and suture-button constructs for syndesmosis repair using a pre- injury and postoperative 3-D model assessment. We hypothesized significant differences would be observed among repair techniques and suture-button constructs would most accurately restore the pre-injury syndesmotic volume.

Methods:

Twelve matched pairs of cadaveric specimens were dissected to identify the syndesmotic ligaments. Specimens were imaged with CT prior to the creation of a complete syndesmosis injury. The disrupted syndesmosis of each specimen was subsequently reduced using one of three randomly assigned repair techniques: (1) tri-cortical syndesmosis screw (3.5 x 50 mm), (2) one suture-button construct and (3) two suture-button constructs. Specimens were imaged postoperatively with CT. 3-D models of all scans and tibiofibular joint space volumes were created to assess restoration of the native syndesmosis (Figure 1). Volumetric joint space measurements were made starting at the distal aspect of the tibiofibular articulation and extended proximally with four 1 cm sections measured separately.

Results:

For each of the three fixation methods, the adjusted least squares means for total post-operative volumes of the syndesmosis were significantly decreased relative to the intact state. Total overall decreases in volume compared to the intact state for the one suture-button construct, two suture-button constructs, and syndesmotic screw were -561 mm3, -964 mm3 and - 377 mm3, respectively. Fixation with one suture-button construct was not significantly different from screw or two suture-button fixations. However, the total decrease in volume was significantly greater with the two suture-button repair compared to screw fixation (p < .05).

Conclusion:

The most important finding of this study was that fixation with one suture-button construct was not significantly different from screw or two suture-button fixations. All repairs significantly reduced the volume of the syndesmosis postoperatively compared to the intact state. Fixation with two suture-buttons resulted in significantly greater decreased volume than screw fixation. The data from the present study suggests that syndesmotic over-compression at time zero, particularly when using multiple suture-button implants, may be another potential factor contributing to malreduction of syndesmosis injuries that deserves further investigation.
Co-Morbidities Are Associated with Increased Cost, Infection Rates, and Duration of Treatment after Primary Achilles Tendon Repair
Authors: Dombrowski Malcolm E. , Murawski Christopher D. , Yasui Youichi , Chen Antonia F. , Kennedy John G. , Hogan MaCalus V.
Published: October 2016

Category:

Sports.

Introduction/Purpose:

The purpose of this study was to assess the rate of surgical site infection (SSI) and surgical irrigation and debridement (I&D) after primary Achilles tendon repair. Secondary objectives were to assess the potential effect(s) of medical comorbidities on cost and duration of treatment of SSI after Achilles tendon repair.

Methods:

De-identified patient insurance records within the government and private national insurance orthopaedic datasets were searched between 2005-2012. The Current Procedural Terminology (CPT) code was used to identify primary Achilles tendon repair and I&D. Subsequently, post-operative SSIs and comorbidities were examined by searching corresponding International Classification of Disease Ninth Revision, Clinical Modification (ICD-9-CM) codes.

Results:

24,269 primary Achilles tendon repairs were identified. Overall, there was a significantly increased rate of SSI if a medical comorbidity was present at the time of surgery compared to those without a comorbidity (17.96% vs. 5.96%, p < 0.0001). Patients with diabetes and vascular complications had the highest SSI rate (OR 7.85, CI 6.25-9.86, p < 0.001), followed by peripheral vascular disease, diabetes with peripheral neuropathy, history of drug abuse, fluid and electrolyte abnormalities, obesity, and uncomplicated diabetes. There was higher rate of surgical I&D in patients with cardiac arrhythmias and uncomplicated hypertension. There was a significant increase in cost of SSI treatment ($6,004.09 vs. $4,184.62, p=0.006) and duration of treatment (8.41 days vs. 5.54 days, p < 0.001) if a medical comorbidity was present in Achilles tendon patients with SSI.

