bluuebunny/crossref_metadata_2025 huggingface dataset:
Talar Osteo-Periostic grafting from the Iliac Crest (TOPIC): 1-year Results of a New Press-fit Surgical Treatment for Large Talar Osteochondral Defects
Authors: Kerkhoffs Gino , Stufkens Sjoerd , Dahmen Jari , Altink Nienke
Published: October 2019

Category:

Ankle

Introduction/Purpose:

The purpose of this study was to present the surgical technique and to evaluate the short-term clinical and radiological outcomes of a new press-fit OATS technique for large primary and secondary talar osteochondral defects of the talus, Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC).

Methods:

Twenty-eight underwent a press-fit TOPIC procedure. Mean age was 38 years (SD 4.6). Pre- and postoperative clinical assessment at 12 months follow-up included the American Orthopaedic Foot & Ankle Society (AOFAS) score, the Short-Form 36 (SF-36) Mental Component Scale (MCS) and Physical Component Scale (PCS), the Numeric Rating Scales (NRS) of pain at rest, during walking and stairclimbing, and the Foot and Ankle Outcome Score (FAOS) including accompanying subscales. Remodeling of the contour of the talus, bone ingrowth and consolidation of the implanted graft were assessed on computed tomography (CT) one year post-operatively.

Results:

28 out of 29 patients were available for follow up. The AOFAS significantly improved from 45 to 92 (p=0.001). The NRS on pain during rest improved from 3 to 0 (p=0.001), the NRS during walking improved from 5 to 1 and the NRS during stairclimbing also improved from 5 to 1 (p=0.001). Both components of the SF-36 improved. The PCS improved from 34 to 47 (p=0.001) and the MCS improved from 37 to 66 (p=0.001). Finally all FAOS subscales significantly improved. All patients were satisfied with the procedure and indicated that the level of functioning was good or very good. On the post-operative CT scans, all patients showed remodeling of the talus and all grafts showed consolidation as well as bone ingrowth. No complications occurred.

Conclusion:

The TOPIC procedure appears to be a very promising surgical treatment option for large primary and secondary talar OCDs. Despite these good short-term clinical and radiological outcomes, a prospective study with longer follow-up is necessary to assess the clinical outcome and the progression of osteoarthritis at the long term.
Immediate Improvement in Physical Function after Symptomatic Syndesmotic Screw Removal
Authors: Kohring Jessica M. , Baumhauer Judith F. , Flemister Sam , Oh Irvin , DiGiovanni Benedict F. , Ketz John P.
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

The purpose of this study was to investigate the immediate impact of removing symptomatic syndesmotic screws on PROMIS outcomes and ankle range of motion (ROM) in patients who had previously undergone ankle fracture open reduction and internal fixation (ORIF) and syndesmotic fixation and later experienced symptomatic syndesmotic screws and functional limitation.

Methods:

A total of 346 ankle fractures were treated from February 2015 to May of 2018. 58 patients with ankle fractures with syndesmotic instability and fixation who underwent syndesmotic screw removal (SSR) were included in the analysis. Cohort data was collected for 71 patients who underwent ORIF with syndesmotic fixation, but without screw removal during the same study period.

Results:

Patients who underwent SSR had a statistically significant improvement in the physical function (PF) T-score to 44.5 (p<0.01) in the early post-operative period (average 48 days) after screw removal. The screw removal occurred an average of 184 days after initial ORIF. This PF T-score change also met the minimally clinically important difference. There was no significant difference in PF T-scores between the SSR group and cohort comparison group (44.5 vs 41.6; p=0.06) after screw removal. Removal of symptomatic implants resulted in an early improvement of total arc ankle ROM by 20° (p<0.01).

Conclusion:

There was an early clinically meaningful and statistically significant improvement in physical function outcomes and ankle ROM after symptomatic syndesmotic screw removal for patients who underwent ankle fracture ORIF with syndesmotic fixation. The final outcomes after screw removal in these patients was similar to the outcomes of asymptomatic patients who did not require syndesmotic screw removal within the same post-operative timeframe.
13-year Follow-up of Treatment of Osteochondral Lesions with MACI
Authors: Kreulen Chris , Shelton Trevor , Nguyen Jacqueline , Giza Eric , Sullivan Martin
Published: October 2019

Category:

Ankle, Arthroscopy, Hindfoot, Sports, Trauma

Introduction/Purpose:

Surgical management of osteochondral lesions of the talus (OLT) present an ongoing treatment challenge. Previously, matrix-induced autologous chondrocyte implantation (MACI) demonstrated improved pain and function at 7-years postoperative, providing evidence that MACI is a reliable method for treating cartilage. However, it is unknown the long- term results of MACI in OLT. The purpose of this study was to assess 13-year clinical follow-up data and the long-term success of this implant by comparing patient reported outcome measures (PROMs) pre-operatively, at 7-years post-operative, and at 13- years post-operative.

Methods:

A prospective investigation of MACI was performed on 10 patients with OLTs who had failed previous arthroscopic treatment. Of the 10 patients, 9 were available for 7-year and 13-year follow-up. Short Form Health Survey (SF-36) and the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot evaluation were utilized at pre-operative, 7-year, a 13-year postoperative. For each patient, a paired t-test was used to compare 13-year post-operative PROMs to pre-operative PROMs. A single factor analysis of variance (ANOVA) determined whether PROMs were different between pre-operative, 7-year post- operative, and 13-year post-operative time intervals. When a significant difference was detected, a post-hoc Tukey’s determined which time periods were different.

