bluuebunny/crossref_metadata_2025 huggingface dataset:
The Midfoot Contributes to Power and Work During Single-limb Heel Rise
Authors: DiLiberto Frank , Nawoczenski Deborah
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Single-limb heel rise (HR) is used to evaluate muscle performance and clinical outcomes in people with foot and ankle pathology. While the midfoot contributes 13% of total foot/ankle work to forward propulsion during gait, healthy HR performance remains primarily characterized by ankle function. Similar to its function during gait, the midfoot may also generate power during HR to provide the stability needed for ankle push-off power. Further characterization of HR performance by evaluating midfoot kinetics may advance understanding of foot function in the clinical application of the HR task. The purpose of this study was to examine ankle and midfoot power and work during single-limb HR in healthy adults.

Methods:

Twelve healthy adults [Mean (SD): Age 31.3 (4.9) years; BMI 25.2 (3.3) Kg/m2; 50% male] performed twenty barefoot single-limb heel rises. Multi-segment kinematic and ground reaction force data were recorded with an electromagnetic motion capture system and force plate. Subject-specific, three segment foot models (tibia, rearfoot, forefoot) were derived. Inverse dynamic calculations were performed to obtain ankle and midfoot peak positive and negative powers (joint torque x segmental velocity), as well as the timing of peak powers (% of the heel rise). Midfoot work (integral of power with respect to time), reflecting energy production, was examined as a percentage of the entire work performed at the ankle and midfoot during HR. Group descriptive data were examined as mean (standard deviation) [95% confidence interval].

Results:

Ankle peak positive power was 2.8 (0.8) [2.2 - 3.3] W/Kg and occurred during the ascent phase at 7% HR (Figure 1). Midfoot peak positive power was 0.5 (0.2) [0.3 - 0.6] W/Kg occurring at 6%. Ankle peak negative power was 2.1 (0.6) [1.7 - 2.4] W/Kg and occurred during the descent phase at 84% HR. Midfoot peak negative power was 0.4 (0.2) [0.2 - 0.5] W/Kg occurring at 83%. The proportion of midfoot work to total work performed was 13.5 (5.7) [9.8 - 17.1] %.

Conclusion:

Study findings advance understanding of foot function by demonstrating the contribution of midfoot power and work during HR in healthy adults. Midfoot peak powers were approximately 18% of ankle powers and occurred at similar times during HR. Further, midfoot energy production appears to be an important aspect of healthy HR performance because approximately 14% of the total foot/ankle work occurs at the midfoot. Since active internal muscle and ligament mechanisms are attributed to midfoot power generation, practitioners should consider midfoot tissue loading and muscle performance when implementing the HR task in clinical practice.
The Effect of Gender on Hallux Valgus Surgery
Authors: Lim Winston Shang Rong , Liow Ming Han Lincoln , Goh Graham , Loh Bryan , Koo Kevin , Rikhraj Inderjeet
Published: September 2018

Category:

Bunion

Introduction/Purpose:

Men are recognized to possess higher pain thresholds, report less pain and have a greater tolerance for pain. With increasing numbers of males seeking hallux valgus (HV) surgery, there is a paucity of literature comparing health-related quality-of-life (HRQoL) outcomes and satisfaction between males and females undergoing HV surgery.

Methods:

Prospectively collected registry data of 439 patients who underwent HV surgery at a single institution from 2007-2015 were reviewed. Propensity scores generated using logistic regression was used to match males (n=26) to females (n=52) in a 1:2 ratio. Hallux visual analogue scale (VAS) scores, American Orthopaedic Foot and Ankle Society scores (AOFAS), proportion attaining AOFAS minimal clinically important difference (MCID), Short-form 36 (SF-36), satisfaction and expectation scores were analyzed. Hallux valgus (HVA) and inter-metatarsal (IMA) angles were recorded pre- and postoperatively.

Results:

Before PSM, there were significant differences in age (49.8±17.4 vs 55.2±11.8, p=0.03) and SF-36 role-physical (37.5±43.7 vs 59.2±42.6, p=0.01)(Table 1). After PSM, there were no significant pre-operative differences in hallux VAS, AOFAS and SF-36 HRQoL scores between groups (Table 1). At two-years, males had significantly lower SF-36 general health scores (68.7±20.6 vs 79.3±17.8, p=0.02) (Table 2). In addition, lower proportion of males reported good/excellent satisfaction (73.1% vs 78.8%) and expectation fulfilment (80.8% vs 94.2%) at two-years (Table 3). Similar proportion of males attained MCID for AOFAS (53.8% vs 46.2%, p=0.63) (Table 4). Males and females presented with similar pre-operative HVA (29.3±8.4 vs 28.2±9.3, p=0.63) and IMA (14.4±3.2 vs 13.9±3.4, p=0.53), with successful correction of HVA (14.7±6.5 vs 12.5±7.8, p=0.25) and IMA (9.4±3.3 vs 8.3±3.1, p=0.17) post-operatively (Table 5).