Conclusion:

An analysis of a large cohort of patients undergoing Achilles tendon reconstruction revealed that having certain medical comorbidities conferred a significantly greater risk for developing SSI, which increased both the cost of subsequent care and duration of treatment. Furthermore, with the advent of “value”/outcomes based care being linked to reimbursement, SSI is a one measure being used by the Centers for Medicare & Medicaid Services and private insures to determine appropriate orthopaedic care. Thus, patients with modifiable risk factors should be referred for medical management prior to surgery or deferred to a non-operative treatment program to reduce the risk of SSI after Achilles tendon repair.
Biomechanical Analysis of a Semitendinosus Allograft versus Achilles Turndown for Reconstruction of Large Segmental Achilles Defects
Authors: Aynardi Michael , Atwater Lara C. , Parks Brent G. , Melvani Roshan T. , Miller Stuart D.
Published: October 2016

Category:

Sports.

Introduction/Purpose:

Large segmental Achilles tendon defects present a difficult problem to treating surgeons. Multiple procedures have been utilized to reconstruct these defects, but no studies have evaluated the comparative tensile strength of the various repair methods. Our institution has recently described the use of a dual semitendinosus allograft for Achilles reconstruction. Advantages of this procedure include eliminating donor site morbidity and providing an increased surface area for healing and tendon incorporation. Our study investigated the tensile strength of this novel technique as compared to a standard myofascial turndown procedure. We hypothesized that no differences in biomechanical properties would be found between dual semitendinosus reconstruction and Achilles myofascial turndown reconstruction.

Methods:

An 8-cm segmental Achilles defect was created in both specimens of nine matched pair, cadaveric lower extremities. The specimens in each pair were randomly assigned to undergo allograft or turndown reconstruction. The myofacial turndown was secured distally with modified Kessler sutures of 0 braided polyester sutures through bone tunnels in the calcaneus and proximally with multiple interrupted figure-of-8 polyester braid sutures. Semitendinosus grafts were anchored proximally with a Pulvertaft weave and then distally through two bone tunnels within the calcaneus and sutured together around the posterior heel with similar polyester sutures. The foot was disarticulated through the subtalar joint and the Achilles was dissected free of excess soft tissues. The constructs were mounted onto a load frame and differential variable reluctance transducers were applied to the construct. Specimens were preconditioned and then loaded axially. Tensile forces were recorded at 10 mm of displacement and at failure

Results:

Semitendinosus allograft failure occurred via calcaneal bone bridge fracture in 8 of 9 specimens, and all myofascial turndowns failed through suture pullout through the fascial tissue at its insertion. None of the specimens failed at the MTS grip sites or via de novo tendon substance rupture. Average ultimate tensile strength of the semitendinosus allograft reconstruction was 290.9± 83.2 N compared to that of the turndown repair which was 140.7± 43.5 N. At 10 mm of displacement, average tensile strength of the allograft repair was 156.9 ± 29.7 N versus the turndown repair at 101.2 ± 20.0 N. Strength differences between the two repairs were significant at both failure and 10 mm displacement (p < 0.001).

Conclusion:

Dual semitendinosus allograft reconstruction demonstrates superior tensile strength properties when compared to myofascial turndown in a cadaveric model of large Achilles tendon defects.
Arthroscopic Plafond Access for Osteochondral Lesions- The Effect of Limited Ankle Range of Motion on Anterior and Posterior Arthroscopic Accessibility
Authors: Akoh Craig C. , Phisitkul Phinit , Rungprai Chamnanni , Amendola Annunziato , Hartog Bryan Den , Glass Natalie A.
Published: October 2016

Category:

Arthroscopy.

Introduction/Purpose:

Osteochondral lesions of the tibial plafond (OLTPs) can lead to chronic ankle pain and disability. Arthroscopic treatment has been described after failure of initial nonoperative treatment. However, the ideal appropriate approach for OLTPs is controversial, and it is not known if ankle positioning or joint distraction affects the accessibility of these lesions. The purpose of this study was to determine the effects of predetermined ankle flexion angles on arthroscopic accessibility of the distal tibial articular surface through either the anterior or posterior approach. The effects of non- invasive joint distraction were also analyzed.

Methods:

Fourteen below-knee cadaver specimens were subjected to pre-operative range of motion measurements. Joint distraction was measured using sizing rods with the precision of 1 mm. The accessible areas at the tibial plafond were marked using a curette at predetermined ankle positions. Arthroscopy was performed using a 30-degree 2.7 mm camera via standard anterior and posterior approaches in randomized fashion in all specimens. Following arthroscopic accessibility, each cadaveric ankle was disarticulated and arthroscopic accessibility was quantified using a surface laser scan. Statistical analyses were performed to determine the correlation between pre-operative ankle range of motion and amount of distraction on arthroscopic accessibility of the tibial plafond.