Results:

SF-36 data at 13-years showed significant improvements in Physical Functioning (p=0.012), Lack of Bodily Pain (p=0.017), and Social Functioning (p=0.007) compared with preoperative data. There were no differences in other components of the SF-36 outcomes (p>0.05). Although the AOFAS was on average 12 points higher at 13-years postoperative, this was not statistically significant (p=0.173). As for comparing PROMs over time, 13-years post-operative PROMs were comparable to 7-years post- operative (Table 1). There were better PROMs for Physical Functioning, Bodily Pain, and Social Functioning at 7- and 13-years post-operative compared to pre-operative while Physical Role Functioning was also better at 7-years post-operative compared to pre-operative.

Conclusion:

This study shows MACI provides greater pain relief and function at 13-years post-operative with stable long-term follow-up. MACI should be considered for osteochondral lesions that fail initial microfracture.
Patient Reported Opioid Consumption Following Outpatient Foot and Ankle Surgery
Authors: Thompson Samuel F. , Burrow Zackary P. , Conant Scott H. , Kelly Samantha P. , Fene Evan S. , Morrisett Ryan W. , Haleem Amgad M.
Published: October 2019

Category:

opioid consumption

Introduction/Purpose:

The expanding opioid crisis has forced orthopedic surgeons to evaluate their prescribing practices, yet there remains limited evidence to guide providers in achieving safe and effective postoperative analgesia. Our goal was to prospectively evaluate opioid consumption following outpatient foot and ankle surgery and determine predictors of increased narcotic usage.

Methods:

We prospectively enrolled adult patients scheduled for outpatient foot and ankle surgery and conducted phone and in- person interviews postoperatively to determine pain level, number of pills consumed, satisfaction with pain control, and whether other analgesic medication was used. Interviews were performed at four separate time points: 5 days, 10 days, 2 weeks, and 6 weeks following surgery. Additional data collected included age, gender, payer status, education level, preoperative pain level, procedure performed, whether opioid pain medication had been used by the patient in the 12 months preceding surgery, and the amount of narcotic prescribed postoperatively.

Results:

Complete data was available for 52 patients (median age, 42 years). The median number of opioids prescribed postoperatively was 45 pills (337.5 morphine milligram equivalents (MMEs)). A refill narcotic prescription was provided for 36.5% of patients. The number of opioid pills consumed following surgery ranged from 0 to 120 (median, 40 pills). Forty-six percent of patients had discontinued the use of opioids by post-op day 10 and 86.5% by post-op day 20. Increased pre-operative pain level (p = 0.02) and an increased quantity of pills prescribed at the first prescription (<0.0001) were significantly associated with increased narcotic consumption. Eighteen (39.1%) patients filled a narcotic prescription in the 12 months prior to surgery, however, narcotic use prior to surgery did not significantly increase total opioid consumption.

Conclusion:

We found that the median number of opioids consumed following outpatient foot and ankle surgery was 40 pills. Nearly 90% of patients had discontinued narcotic use by 20 days postoperatively. Pre-operative pain level and the number of pills provided at the first prescription were predictive of increased narcotic usage.
Primary Arthrodesis Compared with Open Reduction and Internal Fixation for Lisfranc Injuries with the First Tarsometatarsal Joint Dislocation: A Randomized Controlled Trial
Authors: Zhang Mingzhu , Yu Guangrong
Published: October 2019

Category:

Midfoot/Forefoot, Trauma

Introduction/Purpose:

Prospective analyses of treatment for the first tarsometatarsal joint dislocation with Lisfranc injury. Comparison of open reduction internal fixation (ORIF) and primary arthrodesis was conducted for the injury.

Methods:

78 Lisfranc injuries with first tarsometatarsal joint dislocation underwent surgical intervention. They were 46 males and 32 females with mean age of 41.2 years. Two groups were randomized by ORIF group and primary arthrodesis group. 43 patients were performed by ORIF, while primary arthrodesis group including 35 cases. Outcome measures included radiographs, AOFAS scores, VAS and SF-36 scores. Complications and revision rate were analyzed also.

Results:

73 patients were followed up for 21 months. At 1.5 years postoperatively, the AOFAS score was 75 and 83 in ORIF group and arthrodesis group. The VAS score was 3.0 and 2.1 separately in two groups. The mean Physical Functioning sores of SF- 36 was 81.2 points and 84.1 points. The Bodily Pain score of SF-36 was 79.3 points and 85.2 points. Redislocation of first tarsometarsal joint were observed in 11 cases among ORIF group.31 patients in ORIF group had pain in midfoot, six of them had persistent pain with the development of deformity or osteoarthrosis. No redislocation and no hardware failure was identified in arthrodesis group.