Conclusion:

Our findings suggest that males may experience lower expectation fulfilment when compared to females after HV surgery, despite resolution of hallux pain, satisfactory radiological correction and attainment of similar proportion of MCID in AOFAS scores. These findings highlight that males may possess higher expectations towards hallux valgus surgery. Future research should focus on factors affecting expectation fulfilment in males undergoing HV surgery.
Comparison of Non-Union and Complication Rates in Primary versus Revision Tibiotalar Arthrodesis
Authors: Neumann Julie , Weinberg Maxwell , Saltzman Charles , Barg Alexej
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

Tibiotalar arthrodesis is generally a successful treatment option for patients with end stage ankle arthritis. However, there is a 9% risk of nonunion in patients undergoing primary tibiotalar arthrodesis. Patients with a nonunion often undergo revision ankle arthrodesis, as it is the most common salvage procedure in this situation. To date, only a few studies have evaluated outcomes in patients with revision ankle arthrodesis. The purpose of this clinical study is to directly compare the rate of union and complications in primary versus revision tibiotalar arthrodesis. The hypothesis of this study was that there would be no difference in rate of union and complications between primary and revision ankle arthrodesis.

Methods:

This is a retrospective review of 455 consecutive patients that underwent either primary or revision tibiotalar arthrodesis between March 2002 to November 2014. Three-hundred eighty-five patients underwent primary arthrodesis and 70 patients underwent revision arthrodesis. Age, gender, body mass index, smoking, and preoperative radiographic deformity were controlled. The primary outcome measure was union rate of tibiotalar arthrodesis. Secondary outcome measures were time to union, rate of wound complications, rate of return to operating room, and rate of development of post-operative deep vein thrombosis (DVT).

Results:

Average age of the patients was 56 +/- 15 years (range 18-89). The mean follow-up time was 38.3 +/- 27.4 months (range 12-150.4 months). All patients had a minimum follow-up of 12 months. Unions were assessed on routine post-operative radiographs. If there was a concern for nonunion, patients were further assessed with a computerized tomography scan. The nonunion rate of patients who had primary arthrodesis was 37/385 (9.6%) and revision arthrodesis was 6/70 (8.5%) (p=0.74) (Table 1). Additionally, there was not a significant difference between those who had primary versus revision ankle arthrodesis surgery in rate of wound complication, return to the operating room, and post-operative DVT (Table 2). There were no major complications in this study.

Conclusion:

This is the largest study to directly compare union rates and complication rates in patients who underwent primary versus revision ankle arthrodesis. In this study, primary versus revision tibiotalar arthrodesis does not affect union rate, time to union, rate of wound complications, rate of return to operating room, and rate of development of post-operative DVT.
Percutaneous surgery for overlapping fifth toe
Authors: Bilbao Facundo , Verbner Jonathan , Parise Ana , Villena Daniel , Araujo Maria Gala Santini , Sotelano Pablo , Carrasco Nelly , Carlucci Sofia , Conti Leonardo , Migues Atilio
Published: September 2018

Category:

Lesser Toes

Introduction/Purpose:

Overlapping fifth toe is an unusual disease in which the fifth toe is adducted, rotated, and hyperextended. This pathology is often asymptomatic, however pain may occur with footwear. Although there are many surgical techniques available, there is yet no gold standard. While old techniques were aggressive and cosmetically inappropriate, newest techniques involve large surgical incisions and risk of neurovascular damage. Percutaneous surgery is a novel approach which avoids the disadvantages that old and new techniques present. It was originally described by De Prado but no case series have been reported in adults up to date. The aim of this study is to describe a percutaneous corrective technique of the overlapping fifth toe and to evaluate its functional results and patient satisfaction.

Methods:

We performed a retrospective review of 12 feet in 10 adult patients who were surgically treated between 2008 and 2016. The percutaneous surgical technique consisted in a dorsal capsulotomy and extensor tenotomy followed by an osteotomy of the proximal phalanx (as described by De Prado). We added to his procedure the use of a K-wire to stabilize the osteotomies. In 6 of these feet a percutaneous oblique osteotomy of the fifth metatarsal was also performed. This osteotomy was stabilized using the same K-wire, which was removed 1 month after surgery. All patients were clinically rated prior to surgery and at the final follow-up visit using the AOFAS Score for lesser toes. In addition, patients were asked to provide a subjective qualification of the results (pain/cosmetic) as “excellent”, “good”, “regular” and “poor” and to state if they would recommend the surgical procedure to one of their peers.

Results:

The average follow up was 48 months (104 - 9). Osteotomy consolidation was completely achieved in all patients. There were no infections or wound complications. Mean preoperative AOFAS score was 38 (20-55) and postoperative score was 84 (62-95). Patient subjective qualification after surgery was: excellent for 7 feet, good for 3 and regular and poor for the remaining 2 feet. Nine of the ten patients stated that they would recommend the procedure.

Conclusion:

Percutaneous treatment of the overlapping fifth toe is a reproducible surgical technique with good functional results, low postoperative complications and good cosmetic acceptance by the patients.
Prognostic risk factors for complications associated with Tibiotalocalcaneal fusion with a nail
Authors: Callahan Ryan , Aynardi Michael , Walley Kempland , Saloky Kaitlin , Juiano Paul
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Tibiotalocalcaneal (TTC) fusion with a nail is an effective salvage procedure for several foot and ankle pathologies, but it is associated with a relatively high complication rate and often performed on patients with multiple medical comorbidities. There is a paucity of literature that aids in predicting outcomes for patients undergoing TTC fusion with a nail.

Methods:

Clinical and radiographic outcomes for 82 patients from 2012-2016 who underwent TTC fusion with intramedullary nailing were retrospectively evaluated. Postoperative complications of nonunion, infection, reoperation, and hardware failure were included for comparison. Patient dependent variables and surgeon dependent variables were evaluated for association with these postoperative complications.