Results:

The average accessibility of the tibial plafond was 56 percent and 68 percent for the anterior and posterior approaches, respectively (p = 0.056). There was no difference in accessibility from the anterior approach with increasing level of plantarflexion (p >0.05). Increasing dorsiflexion during the posterior approach significantly reduced ankle accessibility (p = 0.028). There was a significant increase in accessibility through either anterior or posterior approach with increasing level of ankle distraction; (parameter estimates ±SE): anterior= 14.2±3.34, p < 0.01 and posterior= 10.6±3.7, p < 0.05).

Conclusion:

Arthroscopic accessibility for the treatment of OLTPs was vastly dependent on the amount of intra-operative joint distraction achieved. Posterior approach had more joint distraction and wider plafond accessibility. Increasing ankle distraction significantly improved arthroscopic plafond accessibility for both anterior and posterior approaches while ankle joint position did not influence accessibility from either approach.
Trabecular Metal Total Ankle Using Transfibular Approach
Authors: Barg Alexej , Lyman Mikayla , Gililland Jeremy
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

The Trabecular Metal total ankle, introduced in 2012, is the most recent design of a lateral approach, total ankle replacement. The objectives of this study were to (1) determine postoperative radiographic outcomes including hindfoot alignment, alignment of prosthesis components, and periprosthetic radiolucencies, and (2) determine the failure rate of prosthesis components in the short-term.

Methods:

Fifty-six consecutive primary total ankle replacements were performed between October 2012 and November 2014 using a Trabecular Metal prosthesis (Zimmer Biomet, Warsaw, IN, USA) through transfibular approach. There were 30 male and 26 female patients with a mean age of 66.7 ± 9.2 years (46.7–84.9). Radiographic assessment was performed using preoperative and postoperative weight-bearing radiographs (Figure 1). Periprosthetic radiolucency was assessed by two independent observers, according to each of the 6 zones around the tibial and talar components. Hindfoot alignment was analyzed by medial distal tibial angle, tibio-talar tilt, calcaneal moment arm, and anterior distal tibial angle. Degenerative changes in the tibiotalar and adjacent joints were assessed according to the Kellgren-Lawrence scale. Prosthesis alignment was measured by α, β, and γ angles. The mean time to final follow-up was 19.5 ± 5.2 months (12.0-32.8). All patients were available for a minimum of one year of follow-up.

Results:

At the latest follow-up, radiolucencies were observed in tibial zones 1 through 6 in 33.9%, 26.8%, 7.1%, 5.4%, 10.7%, and 21.4%, respectively. Radiolucencies were seen in talar zones 1 through 6 in 12.5%, 3.6%, 0.0%, 0.0%, 5.4%, and 0.0%, respectively. The prosthesis alignment α, β, and γ angles were 87.0° ± 3.1° (80°–95°), 87.1° ± 5.3° (75°–100°), and 5.2° ± 6.1° (-7°–20°). In all patients, osseous union of the fibular osteotomy was observed within 4 months postoperatively. In two patients, a painful loosening of the tibial component was observed, resulting in revision of tibial component at 17.6 and 24.6 months after the index procedure.

Conclusion:

The short-term results of a lateral approach, Trabecular Metal implant are encouraging and comparable with those of other third-generation ankle implants. All osteotomies healed in appropriate alignment.
A New Concept of 3D Biometric for Hindfoot Alignment Using Weight Bearing CT
Authors: Lintz François , Welck Matthew J. , Goldberg Andy J.
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

Hindfoot alignment measures based on 2D radiographs present many anatomical and operator-related bias and do not account for the contribution of the forefoot in ankle biomechanics. Weight-bearing CT provides an opportunity to solve this. In this study, a new system: TALAS™ (Torque Ankle Lever Arm System) designed for weight-bearing CT was used to calculate an innovative 3D biometric: FAO (Foot Ankle Offset) which represents the lever arm generated in the ankle from the actions of body weight and ground reaction force. The objective was to describe the distribution of FAO in a series of anonymised datasets from clinically normal or varus cases. We hypothesized that normal and varus cases should be significantly different and that the distribution should be Gaussian in the normal population.