Conclusion:

Primary stable arthrodesis of the first ray gives a better short and medium term outcome than open reduction and internal fixation for Lisfranc injury with the first ray dislocation. Possible complication and revision could be avoided by primary arthrodesis for dislocated first ray injuries.
Does Retention of Fibula in Transfibular Approach Leads to Complication?
Authors: Abyar Eildar , Hess Matthew , McKissack Haley , Johnson Michael
Published: October 2019

Category:

Ankle, Ankle Arthritis, Hindfoot

Introduction/Purpose:

A variety of operative approaches and fixation techniques have been described for tibiotalar (TT) and tibiotalocalcaneal (TTC) arthrodesis. In the past two decades, authors have begun to more robustly examine outcomes of the transfibular approach for TT arthrodesis and expanded its indication to include TTC fusion. The transfibular technique is broadly divided into two categories: 1) Complete excision of fibula 2) Soft tissue preservation techniques with retention of fibula. The purpose of this study was to retrospectively assess the surgery outcomes in transfibular approach and compare the fibula excision versus fibula retention techniques and examine the factors that play into the risk.

Methods:

Following institutional review board approval, a retrospective review was performed on all patients who underwent TT and TTC arthrodesis through a lateral transfibular approach with minimum 1 year clinical and radiologic follow up. All other operative approach and fixation combinations for arthrodesis were excluded. Primary outcomes examined were union rate, revisions, and complications related to fibula excision versus retention group. Sixteen patients underwent TT and TTC arthrodesis with fibular retention and twelve with fibular excision techniques.

Results:

The overall union rate was 89%, 87% (14 of 16 ankles) for the fibula retention group, and 91% (11 of 12) for fibula excision group (P = .72). Symptomatic nonunion requiring revision arthrodesis occurred in 6% (1 of 16) of the retention group versus 8% (1 of 12) in the excision group (P = .83). There were no significant differences in individual tibiotalar or subtalar union, reoperation, superficial wound problems, infection and symptomatic hardware rates. Elective hardware removal was performed in 12%(2of 16) in fibular retention group versus 25%(3 of 12) in fibula excision group (P = .39), none of the hardware removal was related to the fibula fixation. Each group had three episodes of reoperation due to non-union, osteomyelitis and painful hardware.

Conclusion:

Union, reoperation rates were similar in fibula resection versus retention groups. The frequency of infection and wound complication was not significantly different in both groups, despite the wide variety of patient population and preoperative indications.
Short Term Radiographic Analysis of the Cartiva Implant for Hallux Rigidus
Authors: Adair Christopher R. , Zide Jacob R. , Royer Christian T , Reddy Veerabhadra , Brodsky James W.
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Cartiva (Wright Medical Group N.V.) was developed as an implantable interposition device for the treatment of hallux rigidus. It is performed along with a limited cheilectomy and serves as a joint preserving alternative to arthrodesis. In some patients, we have noticed gradual decreases in the joint space after surgery with Cartiva, presumably representing subsidence of the implant. The aim of this study is to report a radiographic analysis of visible joint space in surgical cases of hallux rigidus where dorsal cheilectomy and Cartiva were used.

Methods:

A prospectively collected patient database was queried for CPT code 28291 and those patients in which Cartiva was implanted were determined. The pre-operative and post-operative radiographs were analyzed for hallux rigidus grade, and measurements of visible joint space prior to and after Cartiva was implanted were performed at two weeks, one month, three months, and six months post-operatively. The percentage of visible joint space increase or decrease after implantation of Cartiva was calculated for each post-operative time point.

Results:

A total of 79 Cartiva were implanted in 74 patients between April 2017 and Sept 2018. The procedure was performed for Grade I hallux rigidus in 11% of patients (n=9), 66% grade II (n=52), 23% grade III (n=18). Mean pre-operative visible joint space measured 1.1 mm (n=79). Visible joint space measured at two weeks post-surgery was 2.2 mm (n=74); one month, 1.6 mm (n=65); three months, 1.2 mm (n=64); six months, 1.0 mm (n=30). Implantation of Cartiva resulted in 100% increase in visible joint space compared to pre-operative measurements at two weeks post-surgery, 45% increase at one month, 9% at three months, and a 9% decrease in visible joint space at six months.

Conclusion:

Cartiva implantation and limited cheilectomy for patients with symptomatic hallux rigidus provided a 100% increase in visible joint space on radiographs taken two weeks post operatively. However at six months post-surgery there was an overall 9% decrease in visible joint space presumably representing a subsidence of the Cartiva implant with time.
Comparison of Beaming Screw Outcomes with and without Subtalar Arthrodesis in Midfoot Charcot Reconstruction
Authors: Ahn Junho , Wukich Dane K. , Liu George T. , Raspovic Katherine M. , VanPelt Michael D. , Lalli A.
Published: October 2019

Category:

Diabetes, Midfoot/Forefoot

Introduction/Purpose:

Charcot neuroarthropathy (CN) is a complication of neuropathy secondary to diabetes mellitus (DM) and may involve multiple joints of the foot, in particular the midfoot. Patients with CN deformity associated with infection, ulceration or pre-ulceration are at risk of losing their limb. In these patients, reconstruction of the foot structure through beaming arthrodesis screws for stabilization is often required. In addition to midfoot beaming, previous reports have advocated for subtalar arthrodesis. Fixation of the subtalar joint restricts motion of the hindfoot. This rigid fixation has been hypothesized to offer greater stability and fewer hardware failures. The aim of this study was to describe failure of midfoot beaming screws after midfoot reconstruction of CN with and without subtalar arthrodesis.