Results:

The overall complication rate for TTC fusion with a nail was 47/82 (57.3%). Diabetes (p=.049), diabetic neuropathy (p=.031), ASA classification (p=.005), and Charcot neuropathy (p=.003) were associated with nonunion of either the tibiotalar or subtalar joints in 29/82 (35.3%) patients. Diabetic neuropathy was associated with need for reoperation (p=.016) in 21/82 (25.6%) patients. Diabetic neuropathy (p=.022) and HbA1C >7.5 (p=.047) was associated with hardware failure in 13/82 (15.9%) patients. The odds ratio (OR) for diabetic neuropathy was 2.99 (p=0.038) for nonunion in the tibiotalar or subtalar joints, 3.46 (p=0.021) for re-operation, and 4.11 (p=0.035) for hardware failure. High ASA classification had an odds ratio of 3.93 (p=0.006) for nonunion in the tibiotalar or subtalar joints.

Conclusion:

Patients with diabetic neuropathy, Charcot neuropathy, elevated HbA1C, and higher ASA classification demonstrated a higher complication rate in patients undergoing TTC fusion with a nail.
Treatment trends for acquired hallux valgus among orthopedic surgeons and podiatrists
Authors: Callahan Ryan , Aydogan Umur , Liu Guodong , Ba Djibril
Published: September 2018

Category:

Bunion

Introduction/Purpose:

Foot and ankle surgery is unique in that both orthopedic surgeons and podiatrists perform many of the same procedures. Very little data exists comparing the two groups for treatment trends and potential complications for acquired hallux valgus deformity. The Truven Health MarketScan® Commercial Claims and Encounters database offers a breadth of information for comparing commercially available health insurance claims. The MarketScan® database was utilized to gain understanding in treatment trends between podiatrists and orthopedic surgeons.

Methods:

MarketScan® database was used to retrospectively search from 2005-2014 for cases involving a diagnosis of hallux valgus (ICD-9 735.0) that included procedural codes for distal metatarsal osteotomy (CPT 28296), double osteotomy (CPT 28299), and first tarsometatarsal arthrodesis (CPT 28297). The procedures were then divided into the provider groups of podiatry (PO) or orthopedic surgery (OS) to compare the trends in treatment options. Additionally, hospital admission within 3 months, reoperation, and pain medication prescriptions were tracked for the separate groups and for the individual procedures within those groups.

Results:

From 2005-2014, 206409 patients were identified for comparison. Podiatrists performed 87.5% of hallux valgus corrective procedures with significantly different (p<0.0001) treatment approaches with 78.9% distal metatarsal osteotomy (OS 63.2%), 16.2% double osteotomy (OS 25.3%), and 4.9% first tarsometatarsal arthrodesis (OS 11.5%). Orthopedic surgeons and podiatrists demonstrated similar hospital admission rates 3 months from surgery or reoperation at 1.8% and 1.5% respectively. Amongst all providers, there was significantly more (p<0.001) reoperations and admissions after first tarsometatarsal arthrodesis (2.1%) when compared with distal metatarsal (1.5%) and double (1.6%) osteotomies. 9254 patients were available for prescription drug comparison that demonstrated significantly different prescribing trends with orthopedic surgeons prescribing hydrocodone 2.8% (PO 12.9%), oxycodone 39.4% (PO 10.8%), and tramadol 43.4% (PO 60.0%).

Conclusion:

A large portion of hallux valgus correction is being performed by podiatrists amongst privately insured patients. Podiatrists were much more likely to perform distal metatarsal osteotomy while orthopedic surgeons were more likely to perform double osteotomies and first tarsometatarsal arthrodesis. Hospital admission within 3 months was similar for the providers. Podiatrists were more likely to prescribe hydrocodone and tramadol while orthopedic surgeons demonstrated greater numbers with oxycodone prescriptions.
Payment drivers in Medicare patients undergoing total ankle arthroplasty
Authors: Cunningham Daniel , Adams Samuel , Easley Mark , Karas Vasili , DeOrio James
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

The Comprehensive Care for Joint Replacement model (CJR) provides bundled payments for in-hospital and 90-day post-discharge care of patients undergoing total ankle arthroplasty (TAA). Defining patient factors associated with increased costs during TAA could help refine patient selection strategies and identify modifiable preoperative patient factors that can be addressed prior to the patient entering the bundle.

Methods:

This study is part of an IRB-approved single-center observational study of patients undergoing TAA from 1/1/2012 to 12/15/2016. Patients were included if they met CJR criteria for inclusion into the bundled payment model and had Medicare as the insurance payer. Costs related to readmissions, diagnosis, and procedures that had been excluded by CJR were also excluded from this financial analysis. All inpatient and outpatient payments beginning at the index procedure through 90 days postoperatively were identified. Patient medical profile including Charlson-Deyo and Elixhauser comorbidity scores, preoperative comorbidities, and perioperative factors were then completed based on institutional data and chart review. Additionally, post-discharge disposition, readmissions, emergency department (ED) utilization, and outpatient plastic surgery consultation were recorded within the 90-day bundled payment period.

Results:

Out of 199 patients with Medicare payments in the study timeframe, 137 had consented to the study and were analyzed. Baseline and operative characteristics are given in Table 1. Increased length of stay (LOS) at the initial procedure, increased Charlson-Deyo comorbidity score, cerebrovascular disease, and peripheral vascular disease were significantly associated with higher payments. Discharge to skilled nursing facility (skilled nursing facility), admissions, ED visits, and wound complications were significant drivers of payment.