Methods:

This is a retrospective cohort study, level 3 evidence. Thirty four anonymous datasets (26 normal, 8 varus) from weight bearing scans (PedCAT, CurveBeam LLC, Philadelphia, USA) were obtained from an existing database in a specialized foot and ankle unit. Datasets were screened by an independent observer who collected the 3D coordinates of specific anatomical landmarks, which included the weight bearing points of the calcaneus, and the 1st and 5th metatarsal heads as well as the highest and centermost point on the talar dome. This data was processed with the TALAS™ system, which resulted in an FAO value for each case, given as a percentage of foot length.

Results:

Mean value for the Foot Ankle Offset in normal cases was 2.34%, Median was 2.44% (range:-3.22; 9.09%), Standard Deviation was 2.92%. In varus cases, Mean was -11.36%, Median was -10.74%(range:-22.36;-1.05), Standard Deviation was 9.19%. FAO values were significantly different in normal and varus cases (p < 0,005). The distribution of the normal population demonstrated a Gaussian shape.

Conclusion:

This pilot study suggests that the FAO is efficient in measuring hindfoot alignment using weight bearing CT. Drawbacks are the limited number of cases and the use of a beta version of TALAS™ which requires more development in order to be usable in daily practice. Further research in larger patient populations is necessary. Previously published research in this field had looked at weight bearing CT but only tried to adapt 2D biometrics. The present study suggests the possibility of discovering and describing new 3D biometrics in the foot and ankle field.
Adjacent Joint Kinematics after Ankle Arthrodesis in Cadaveric Gait Simulation
Authors: Demetracopoulos Constantine A. , Sturnick Daniel R. , Ellis Scott J. , Deland Jonathan T. , Baxter Josh R.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthrodesis is an effective treatment for decreasing pain in patients with end-stage ankle arthritis. However, all patients with an ankle arthrodesis will eventually develop adjacent joint arthritis. The etiology of adjacent joint arthritis after ankle arthrodesis is not fully understood due to the difficulty of investigating these joints in vivo. Cadaveric simulation provides a unique capability of studying intrinsic foot and ankle joint mechanics. The objective of this study was to establish the effect of ankle arthrodesis on adjacent joint kinematics using cadaveric gait simulation. We hypothesized that adjacent joint motion of the hindfoot would increase after ankle arthrodesis.

Methods:

Four mid-tibia cadaveric specimens were potted and secured to a static mounting fixture about a six-degree of freedom robotic platform.(Figure 1A) The nine extrinsic ankle tendons were isolated and connected to linear actuators instrumented with load cells in series. During simulations, a force plate was moved relative to the stationary specimen through an inverse tibial kinematic path. Three-dimensional ankle and hindfoot kinematics were captured using a motion capture system. After ankle arthrodesis, kinematics were recorded using the same muscle force and kinematic inputs as the intact condition to determine how the hindfoot would behave when simulating normal gait. To assess the effect of ankle arthrodesis during simulated walking on adjacent joint kinematics, pre- and post-arthrodesis kinematics of the subtalar and talonavicular joint were directly compared along the stance phase and differences were assessed using two-tailed, paired Student’s t-tests with an alpha value set at p = 0.05.

Results:

Subtalar and talonavicular joint plantarflexion was greater during the early phase of stance in the ankle arthrodesis condition.(Figure 1B and 1C). Talonavicular joint motion also demonstrated greater dorsiflexion during late stance following ankle arthrodesis (Figure 1C). Ankle arthrodesis had no detectable effect on axial or coronal plane motion in adjacent joints of the hindfoot.