Methods:

We retrospectively reviewed patients with DM diagnosed with CN. Patient radiographs were evaluated for type of midfoot Charcot reconstruction and hardware failure. Patients included in the study had follow up of 3 months or more. The main outcome variable of interest was hardware breakage.

Results:

Eighteen patients who underwent midfoot reconstruction for CN were included. The average age was 52.7 years (±8.4 years), 10 (55.6%) were male, and the average body-mass index (BMI) was 35.8 kg/m2 (±10.3 kg/m2). The average follow-up time was 6.5 months (±3.7 months). In the current series, thirteen out of 18 (72.2%) patients underwent subtalar fusion along with midfoot fusion. Screw breakage occurred in two patients, one at the 1st tarsometarsal joint and 2nd-4th tarsometarsal screws in another patient at 9 and 6 months respectively. Both patients with screw breakage had subtalar fusion. A third patient who had subtalar fusion subsequently developed collapse of their talus leading to subtalar screw removal 3 months after initial surgery. Patients without subtalar fusion did not experience screw breakage.

Conclusion:

An extended medial column fixation with subtalar arthrodesis has been previously proposed to provide better fixation after midfoot CN reconstruction with beaming screws as it restricts motion of the hindfoot. However, little to no evidence has been reported in favor of this technique. Our findings suggest that subtalar arthrodesis may result in fixation that is too rigid, which may place the beaming screws at higher risk of breakage. However, the number of observations is a limitation of our study, and further investigation comparing these techniques is needed to fully evaluate the effect of subtalar arthrodesis on midfoot beaming outcomes.
Talar Prosthesis Template: A Cadaveric Study of the Size Discrepancy between Right and Left Tali
Authors: Angthong Chayanin , Rajbhandari Prasit , Piyapanee Attaporn , Stufkens Sjoerd Antoine Sebastian
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Nowadays, the talar prosthesis has been designed for its size and shape based on the data of its contralateral talus. However, little is known about the discrepancy of the sizes between right and left tali. The present study was to demonstrate the difference between right and left talar sizes in the matched pairs of cadaveric specimens.

Methods:

A total of twenty four tali as twelve matched pairs of tali were collected in this study. All tali were measured with a Vernier caliper which provided the data for further analyzed regarding the talar size. The data was calculated to demonstrate the difference between right and left talar sizes in a matched pair method included the general size of talus. There was a talus which was not used in the data calculation due to its crystal deposition from an underlying disease of a cadaver.

Results:

In overall, an average talar length (TaL) was 53.5 millimeters (mm). An average talar dome height (TaH) was 31.2 mm. An average talar body width (TaW) was 41.3 mm. The average anterior trochlear width (TrAW), middle trochlear width (TrMW), posterior trochlear width (TrPW), and trochlear length (TrL) were 31.8, 31.2, 28.3, and 30.7 mm. Based on eleven matched pairs of tali, the paired T-test showed the significant difference of TaH (P-value: 0.019), TrMW (P-value: 0.027), and TrPW (P-value: 0.016) between right and left tali.

Conclusion:

The present study demonstrated the discrepancy of right and left talar sizes about three important parameters in the matched pairs of tali. Talar prosthesis template may be necessary to use other method to determine its size for the prosthesis manufacturing in addition to the utilization of measured profiles from the contralateral talus.
Syntethic Neoligamentplasty with FiberTape has the Same Rigididy than Transarticular Screws in Lisfranc Subtle Lesions
Authors: Baumfeld Daniel , Nery Caio , Baumfeld Tiago , Wagner Pablo , Prado Marcelo , Wagner Emilio
Published: October 2019

Category:

Midfoot/Forefoot, Sports

Introduction/Purpose:

Lisfranc joint injuries occur due to direct or indirect trauma, where a twisting or axial force is transmitted to the foot. Recently, new treatment options are being sought in order to use methods that allow a more physiologic fixation of this joint. The purpose of this study was to analyze the stability of a cadaveric Lisfranc injury model fixed with a synthetic neoligamentplasty in comparison to the traditional trans-articular screw fixation.

Methods:

24 fresh frozen lower leg cadaveric specimens were utilized. The medial (C1) and intermediate (C2) cuneiforms, first (M1) and second (M2) metatarsal bones were marked. A complete ligament injury was performed between C1-C2 and C1-M2 in 12 specimens (Group 1), and between C1-C2, C1-M2, C1-M1 and C2-M2 in 12 matched specimens (Group 2). The groups were further divided in fixation with screws (G1 Screws and G2 Screws) and with Tape (G1 Tape and G2 Tape). The tape fixation group used a fixation technique described by this group, using FiberTape (Arthrex, Inc.). After ligament lesion and fixation, the construct rigidity was measured with the help of a 3D Digitizer arm, comparing the distances between the marked bones over a stress condition (pronation and supination of the forefoot).

Results:

Distance C1-C2 increased 3 mm after ligament injury (23% increase) with supination motion. C1-M2 increased 4 mm after ligament injury (21% increase) with pronation motion. Distances between C1-M1 and C2-M2 only changed in Group 2, increasing 3 mm (14%) and 2 mm (16%) respectively. Rigidity between C1-C2, C1-M1 and C2-M2 did not differ between the fixation with screws and with tape. The fixation with screws presented more rigidity in C1-M2 distance (p=0,03), but only in pronation stress.