Conclusion:

Increased Charlson-Deyo score and vascular disease along with increased LOS were associated with increased payments from Medicare. Discharge to SNF, readmission, ED visits, and wound complications considerably increased payments. This study identifies the relationship between patient profile and increased financial burden, highlighting the potential utility of pre-operative mitigation of modifiable risk factors and stratification of payments based on patient profile. Lastly, reducing rates of SNF placement, readmission, ED visitation, and wound complications are targets for decreasing costs for patients undergoing TAA.
Pronation of the First Metatarsal in Hallux Valgus Deformity
Authors: Cychosz Chris , Johnson Alyssa , Phisitkul Phinit
Published: September 2018

Category:

Bunion

Introduction/Purpose:

Hallux Valgus is a common condition often resulting in chronic pain and disability. However, the precise etiology of Hallux Valgus deformity remains poorly understood and likely results from a combination of intrinsic and extrinsic factors. There is conflicting evidence regarding as to whether hallux valgus deformity is associated with increased pronation of the first metatarsal. The purpose of this study was to investigate the correlation between hallux valgus and pronation of the first metatarsal in relation to other structural parameters of the foot.

Methods:

Eighty-five consecutive patients with clinically and radiographically diagnosed hallux valgus, pes planus, or cavovarus that underwent imaging with weightbearing CT between January 2014 and May 2016 were retrospectively enrolled and compared to a control group consisting of patients who with scans completed for indications unrelated to hallux valgus (e.g. ankle arthritis) and were determined to have normal foot structure. Using a weightbearing CT axial view, the alpha angle of the first metatarsal was measured and correlated with other radiographic parameters on plain weightbearing radiographs including Meary’s angle, hallux valgus angle, intermetatarsal angle, and calcaneal pitch.

Results:

There were 39 males and 46 females (91 feet) with a mean age of 47.16 (SD14.89) years and BMI of 32.99 (SD 7.35) kg/m2 included in this study. Mean pronation of the first metatarsal significantly (p<0.001) different in all group compared to the control: 15.23 (SD 7.96) in the hallux valgus group, 15.22 (SD 8.56) in the pes planus group, negative 0.23 (SD 5.99) in the cavovarus group, and 6.98 (SD 5.09) in the control group. There was moderate correlation between meary’s angle, tripod index, calcaneal pitch, and the alpha angle (negative 0.70, 0.65, negative 0.53, respectively) with a p-value < 0.001. HVA demonstrated little correlation with the measured alpha angle (0.23), p<0.03.

Conclusion:

Patients with hallux valgus deformity demonstrated a significantly higher pronation of the first metatarsal compared to the control group. However, a greater number of patients in the hallux valgus group had flatfoot deformity and further analysis revealed a greater correlation between foot type and pronation of the first metatarsal. Weightbearing CT is a reasonable way to image complex forefoot deformities prior to bunion surgery and it is important to take into account rotation of the first metatarsal in bunion surgery.
A Comparative Study of Two Different Techniques for Calcaneal Displacement Osteotomy
Authors: Gutteck Natalia
Published: September 2018

Category:

Hindfoot

Introduction/Purpose:

The lateral oblique incision is widely used for calcaneal displacement osteotomy in correction of hindfoot deformities. Wound healing problems and neurovascular injury are limitations of this procedure. A technique using a Shannon burr for calcaneal displacement osteotomy was introduced to avoid these complications. The advantages of the percutaneos calcaneus osteotomy have been evaluated in a comperative study.

Methods:

Lateral oblique incision for calcaneus osteotomy was performed in 58 patients. The senior author changed the osteotomy technique 2014. Further 64 calcaneus osteotomies were performed percutaneously. The main indication for the calcaneus osteotomy was correction of hindfoot deformities. Complementary the number of screws used for the fixation have been axamined in the study.

Results:

The mean age of the patients was 51,6 (14-72) years. The patients were folled up for 12 months. All cases achieved radiographic union. Wound healing problems have been registrated in the open technique group in 16 patients (27,6%). Six of them (10,3%) required a surgical revision. No wound healing problems appeared in the percutaneous group. N. suralis was affected in the open technique group in 12 patients (20,6%) and in 4 patients (6,2%) in the percutaneous osteotomy group (p 0,02). The operating time was significantly shorter in the percutaneus osteotomy group. The correction of the hindfoot axis succeed in all patients. Risk of complication did not differ significantly between single and double screw in the percutaneous osteotomy group.

Conclusion:

The clinical and radiological examinations showed outstanding results. There is no evident difference between the two techniques in the radiological results. Use of a single screw in percutaneous osteotomy of the calcaneus did not increased the complication rate. The percutaneous calcaneal osteotomy had a lower complication rate in our study and is probably a useful technique in patients with diabetes and affected perfusion. Further randomised studies should consider this results.
New screening method for hallux valgus with using smartphone
Authors: Hayatoshi Shibuya , Nakasa Tomoyuki , Sawa Mikiya , Tsuyuguchi Yusuke , Kanemitsu Munekazu , Ota Yuki , Adachi Nobuo
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

We developed a new screening method for hallux valgus during weight bearing using the photo-capturing function in cell phones.

Methods:

We compared apparent hallux valgus angles measured from photographs of people in a standing position during weight bearing, which were captured on a smartphone (smartphone Hallux Valgus Angle: SP-HVA) (Smartphone Method), with hallux valgus angles determined using conventional radiography in a standing posture during weight-bearing (X-ray HVA: XR-HVA). We evaluated 37 feet of 25 patients (5 men and 25 women) who visited our hospital. The mean age at the time of the visit was 73.9 years. In the Smartphone Method, subjects stood upright and the examiner used a smartphone to take photos of both feet from above while holding the phone at the level of the anterior knee.