Conclusion:

This study reveals that sagittal plane motion in the hindfoot is increased following ankle arthrodesis. These results provide further insight into how motion is redistributed to adjacent joints after arthrodesis during gait. Such compensatory motions may be related to changes in contact mechanics in adjacent joints which can lead to degenerative changes.
A Biomechanical Comparison of First Metatarsophalangeal Arthrodesis Using Crossed Screws and Shape-Memory Staples in Various Configurations
Authors: Grice John E. , Willmott Henry , Halewood Camilla , MBiomedE MEng , Dunning Mike , Amis Andrew
Published: October 2016

Category:

Midfoot/Forefoot

Introduction/Purpose:

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is a commonly performed procedure for the treatment of hallux rigidus. A range of fixation methods have been used. Most recently, the shape-memory staple has been described. Made from an equiatomic alloy, the staple changes its shape when heated to body temperature so as to provide compression across the arthrodesis. We aimed to determine load to failure, cyclic loading and failure characteristics of different staple configurations compared to crossed screws.

Methods:

A cadaveric porcine model was used to simulate first MTPJ arthrodesis. Five forms of fixation were tested: single vertical staple; single horizontal staple; paired staples in orthogonal superior-inferior and medial-lateral configuration (0-90° to sagittal plane); paired staples in an oblique orthogonal configuration (45-135° to sagittal plane); two crossed screws. Using a materials-testing machine, specimens were loaded in dorsiflexion to simulate weight bearing. Cyclical loading was performed from 5-40N at a rate of 0.5 Hz for 1000 cycles. Plantar gapping, shear and creep were measured. Specimens were then loaded to failure in order to generate a load-displacement curve. The mechanism of failure was noted for each group.

Results:

Single staple configurations failed at very low loads. Single vertical staples failed at a mean load 15N±5N and single horizontal staples at 19N±3N. Mean failure load for paired 0-90° staples was 43N±9N which was significantly lower than the paired 45-135° staples which failed at 141N±25N (p < 0.001) and crossed screws, which failed at 180N±67N (p < 0.001). The was no significant difference between the 45-135° staples and crossed screws. Cyclic testing demonstrated plantar gap formation of 0.2mm±0.1 mm in the crossed screw specimens and 0.4mm±0.4 mm in the 45-135° staple specimens. However, stapled specimens demonstrated more shear compared to crossed screws (mean 1.0mm±0.5 mm compared to 0.14mm±0.4 mm, p < 0.01). Furthermore, crossed screw specimens showed mainly plastic deformation whereas stapled specimens showed combined plastic and elastic deformation.

Conclusion:

First MTPJ arthrodeses fixed with single staples failed at very low loads and cannot be recommended. The widely accepted 0-90° orthogonal staple configuration proved to be significantly less strong than two crossed screws. However, changing staple position to an oblique configuration at 45° and 135° to the sagittal plane significantly improved stability, rendering the construct as strong as crossed screws. Nevertheless, none of the constructs would have been strong enough to withstand full weight-bearing in the immediate post-operative period.
Does Arthrodesis of the First Metatarso-Phalangeal Joint Correct the Intermetatarsal M1M2 Angle? Analysis of Continuous Series of 208 Arthrodesis Plate-Osteosyntheses
Authors: Besse Jean-Luc , Dalat Frederic , Cottalorda Francois , Fessy Michel-Henry
Published: October 2016

Category:

Midfoot/Forefoot

Introduction/Purpose:

MTP-1 arthrodesis allows effective correction of both inter-metatarsal M1M2 and M1P1 angles. Undercorrection of wide M1M2 angle after MTP-1 arthrodesis causes persistently wide forefoot, metatarsalgia and unaesthetic gap between first and second toes. In severe deformities, Rippstein recommended supplementary first metatarsal osteotomy or cuneo-metatarsal arthrodesis. The present study sought to investigate correction of inter-metatarsal M1M2 angle after MTP-1 arthrodesis according to aetiology and pre-operative deformity severity.

Methods:

A prospective continuous series (June 2007- March 2011) included 208 patients: 48% severe hallux valgus and/or osteoarthritis, 18% hallux rigidus, 16% rheumatoid osteoarthritis, 13% revision, 5% hallux varus; mean age, 62.4±9.9 years (19-87 years). All patients were operated on by a single senior surgeon with the same technique: articular surface reaming (cup-ball), osteosynthesis with titanium anatomical plate (Fyxis-Biotech) and the same rehabilitation procedure. Pre- and post-operative hallux positions were analysed on antero-posterior and lateral weightbearing views. M1M2 and M1P1 were measured according to American Orthopaedic Foot and Ankle Society guidelines.