Conclusion:

Pronation and supination motion of the forefoot relative to the hindfoot produces measurable joint displacements. Tape and Screws can produce the same rigidity after repairing Lisfrac Ligament injuries, except for distance C1-M2 in pronation stress.
3D Printed Cage in Patients with Tibiotalocalcaneal Arthrodesis Using a Retrograde Intramedullary Nail: Early Outcomes
Authors: Bejarano-Pineda Lorena , Adams Samuel B. , Parekh Selene G.
Published: October 2019

Category:

Diabetes, Hindfoot, Trauma, salvage procedure

Introduction/Purpose:

Segmental bone loss in the hindfoot hinders the chance of successful outcomes. Tibiotalocalcaneal arthrodesis is a reliable option; however, the risk of nonunion is high. Structural graft is needed to fill the gap, but the use of bone grafts are limited by the availability, risk of collapse, and disease transmission. Three-dimensional (3D) printed titanium implants offer a strong scaffold that can be customized and present similar healing rates. The purpose of the study was to describe the clinical outcomes and the radiologic union rate of a case series of patients with hindfoot arthrodesis, using a retrograde intramedullary nail associated to a 3D printed titanium cage.

Methods:

After obtaining approval from our institution review board, a retrospective chart review was performed on seven patients undergoing hindfoot arthrodesis, using a retrograde intramedullary nail associated to a custom 3D printed titanium cage from March 2015 to December 2017. Demographic and clinical data were collected. Functional outcomes were assessed using The American Orthopedic Foot and Ankle Score (AOFAS) and the Visual Analog Scale (VAS) for pain. Hindfoot alignment was evaluated using preoperative and postoperative weightbearing radiographs that included anteroposterior, lateral and Saltzman views. Radiographic union was assessed using computed tomography scan at 6 and 12 months postoperatively.

Results:

All patients had ankle arthritis and six of them (85%) had prior surgery in the compromised hindfoot. The average age at TTC fusion was 57 (range, 29 to 71) years. The mean follow-up time was 21 (range, 12 to 32) months. Six patients had a healed fusion and one patient underwent below knee amputation due to recurrence of chronic osteomyelitis in the ankle. Two additional patients had minor complications. The average AOFAS at pre-op was 35 (range, 20 to 42) points as compared to 68 (range, 53 to 78) points at final follow-up; P=0.004. Preoperative VAS pain was 80.4 (range, 70 to 85) points as compared to 26.8 (range, 6 to 60) points; P=0.002.

Conclusion:

Tibiotalocalcaneal arthrodesis using customized titanium cages for patients with large bone defects has shown a high rate of union in those at high risk of nonunion. Further research is needed to monitor the development of late complications.
Virtual Scribe Services Decrease Documentation Burden Without Affecting Patient Satisfaction: A Randomized Controlled Trial
Authors: Benko Savannah , Idarraga Alex , Bohl Daniel D. , Hamid Kamran S.
Published: October 2019

Category:

Other

Introduction/Purpose:

Scribes are utilized as a means to reduce administrative burden on surgeons and enhance the physician- patient interaction. Virtual scribe services (VSS) are a contemporary take on the scribe that use a HIPAA-compliant smart device to record patient encounters for transmission, remote transcription, and insertion into the electronic medical record. The purpose of this study was to determine if the use of a VSS could decrease the total time an orthopaedic surgeon spends on documentation without diminishing the patient experience when compared to traditional post-encounter dictation (TD).

Methods:

Patients presenting for a first-time visit with an orthopaedic foot and ankle surgeon were consented and randomized to VSS or TD prior to the physician-patient encounter. Time spent with the patient in the exam room and time used to document away from the patient were recorded. A validated post-encounter survey assessed patient satisfaction, perception of physician empathy, understanding of the plan, and perception of the amount of time spent with the physician on scales of 0 to 10. An a priori sample size calculation with an alpha level set at 0.05 and power of 80% estimated that 50 patients were necessitated to demonstrate a 2-minute difference in time spent documenting away from the patient. Comparisons were made using a two-sample Student’s t-test.

Results:

Of the 50 patients enrolled, 25 were randomized to VSS. No differences in demographic characteristics were identified between cohorts (p>0.05 for each). Time spent documenting away from the patient differed between VSS and TD (1.19±0.65 minutes for VSS versus 5.80±1.70 minutes for TD, p<0.001) as did time elapsed between the end of the visit and the start of dictation (0±0 for VSS versus 123±70 minutes for TD, p<0.001). There was a trend towards more time spent with the patient in the VSS group than in the TD group (14.25±5.86 minutes versus 11.37±5.07 minutes, p=0.069). There were no differences between groups in survey responses regarding satisfaction, empathy, understanding, or perception of sufficient time spent with the physician (p>0.05 for each; Table 1).