Results:

The mean value was 36.2° for SP-HVA and 36.7° for XR-HVA; the two methods showed a statistically significant correlation (correlation coefficient of 0.86).

Conclusion:

Our smartphone-assisted screening method for hallux valgus was possible to make a diagnosis equivalent to conventional radiography method without radiation exposure.
Ankle Arthrodesis Through an Anterior Approach
Authors: Jarrell Kathleen , Denisiuk Marek , McDonald Elizabeth , Raikin Steven
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Ankle arthrodesis can be approached anteriorly, laterally, medially, or posteriorly, and debate remains as to which approach is most advantageous. Although an anterior approach using the interval between the extensor hallucis longus and tibialis anterior is commonly performed, there is a paucity of studies showing the clinical outcomes after this procedure. This study aims to evaluate the functional outcomes and patient satisfaction at mid-term follow-up after ankle arthrodesis via an anterior approach.

Methods:

All isolated primary ankle arthrodeses performed with the anterior approach by a single fellowship-trained foot and ankle surgeon between May of 2011 and December of 2015 were retrospectively included. Chart review was performed and patient reported outcomes were collected including FAAM ADL, FAAM Sports, VAS, and SF-12 scores pre-operatively and at a minimum of two-years post-operatively. At final follow-up, a survey was distributed via phone or email inquiring about level of satisfaction and whether they would undergo the procedure again. A total of 108 patients were included, of which only 45 (41.67%) had pre-operative functional scores, 24 (22.2%) completed both pre- and post-operative functional scores, and 20 patients (18.5%) had satisfaction results. The average length of follow-up was 4.4 years (range: 1.7 – 7.9, SD 1.6).

Results:

FAAM ADL scores improved from a mean of 48.1 to 67.6, FAAM Sports increased from 18.1 to 34.9, VAS Pain decreased from 73.2 to 44.9, SF-12 MCS changed from 44.2 to 46.7, and SF-12 PCS increased from 31.0 to 42.2. Using a linear mixed effects model and controlling for length of follow-up, all functional and pain score improvements were significant except SF- 12 MCS (Table 1). Overall, 65% of patients were satisfied with their results and 85% of patients would consider the same surgery if needed. Patients who were more satisfied with their surgery were more likely to say that they would consider the same surgery given similar circumstances (p = 0.001).

Conclusion:

Post-operative functional scores were significantly improved and pain scores were significantly decreased compared to pre-operative scores in a cohort of patients who underwent ankle arthrodesis using an anterior approach. Satisfaction with the surgery was lower than expected given the improvement in functional scores. Further study is indicated to determine methods to improve satisfaction. Our study suggests that an anterior approach to ankle arthrodesis is an effective technique to improve function and pain in patients with ankle arthritis, however satisfaction after surgery is no guarantee. The study is limited by the small subset of patients with pre- and post-operative functional scores.
All-inside Arthroscopic Modified Broström Operation for Lateral Ankle Instability with Os Subfibulare
Authors: Kim Woo Jong , Lee Young Koo
Published: September 2018

Category:

Sports

Introduction/Purpose:

Os Subfibulare(OSF) is an accessory ossicle that lies at the tip of the lateral malleolus of the ankle. Patients with chronic lateral ankle instability (CLAI) have a high incidence of OSF, and there relationship implies that there is a correlation between OSF and CLAI. The all-inside arthroscopic Modified Broström Operation (MBO) has been developed for the treatment of chronic lateral ankle instability (CLAI) and the outcome was reported as good or excellent. But there were no report about comparison of the outcome between OSF and non-OSF patients with chronic lateral ankle instability treated by all-inside arthroscopic MBO. The purpose of this study was to evaluate the clinical and radiologic outcomes of the arthroscopic MBO procedure for CLAI with or without OSF.

Methods:

From January 2013 to september 2016, arthroscopic MBO was performed on 133 patients with CLAI. Of these, 126 ankles were evaluated for this study. Patients were divided into two groups: the OSF group (26 patients), without OSF group (100 patients). Evaluation tools included the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot ankle score and pain Visual Analogue Scale (VAS) at preoperatively, 6 and 12 months postoperatively for clinical outcomes. And we also evaluated the talar tilt angle in the varus stress radiograph at preoperatively, 6 and 12 months postoperatively for radiologic outcomes.

Results:

There were no difference in age, sex, preoperative AOFAS hindfoot ankle scores and VAS scores and talar tilt angle between the two groups preoperatively(P >.05). And there also were no difference at the final follow-up (P >.05).The final follow-up AOFAS hindfoot ankle score and Vas in both group showed improvement compared with preoperaive values.