Results:

Mean follow-up was 18.6±12.4 months; fusion rate, 97%; 5% plate removal. Mean M1P1 angle was 33.8±19.7° (-45° to 67°) preoperatively, and 13.4±5.3° (0-32°) at follow-up; M1M2, 14.2±5.4° (0° to 26°) and 6.5± 2.3° (0-12°) respectively. M1M2 angle was < 15° in 97 patients, 15-19° in 78 and ≥20° in 33 preoperatively, and respectively 5.8±2.1° (0-10°), 6.7±2.2° (0-10°) and 8.1±2.4° (3-12°) at follow-up. No significant differences were observed according to aetiology. M1M2 angle was >10° in only 2 patients (0.9%) associated with cuneometatarsal osteoarthritis. Improvement increased with severity of preoperative M1M2 angle (p < 0.05). However, mean postoperative M1M2 angle in the severe group was nevertheless wider than in the moderate group.

Conclusion:

MTP1-arthrodesis corrected M1M2 angle even in severe deformity, of whatever aetiology, in agreement with the literature, whereas Rippstein recently recommended supplementary M1 osteotomy or C1M1 arthrodesis for preoperative M1M2 angle >10°. Pydah correlated preoperative and postoperative intermetatarsal angle with a regression line, without recommending any secondary procedure to improve M1M2 angle. In severe increased preoperative M1M2 angle, we do not recommend associating systematic C1M1 arthrodesis or basal metatarsal osteotomy to MTP-1 arthrodesis, but suggest that additional basal metatarsal osteotomy or C1M1 fusion might be required only in exceptional associated degenerative C1M1 joint.
Effect of First Ray Insufficiency and Metatarsal Index on Metatarsalgia in Hallux Valgus
Authors: Slullitel Gaston , Lopez Valeria , Calvi Juan P. , Seletti Maximiliano C. , Bartolucci Carla , Pinton Gustavo
Published: October 2016

Category:

Midfoot/Forefoot

Introduction/Purpose:

There are two concepts that tried to explain the etiology of metatarsalgia in hallux valgus patients: First, the one that states that as the magnitude of hallux valgus increases, there is a mechanical overload of the lesser metatarsals. Second, that an increased relative lesser metatarsal length is a factor in the development of metatarsalgia. However there is no current evidence that these facts predisposes for primary metatarsalgia. The purpose of the study was to evaluate the factors associated with metatarsalgia in hallux valgus patients.

Methods:

A cross-sectional study of 121 consecutive adult patients with non-arthritic hallux valgus was carried out. Binary logistic regression was performed to identify the effect of the clinical and demographic factors on the occurrence of metatarsalgia.

Results:

One hundred twenty one patients (184 feet) with hallux valgus were analyzed. The median weight was 65 Kg (IQR 58 – 72). Metatarsalgia was present in 84 (45.6%) feet. The binary logistic regression showed that lesser toe deformity (OR 2.6 IC95% 0.2-0.5), gastrocnemius shortening (OR 5.8 IC95% 2.8-12.3), metatarsal index (OR 0.3 IC95% 0.2-0.5) and weight (OR 2.5 IC95% 1.2-5.3) were significantly associated.

Conclusion:

Metatarsalgia occurs in almost a half of hallux valgus patients. It has a multifactorial etiology. Our finding questions the common theory that both the magnitude of hallux valgus deformity and an increased length of a lesser metatarsal by themselves, predisposes for primary metatarsalgia. Metatarsalgia was associated with Achilles shortening, excessive weight and associated lesser toe deformity. These factors should be addressed in order to treat this disorder adequately.
The Use of Infrared Thermometry in Confirming First Metatarsophalangeal Joint Fusion
Authors: Mayich D. Joshua , Myerson Mark S. , MacNeill A. Luke
Published: October 2016

Category:

Midfoot/Forefoot

Introduction/Purpose:

Confirming the presence or absence of union is a critical determination in the care of individuals following attempted surgical fusion. This most commonly is done using clinical examination in conjunction with imaging. Infrared thermometry (IRT) has been used in other areas of clinical foot and ankle care, and has been shown to be a reliable method of measuring skin temperature. Given the complex morphology of the foot and ankle and the confounding clinical presentation of cases of foot and ankle fusions during the post-operative recovery, trying to determine the presence of absence of clinical union can be difficult. An adjunctive method to further inform the post-operative recovery would be helpful. In this study, IRT is investigated as an adjunctive method of confirming clinical union of attempted first metatarsophalangeal (or 1st MTP) fusion.