Conclusion:

VSS in an orthopaedic foot and ankle practice decreases documentation time by approximately 4 minutes per new patient compared to TD, resulting in 2 hours of reclaimed physician time for every 30 new patients. With VSS, documentation is completed during the visit versus TD which is dictated on average 2 hours later. A validated survey identified no differences in patient satisfaction, perception of physician empathy and sufficient time spent with the physician, or understanding of the plan with VSS versus TD. Orthopaedic surgeons should consider VSS a HIPAA-compliant documentation option with time savings and no measurable difference in patient satisfaction.
Pes Cavovarus in Charcot-Marie-Tooth Compared to the Idiopathic Cavovarus Foot: A Preliminary Weightbearing CT Analysis
Authors: Bernasconi Alessio , Cooper Lucy , Lyle Shirley , Patel Shelain , Cullen Nicholas , Welck Matthew
Published: October 2019

Category:

Ankle, Hindfoot

Introduction/Purpose:

Charcot-Marie-Tooth disease (CMT) is an inherited sensory motor peripheral neuropathy progressively leading to cavovarus deformity of the foot. Conversely, the idiopathic cavovarus foot represents a non-neurological condition, with a spectrum from subtle to markedly deformed. Our aim was to investigate morphological differences between CMT pes cavovarus (CMT-PC), idiopathic pes cavovarus (I-PC) and normally aligned feet using three-dimensional (3D) cone beam weightbearing computed tomography (WBCT) measurements. We hypothesised that the hindfoot alignment was significantly different between the three groups.

Methods:

Retrospectively, we compared 17 CMT-PC (15 patients) with 24 I-PC and 24 clinically normally aligned feet. Patients were comparable by age, sex and body mass index. All WBCTs were performed during routine investigation. Exclusion criteria included previous ipsilateral foot/ankle surgery and inability to heel weightbear. Three measurements were made by one orthopaedic surgeon: foot and ankle offset (FAO), a three-dimensional calculation describing the relationship between the centre of gravity of the tripod of the foot and the centre of the ankle; calcaneal offset (CO), measuring the distance between a theoretically neutral position of the calcaneus and its true position; and hindfoot angle (HA), an estimative of coronal angular hindfoot alignment. These measurements were all repeated twice for intraobsever reliability calculation (Pearson correlation). The mean values were compared using one-way ANOVA (values normally distributed after Shapiro-Wilk test) with the Bonferroni test.

Results:

Intraobserver reliability was excellent for all the three measurements (r=0.98 for FAO, CO and HA). Mean FAO value ± standard deviation in CMT-PC group (-14.1% ± 7.2) and in I-PC group (-9.6% ± 5.2) both differed from normal feet (1.6% ± 3.3) (p< .001). Of note, a difference was found between mean FAO in CMT-PC and I-PC feet (p .025). Furthermore, the mean CO (- 23.6 mm ± 11.3 in CMT-PC, -16.7 mm ± 8.2 in I-PC and 3.1 mm ± 6 in normal feet) and the mean HA (-44.9° ± 21.7 in CMT-PC; - 30.3° ± 16.9 in I-PC; 5.1° ± 10.1 in normal feet) significantly differed in three groups (p< .001) and specifically between CMT-PC and I-PC feet (p .032 and p .02 for CO and HA, respectively).

Conclusion:

This study confirms our hypothesis. Hindfoot alignment in patients diagnosed with CMT cavovarus and idiopathic cavovarus feet significantly differed between them and from normal controls, with a more accentuated varus deformity in CMT patients. This probably reflects the presence of a known neuromuscular imbalance driving the deformity over time in CMT feet. We therefore propose using a reliable method of quantifying heel varus and seeking a potential neurological diagnosis in the more severe.
Medial and Lateral Malleoli Impose Anatomical Constraints on Total Ankle Arthroplasty Design
Authors: Bischoff Jeffrey E. , Snyder Sandra , Coetzee J. Chris , Miller Stuart , Philbin Terrence
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Contemporary total ankle arthroplasty (TAA) techniques reconstruct the tibiotalar articulation while preserving the medial and lateral malleoli. The malleoli place anatomic constraints on the design of the talar component of the TAA system. If these constraints are not respected, then proper placement of the talar component may be compromised intra- operatively, or unintended contact between the prosthesis and bone may occur post-operatively. The goal of this study was therefore to quantify the medial and lateral malleolar boundaries.

Methods:

The orientation of the talus from a frontal view was quantified based on CT scans of left leg, non-arthritic specimens (n=89; 52M/37F) (Figure 1a). The talar dome was identified as the portion of the talus superior to the talar neck. The frontal profile of the dome defined by a plane positioned through the medial and lateral high points was extracted for each specimen. Statistical shape analysis was performed to identify the modes of variation of the frontal profile. Medial and lateral lines were fit to each profile, and resulting angles relative to the superior-inferior axis were measured. A paired student t-test (P<.05) was used to assess differences between the medial and lateral malleolus.

Results:

Figure 1b shows the average frontal profile of the talar dome, as well as ±1 and ±2 standard deviations. The average medial and lateral taper angles of the talus were 15.5° ± 5.9° and 7.6° ± 2.9°, respectively, with the lateral taper angle being significantly smaller than the medial taper angle (P<.001). The medial taper increased with talus size (as measured by the medial- lateral width of the dome) whereas the lateral taper decreased with talus size (Figure 1c), though both regressions were weak (R2 < 0.1). No statistically significant difference in taper angles was found between genders.