Conclusion:

There were no difference in both clinical and radiologic outcomes between OSF group and non-OSF group at a minimum 12 months follow-up. We achieved similar successful outcomes in both groups using All-inside arthroscopic MBO. Arthroscopic MBO should be considered as a reasonable alternative method in patients who have chronic lateral ankle instability regardless of the presence of OSF.
Effect of CAM boot immobilization on weightbearing stability in syndesmotic injuries
Authors: Lamer Stéphanie , Dube Vincent , Hebert-Davies Jonah , Stephane Leduc , Menard Jeremie , Nault Marie-Lyne
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Ankle injuries are one of the most frequent traumas of the lower limb. They typically involve the lower lateral ligaments of the ankle, but the syndesmosis is also affected in up to 18% of cases. The degree of instability of syndesmotic joint depends on which ligaments are affected. Adequate management of syndesmotic injuries is crucial to avoid long term complications. The primary goal of our study was to evaluate the effect of simulated weightbearing on syndesmotic instability resulting from isolated AiTFL injury and from combined AiTFL/IOL injuries. The secondary goal was to evaluate the effect of a controlled ankle motion walking boot on syndesmosis stability following injury. We hypothesized that the CAM boot would prevent significant instability even in two ligaments injuries.

Methods:

Ten cadaveric specimens were dissected to expose the syndesmosis to create progressive iatrogenic syndesmosis ruptures. Uninjured syndesmoses were compared to isolated AiTFL and combined AiTFL/IOL ruptures. The specimens were fitted in a custom-made device to allow stabilization of the leg and apply a reproducible axial load (AL) of 750 N, equivalent to the weight of a 168-pound person. For each specimen and injury pattern, CT-scan images were obtained with and without AL, and with a CAM boot under AL. Distal tibio-fibular relationship was evaluated in three planes using a previously validated measurement system developed on CT. Wilcoxon tests for paired samples and non-parametric data were done to compare the different conditions.

Results:

For our first objective, when comparing ankles with isolated AiTFL to combined AiTFL/IOL rupture with and without AL, the only significant difference was an increase in internal rotation between the incisura and a line drawn in the axis of the fibula. Even with minimal statistical differences, it appears that axial loading does not impact syndesmotic stability apart from a slight increase in internal rotation with a single or two-ligament injury. As for our second end point, with the CAM orthopedic boot, no significant widening of the syndesmosis happened when either one or both ligaments were sectioned, in an axial loading state. We therefore confirmed our hypothesis that even with two syndesmotic ligament injuries, axial loading in a CAM boot does not affect distal tibio-fibular anatomy.

Conclusion:

This study reveals that weight bearing without rotational force does not affect the stability of the syndesmosis. Incomplete syndesmotic injuries can likely be treated with nonoperative treatment in a CAM boot and weight bearing as tolerated. Further clinical studies are needed to confirm these findings.
The valid diagnostic parameters in static bilateral CT scan to predict unstable syndesmotic injury with ankle fracture
Authors: Lee Si Wook
Published: September 2018

Category:

Trauma

Introduction/Purpose:

The purpose of this study is to evaluate valid and reasonable parameters to predict syndesmotic injury in ankle fracture.

Methods:

Seventy patients who underwent preoperative bilateral CT scans were enrolled retrospectively. On preoperative x-ray, tibiofibular overlap (TFO) and tibiofibular clear space (TFCS) were measured. On preoperative CT scan, anterior fibular distance (AFD), posterior fibular distance (PFD), anterior translation distance (AT), fibular diastasis (FD), anterior-posterior translation (APT), fibular length (FL), surface area of syndesmosis (SAS), surface area of syndesmosis of 1.5 cm above the ankle joint line (SAS1.5) were measured. Those measured values were divided with those of uninjured side, in order to minimize the differences among the individuals.

Results:

Statistically significant differences has been shown between The measurements of ratio (Injured/Uninjured) of TFO, PFD, APT, Diastasis, and SAS of groups which required transfixation have shown statistically significant difference, compared to those of groups which did not require transfixation. Other measurements were not showing significant difference. Furthermore, using ROC curve analysis, a ratio of measurement which is the most reasonable to predict transfixation was SAS (95% confidence interval = 0.598 – 0.869, cut of value = 1.555)

Conclusion:

Measuring TFO, PFD, APT, Diastasis, and SAS from CT scans and comparing with uninjured side preoperatively can provide surgeon an reasonable evidence to perform transfixation intraoperatively
Functional treatment for fractures to the base of the 5th metatarsal - Influence of fracture location and fracture characteristics
Authors: Polzer Hans , Braunstein Mareen , Baumbach Sebastian
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Fractures to the base of the fifth metatarsal are common, but their treatment remains controversial. Especially for Lawrence and Botte (L&B) type II fractures, there is conflicting evidence and consequently no consensus. Further, many authors consider displacement, articular involvement, and number of fragments an indication for surgery, although evidence is missing. The aim of this study was to evaluate the outcome of functional treatment for all L&B type I and II fractures. Of special interest were the influence of (1) the fracture location (L&B type I vs. II) and (2) the fracture characteristics (displacement, intra- articular involvement, communition) on the subjective outcome.

Methods:

Retrospective registry study with a prospective follow-up. Patients with an acute, isolated, epi-metaphyseal fracture to the fifth metatarsal bone (L&B type I and II) treated by full weightbearing with a minimum follow-up of 6 months were included. Fracture location (L&B type I and II) and characteristics (displacement <2 mm or >2 mm, intra-articular involvement, and number of fragments) were assessed. Outcome parameters were return to work, return to sports, VAS-FA, and SF-12. The influence of the fracture location and -characteristics on these parameters was tested.

Results:

39 patients (40±15 years, 56% female) were enrolled with a mean follow-up of 22±10 months. L&B type I fractures occurred in 59%, type II in 41%. Thirty-one percent of all fractures were dislocated, 74% intra-articular, and 41% multi-fragmentary. Patients returned to work after 17±12 days, to sports after 53±22 days. The VAS-FA score at the final follow-up was 96±4, SF-12 PCS score 57±5 and MCS score 51±8. No complications were reported, no patient required surgery. None of the assessed outcome parameters differed significantly between (1) the different fracture locations (L&B type I vs. II) or (2) the different fracture characteristics (displacement, intra-articular involvement, and number of fragments).