Methods:

Thirty-three individuals undergoing 1st MTP joint fusion were prospectively measured using IRT. Temperature at the 1st MTP site was recorded preoperatively, 10-14 days postoperatively, 42 days postoperatively, and 90 days postoperatively. Each case was followed post-operatively as per usual clinical care guidelines, and union was confirmed by a combination of clinical examination and radiographs. All data were collected from two testing centers, using compatible IRT devices.

Results:

Temperature at the 1st MTP site increased from preoperatively (82.7°F ± 4.4°) to 10-14 days postoperatively (89.2°F ± 2.7°; p < .001); it declined from 10-14 days postoperatively to 42 days postoperatively (84.5°F ± 3.9°; p < .001); and it declined from 42 days postoperatively to 90 days postoperatively (81.5°F ± 4.6°; p < .001). The final temperature was statistically not significant from the pre-operative value, or the value measured on the opposite 1st MTP joint. Temperature data collected from one of the testing centers was significantly higher than the data collected from the other center (p < .001), suggesting a potential location or climate effect. No non-unions were recorded during the study.

Conclusion:

Results suggest that IRT was successful in predicting and confirming union in the setting of 1st MTP joint fusion - where temperature of the 1st MTP joint returned to pre-operative and opposite side levels. For this reason, IRT presents itself as a valuable adjunct in the setting of 1st MTP joint fusion. Collecting contralateral foot temperature data may be a less biased means of tracking the progression of healing than the use of absolute foot temperatures, and a method to avoid regional ambient temperature differences.
Collagen Dressing in the Treatment of Diabetic Foot Ulcer
Authors: Park Yoo Jung , Hwang Yeokgu , Park Kwang Hwan , Suh Jae Wan , Shim Dong-Woo , Han Seung Hwan , Lee Jin Woo , Choi Woo Jin
Published: October 2016

Category:

Diabetes

Introduction/Purpose:

Ulcer healing in the diabetic patients is challenging due to a prolonged inflammatory response, extracellular matrix degradation irregularities, and increased bacteria presence. Collagen components are fundamental to the process of wound healing and skin formation. Recently, collagen-containing wound dressings, which create a biological scaffold matrix, have been used in the treatment of diabetic foot ulcer (DFU). However, there is not enough evidence to support that 100% collagen dressing can replace the diabetic wound management. In this study, we examined the effectiveness and safety of a new collagen dressing material in the treatment of DFU.

Methods:

This study was a prospective, randomized, placebo-controlled, single-center study conducted between November 2011 and September 2014. The inclusion criteria were type 1 or 2 diabetes, a ulcer size ≥ 1.0 cm2 that did not exhibit signs of healing for 6 weeks, Wagner grade 1 or 2, and palpable pulses at the ankle. The assessments of DFU included size, microbial culture study, detailed description of DFU, and clinical photos. Patients in the study group were treated with a collagen dressing material (100% porcine type I collagen) and foam dressing, while patients in the control group were treated with only foam dressing. Dressing changes had been performed two or three times per week. Complete ulcer healing rate was evaluated as a primary endpoint and ulcer size were compared between the two groups as a secondary endpoint.

Results:

Thirty patients were included in the final analysis (study group: 17 patients, control group: 13 patients). There were no significant differences between two groups regarding demographic factors and baseline DFU characteristics. The study group presented a higher rate of complete healing as compared to that in the control group [82.4% (14/17), 38.5% (5/13), respectively, P = 0.022]. At the last follow-up, ulcer sizes of the study group were smaller than those of the control group (P = 0.048). The Kaplan-Meier analysis for the complete ulcer healing also showed a significantly higher rate of complete healing in the study group (Hazard ratio = 3.0, log-rank P = 0.025). There were no adverse events related to the dressing materials.

Conclusion:

This study supports that the wound dressing using 100% collagen materials may offer a safe and effective treatment for DFU.