Conclusion:

Restoration of the bicondylar articulation geometry of the tibiotalar joint is an important design goal for TAA. One aspect of this geometry is the anatomic constraints imposed by the medial and lateral malleoli, to minimize unexpected impingement of the TAA prostheses with surrounding anatomic structures. Here, we have quantified those constraints through analysis of the medial and lateral taper of the talus, showing an increased taper angle on the medial side of the talus as compared to the lateral side.
Second Metatarsophalangeal Joint Interpositional Arthroplasty Using Decellularized Human Dermal Allograft
Authors: Bohl Daniel D. , Idarraga Alex J. , Hur Edward S. , Lee Simon , Hamid Kamran S. , Lin Johnny
Published: October 2019

Category:

Lesser Toes

Introduction/Purpose:

Success has been reported in treating first metatarsophalangeal joint osteoarthritis with allograft interpositional arthroplasty, but little has been published regarding the use of similar techniques for the second metatarsophalangeal joint. We hypothesized that second metatarsophalangeal joint allograft interpositional arthroplasty would result in improvement in patient-reported outcomes, a low rate of postoperative complications, and a low rate of reoperation at minimum follow-up of one year.

Methods:

A retrospective review of medical records was conducted for patients having undergone allograft interpositional arthroplasty of the second metatarsophalangeal joint with at least one year of postoperative follow-up. Our technique included a dorsal incision and joint exposure, removal of the cartilage from the metatarsal head using a conical reamer, suture of a human decellularized dermal allograft to the metatarsal head though drill holes, and capsular repair (Figure 1). Preoperative and postoperative findings were compared, including Foot Function Index (FFI) and radiographic joint space measured on the AP view. Postoperative range of motion and satisfaction with the procedure were quantified.

Results:

In total, 5 patients met inclusion criteria. Mean follow-up was 3.2+/-2.1 years. Three of 5 patients (60.0%) reported that they would have the procedure again, and mean satisfaction with the procedure was 6.0+/-5.1 out of 10. One patient had conversion to fusion at 2 postoperative years. Among the 4 unfused patients, Foot Function Index decreased from 75.7+/-29.8 preoperatively to 52.0+/-46.5 at final follow-up (p=0.526). Mean final arc of motion was 35.0+/-7.1 degrees. Radiographic joint space was 0.4+/-0.3 mm preoperatively, increased to 2.2+/-0.5 mm immediately postoperatively, and decreased to 1.5+/-0.8 mm at final follow-up. The final follow-up joint space trended towards a larger number among the patients who stated they would have the procedure again compared to the patients who stated they would not (2.6+/-1.0 mm versus 0.4+/-0.4 mm, p=0.178).

Conclusion:

Second metatarsophalangeal joint allograft interpositional arthroplasty is a reasonable alternative to arthrodesis for management of isolated late-stage second metatarsophalangeal joint osteoarthritis. Arthrodesis of the second metatarsophalangeal joint is suboptimal due to altered gait mechanics; hence, novel joint preserving procedures are of value. Despite the modest results of interpositional arthroplasty in this limited series, the procedure can result in pain relief while allowing for motion in a subset of patients. The major determinant of success among our cohort was the maintenance of radiographic joint space at final follow-up.
Superficial Peroneal Nerve Entrapment: Diagnosis and Surgical Management. A Retrospective Study of 46 Patients
Authors: Brown Cortez L. , Worts Phillip , Borom Andrew
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Superficial peroneal nerve entrapment (SPNE) is an uncommon and often misdiagnosed condition which can lead to pain or paresthesia of a patient’s distal anterolateral leg and dorsal foot. A past medical history of an ankle sprain, specifically an inversion sprain, places SPNE on the differential diagnosis. Mismanagement of SPNE may result in continued lower leg dysfunction, unnecessary medical procedures, increased medical costs, and patient frustration. The purpose of our study was to describe an alternative diagnostic technique for SPNE and clinical outcomes following surgical decompression.

Methods:

Using ICD-9/10 and CPT codes, we identified 46 patients in the private practice of a single foot and ankle orthopaedic surgeon who underwent a SPN surgical decompression between 2012 and 2017. A thorough chart review confirmed all patients underwent an SPN decompression. Additionally, the primary author compiled our variables of interest (mechanism of injury, prior medical management of ankle pain, physical exam findings, diagnostic testing, intraoperative findings, and resolution of pain or paresthesia) from this chart review.

Results:

46 patients (40.1 ± 14.6 years of age; 11 males and 35 females) underwent a decompression of the SPN. Average time to evaluation was 2.8 ± 5.9 years (range: 0 - 25). Ten of 46 patients (22%) reported a history of inversion ankle sprain. Positive exam findings were: tender to palpation at the fascial exit point 40/46 (87%) and positive Tinel’s sign 38/46 (84%). Pre-operative SPN diagnostic nerve block at point of maximum tenderness was performed in 44/46 patients (96%). 31/44 (70%) patients reported complete pain relief after diagnostic block. Of the 31 patients, 26 (84%) reported post-operative pain improvement. When cases were isolated to SPN entrapment with complete pre-operative pain relief following diagnostic nerve block, 18/19 (95%) experienced complete post-operative pain relief.