Conclusion:

Both, L&B I and II fractures featured excellent results with immediate full weightbearing. Consequently, L&B type I and II fractures should be summarized as epi-metaphyseal fractures. Fracture displacement, articular involvement, and number of fragments did not influence the outcome. Therefore, functional treatment should be recommended for all epi-metaphyseal fractures.
Benefit of weight-bearing CT - what have we learned from more than 8,000 scans at a foot and ankle center
Authors: Richter Martinus , Lintz Francois , Barg Alexej , Burssens Arne
Published: September 2018

Category:

Other

Introduction/Purpose:

Weight-bearing CT (WBCT) has been proven to allow for more precise and valid measurement of bone position than conventional weight-bearing radiographs (R) and conventional CT without weight-bearing (CT). Time spent for image acquisition has been shown to be lower for WBCT than for R and CT2. Radiation dose for WBCT has been shown to be lower for WBCT than for CT. A WBCT device (PedCAT, Curvebeam, Warrington, PA, USA) had been brought on line July 1, 2013 in the first author´s foot and ankle department. The purpose of this study was to assess the benefit of using WBCT instead of R and/or CT in a foot and ankle center regarding time spent for image acquisition, radiation dose, disturbances, and cost effectiveness.

Methods:

All patients who obtained WBCT July 1, 2013 until December 31, 2017 were included in the study. Age, sex and primary pathology were analyzed. The time spent for image acquisition (T) was calculated based on an analysis of a previous study as follows: R (bilateral feet dorsoplantar and lateral, metatarsal head skyline view), 902 seconds; CT (bilateral feet and ankle), 415 seconds; WBCT (bilateral), 207 seconds. Radiation dose (RD) per patient was calculated based on previous phantom measurements as follows: R, 1.4 uSV; CT, 25 uSv; WBCT 4.2 uSv. For analysis of cost effectiveness device cost, reimbursement and working time cost of radiology technicians were taken into consideration within the local circumstances. All parameters were compared between the time period using WBCT (yearly average) with the parameters from 2012, i.e. before availability of WBCT.

Results:

8,129 WBCT scans were obtained in 3,874 patients (3,874 (48%) preoperatively, 4,255 (52%) follow-up; mean age, 52.2; 39% male). Primary pathologies were forefoot deformities (n=728 (19%) and ankle osteoarthritis/cartilage defect (n=412 (11%)). 1,804 WBCT scans were obtained on average yearly, and 10 CTs (WBCT group). In 2012, 1,750 R and 250 CTs were obtained (R(+CT) group). Yearly RD was 4.3 uSv for WBCT group and 5.0 uSv for R(+CT) group (difference 0.6 uSv decrease with WBCT 13%, p<0.01). Yearly T was 105 hours in total (3.5 minutes per patient) for WBCT group and 961 hours in total (16.0 minutes per patient) for R(+CT) group (difference, 752.0 hours, decrease with WBCT, 78%, p<0.01). Yearly profit was 34,300 Euro for WBCT group, -846 Euro for R(+CT) group.

Conclusion:

8,129 WBCT scans in 3,874 patients as substitution of R(+CT) over a 4.5 year period at a foot and ankle center resulted in 13% decreased RD (minus 0.7 uSV on average per patient). Yearly T decreased 752 hours (78%) in total (12.5 minutes per patient). Yearly financial profit increased 35,000 Euro in total (19 Euro per patient). RD decreased despite higher radiation dose for WBCT than for R alone, based on substitution of a high number of CTs by WBCT. Other centers with low usage of CT might not decrease RD by substituting R alone by WBCT.
Outcomes of Exogen low-intensity pulsed ultrasound in the management of delayed union following elective foot and ankle surgery
Authors: Scrimshire Ashley , Torres Paulo , Koziara Michal , Allport Jack
Published: September 2018

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Exogen low-intensity pulsed ultrasound therapy is well established in the management of fracture delayed or non-union. Its use in trauma has recently been recommended by the National Institute for Clinical Excellence in England. In comparison the use of Exogen for managing delayed union following elective foot and ankle surgery has not previously been reported in the literature. We aim to review the indications for and outcomes following Exogen therapy for managing delayed union following elective foot and ankle surgery in our English tertiary referral centre.

Methods:

Case notes and imaging were reviewed for all patients receiving Exogen therapy following elective foot and ankle surgery from July 2012 - July 2017 in our centre. Data were collected on patient demographics, smoking status, comorbidities, indications for and type of surgery performed, duration of Exogen therapy and final outcomes. Union was confirmed radiologically and clinically.

Results:

58 patients were included, 18 smokers and 8 diabetic. The mean age was 55 years. 50 underwent an arthrodesis, 8 an osteotomy. Exogen was started a mean of 244-days post-operatively. 24 patients went on to complete union; a further 7 were showing good progress towards union. When grouped together the union rate was 53.4% (n=31). Complete union took a mean of 177-days (range 44–441). The non-union rate was 46.6% (n=27) despite a mean of 330-days treatment (range 72–1112). 1 was complicated by infection. There were no significant differences in age, time to commencing Exogen, number of smokers or diabetics between the groups. The non-union group had significantly longer treatment (p=0.003). Union was more likely following an osteotomy (n=6/8,75%) or surgery to the hindfoot (n=6/7,86%).