Conclusion:

A thorough examination of the foot and lower leg can appropriately diagnose SPNE using palpation of fascial exit point and a positive Tinel’s sign. Additionally, a nerve block proved clinically useful as an effective technique for SPNE diagnosis. Patients undergoing an isolated SPN decompression experienced pain improvement at higher rates compared to patients with concomitant surgical procedures. Future work is needed to determine if a positive diagnostic nerve block is a predictor of post- operative pain improvement. Further, while preliminary evidence is encouraging, larger cohorts across various patient populations are needed.
Endoscopic Treatment for Chronic Achilles Tendon Rupture on High Demand Patients
Authors: Caetano Joao , Dias Rafael , Silva Miguel Duarte , Figueiredo João , de Sousa João Vieira , Wircker Patrícia , Corte-Real Nuno
Published: October 2019

Category:

Ankle, Arthroscopy, Sports, Trauma

Introduction/Purpose:

Chronic Achilles Tendon Rupture (CATR) is still a prevalent condition that includes neglected ruptures and re-ruptures after surgical treatment. CATR is responsible for marked functional impairment that usually requires surgical repair and an open procedure is traditionally performed. Endoscopic treatment has been described but there is no consensus in its role due to lack of quality papers. There is some experience with endoscopic transfer of Flexor Hallucis Longus (ETFHL) but most authors recommend this technique only on low demanding patients. The purpose of this paper is to present our results with ETFHL on athletic patients (recreational sports or high demanding job), contributing to the establishment of this technique.

Methods:

In this retrospective study, the authors report a series of 14 patients submitted to ETFHL, 12 patients due to Chronic Achilles rupture and 2 due to acute re-rupture, between May 2014 and January 2018. The mean follow-up period was 28 months (range 12 to 48 months). We measured pre and post-operative AOFAS score and Achilles Tendon Total Rupture Score (ATRS), along with post-operative heel rise height test.

Results:

In our 14 patients (11 male, 3 female) the mean age was 42 years old (range 23 to 59). There were 10 non-professional athletes and 4 high demand workers. The mean pre-operative AOFAS score was 61,1 (range 49 to 79) and ATRS was 11,6 (range 10 to 14). Post-operative results: the mean AOFAS score was 96 (ranging 90 to 100). All patients were able to do single foot heel rise with a mean height of 6,2 cm (range 5 to 9,6 cm). The mean ATRS was 95 (range 81 to 100). All patients showed complete functional recuperation of the gastrocnemius complex and returned to sports or labor activities at their previous level. One patient had transient hypoesthesia of tibial nerve. No other complications were registered.

Conclusion:

We present a small group of recreational athletes and high demand workers in which ETFHL for CATR showed good results with remarkable functional rehabilitation. Our results are comparable to open classic techniques, with less invasiveness and soft tissue complications. Our experience made us believe that ETFHL may play a role in the treatment of CATR, not only in low demand patients but also in the athletic population. Further studies are necessary to compare this technique with the open procedure to ensure its safety and efficacy.
Total Ankle Arthroplasty and Ankle Arthrodesis Utilization: An American Board of Orthopaedic Surgery (ABOS) Part II Database Study
Authors: Carender Christopher N. , Glass Natalie A. , Amendola Annunziato , Duchman Kyle R.
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Total ankle arthroplasty (TAA) utilization has increased over the last 20 years, while ankle arthrodesis (AAD) utilization has remained constant. However, annual hospital procedure volume for TAA and AAD remains low, with 50% of hospitals performing a median of =5 cases per year. Practicing in a low-volume setting may have implications for technical performance and patient outcomes, especially amongst early-career surgeons. The purpose of this study was to examine trends in utilization of TAA and AAD in ABOS part-II candidates while considering the influence of fellowship training status on treatment of end-stage ankle arthritis.

Methods:

The American Board of Orthopedic Surgery (ABOS) Part II database was queried to identify all candidates who performed =1 TAA or AAD from exam years 2009-2018. Candidates were categorized by exam year and by self-reported fellowship training status. Descriptive statistical methods were used to report procedure volumes. Trends in utilization of TAA and AAD were examined using log-modified regression analyses.

Results:

From 2009-2018, there was no significant change in the utilization of TAA or AAD amongst all candidates (p=0.92, p=0.20) (Table 1). Candidates reporting a foot and ankle (FA) fellowship trended towards increased utilization of TAA relative to AAD versus non-FA fellowship candidates, but this failed to reach statistical significance (p=0.06). The utilization of arthroscopic AAD increased over time (p<0.01) amongst all candidates. There was no difference in the rates of utilization of open versus arthroscopic AAD amongst FA trained candidates. High-volume (=5 TAA) candidates represented 10.5% of all candidates performing TAA, and accounted for 34.2% of all TAAs performed over the study period.

Conclusion:

Utilization of TAA and AAD did not change over the study period, and the number of these procedures performed by early-career surgeons remains low. The majority of both procedures are performed by FA trained surgeons with relatively low practice volumes. There was a trend toward increased TAA utilization relative to AAD utilization in FA trained surgeons, but this did not reach statistical significance. The findings in this study may have implications for technical performance impacting patient outcomes and may guide potential changes in training curricula.