Conclusion:

We have found Exogen can be beneficial in managing delayed union following elective foot and ankle surgery for over half of patients. This can potentially reduce the number of revision surgeries required. We found no correlation between patient age, smoking or diabetes in outcome. Union was more likely following a corrective osteotomy or surgery to the hindfoot. This data can help inform clinicians in their decision-making and in counselling patients.
Postoperative infection in foot & ankle surgery
Authors: Shah Ashish , Huntley Samuel , Abyar Eildar , Lehtonen Eva , Naranje Sameer , Anderson Matthew , Kalra Rishi , Hsu Alan , Dahlgren Nicholas
Published: September 2018

Category:

Other

Introduction/Purpose:

Surgical site infections (SSI) are infections of the incision site, organ, or space at or near the surgical incision within 30 days of the procedure or within 90 days for prosthetic implants. Being the most common nosocomial infection, SSI’s are a burden to the healthcare system as they increase costs, duration of stay, antimicrobial resistance, morbidity, and mortality. While there is limited evidence in the orthopaedic literature suggesting that the incidence of SSI increases during the summer months, this association has not been examined in the setting of foot and ankle surgery. The purpose of this study was to determine whether seasonal variation plays a role in developing SSI’s after orthopaedic foot and ankle surgery.

Methods:

Data from the National Surgical Quality Improvement Program (NSQIP) years 2011-2015 were used in this study. The pooled and individual incidences of superficial incisional SSI, deep SSI, and organ space SSI were calculated and stratified by quarter of admission. The quarters of admission represent the various seasons (1=winter, 2=spring, 3=summer, 4=fall). Differences in the incidence of SSI as well as various demographic, comorbidity, and complication variables were evaluated using ANOVA for continuous variables and Pearson’s Chi-Square for categorical variables.

Results:

A total of 17,939 patients were identified. After pooling the superficial, deep, and organ space infections, the overall SSI rate was highest in the summer months (July-September, 3rd quarter) at 2.68% as compared to 2.20%, 2.33%, and 2.14% in the other respective quarters (p=0.338). There was a total of 218 cases of superficial incisional SSI. The summer months had the highest incidence of superficial SSI at 1.38% compared to 1.14%, 1.13%, and 1.21% for 1st, 2nd, and 4th quarters, respectively (p=0.677). There were 145 cases of deep incisional SSI. The third quarter again had the highest rate at 1.02% compared to 0.72%, 0.93%, and 0.60% for 1st, 2nd, and 4th quarter respectively (p=0.105).

Conclusion:

Our results show that superficial incisional SSI, deep incisional SSI, and open wound infections have increased likelihood during the summer months in the setting of orthopaedic foot and ankle surgery. Some studies have associated the increased temperature and humidity during the summer months with increased rates of infections and our results show similar trends. Additional evidence with larger sample sizes is needed to determine which specific procedures are at highest risk of infection during the summer months.
Innovative ‘Push Screw’ as reduction aid for minimally invasive fixation of calcaneus fracture
Authors: Shah Rajiv
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Percutaneous reduction of depressed and rotated articular fragments is the most challenging job during minimally invasive fixation of fracture calcaneus. A solid, fully threaded, flat ended, 6.5 mm cancellous ‘Push Screw’ designed by us, serves as novel innovative tool for this purpose. ‘Push Screw’, by its pushing ability; not only reduces the articular fragment but also carries with it a big chunk of underlying subchondral cancellous bone for fixation of subarticular raft screws. We present a study of 28 cases of calcaneus fractures treated with minimally invasive techniques where ‘Push Screws’ were utilized to gain articular reduction of subtalar as well as calcaneocuboid joint.

Methods:

Twenty eight intra-articular calcaneus fracture cases where ‘Push Screw’ assisted reduction was done were included in present study. Image assisted method of achieving reduction with ‘Push Screws’ comprised of placement of a subarticular guide wire, drilling and tapping of a pilot hole, driving of a flat ended ‘Push Screw’ followed by placement of a subchondral raft screw in reduced articular fragment. ‘Push Screws’ were either replaced or retained. Sequential tightening and strategic placement of two ‘Push Screws’ helped to correct rotation as well as depression. Cases were segregated as per the joints where ‘Push Screws’ were utilized.

Results:

‘Push Screw’ assisted subtalar joint restoration was carried out in all 28 cases, while 3 cases required restoration of both; calcaneocuboid as well as subtalar joint. Use of more than one ‘Push Screw’ was required in 8 cases, out of which 3 Sander type III cases required use of three ‘Push Screws’. All these cases had involvement of both subtalar as well as calcaneocuboid joint. In 26 out of 28 cases ‘Push Screws’ were replaced with fully threaded 6.5 mm cancellous screws while in remaining 2 cases they were retained. Malreduction was noticed in 3 cases and loss of initial reduction was noticed in 2 cases.

Conclusion:

‘Push Screw’ is a novel innovative tool to achieve articular reduction at minimally invasive reduction of calcaneus fracture. It not only helps to soundly reduce articular facet but also carries with it lifted chunk of subchondral bone for sound fixation of subarticular raft screw. Ease of image aided analysis of reduction, maintenance of reduction and fixation of articular fragment are the unique advantages of ‘Push Screws’. ‘Push Screw’, a cheap and versatile reduction tool also obviates the need for trained assistant.