bluuebunny/crossref_metadata_2025 huggingface dataset:
Early Outcomes and Complications of Synthetic Cartilage Implant for Treatment of Hallux Rigidus in the United States
Authors: Cassinelli Spenser J. , Chen Stephanie , Charlton Timothy P. , Thordarson David B.
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

The aim of this study was to determine the outcomes and early complications following the implantation of a novel hydrogel synthetic cartilage implant (SCI) for the treatment of hallux rigidus by a single surgeon. This implant was FDA approved for implantation for the treatment of hallux rigidus in the United States in July 2016.

Methods:

A retrospective chart review of consecutive patients who underwent treatment for hallux rigidus with an SCI between August 2016 and June 2018 by a single surgeon was performed. Demographic information, radiographic assessment, and concomitant surgical procedures performed were evaluated for all patients. Post operatively, PROMIS physical function and pain scores, patient satisfaction, reoperation, conversion to arthrodesis, and need for further clinical treatment were collected. Seventy SCI were implanted in 65 patients. Follow up averaged 16.3 months (Range 6-27 months).

Results:

16% (11/67) of patients were very satisfied, 31% (21/67) were satisfied, 22% (15/67) were neutral, 6% (4/67) were dissatisfied, and 24% (16/67) were very dissatisfied with their outcome. PROMIS physical function scores averaged 43, indicating mild dysfunction compared to population norms. PROMIS pain interference scores averaged 59, indicating mild pain compared to population norms. 50% (35/70) required a corticosteroid injection post-operatively. 24% (17/70) required advanced imaging with MRI post-operatively. There was a 13% reoperation rate for all-cause reoperation, and a 2.9% rate of conversion to arthrodesis. Subgroup analysis showed that patients undergoing Moberg osteotomy at time of SCI performed better than patients undergoing SCI alone.

Conclusion:

Synthetic cartilage implantation yielded modest patient satisfaction, mild dysfunction in physical measures, and a large proportion requiring further treatment and workup post operatively. We believe patient selection and counseling on the potential for continued pain and dysfunction in the early postoperative period following this procedure are important before proceeding with synthetic cartilage implantation for hallux rigidus.
Peripheral Vascular Disease is Associated with Increased Risk of Acute Postoperative Infection and Failure of Total Ankle Replacements
Authors: Conti Matthew S. , Savenkov Oleksandr , Ellis Scott J.
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

Peripheral vascular disease (PVD) is often cited as a contraindication for total ankle replacement (TAR); however, there are no studies looking at its impact on postoperative complications. The primary purpose of our study was to identify whether preoperative PVD increased the rate of infection, postoperative irrigation and debridement, or failure of the implant in patients undergoing total ankle arthroplasty using a large dataset.

Methods:

The PearlDiver Database was used to identify Medicare patients who underwent a TAR from 2005 to 2014 using ICD- 9 and CPT codes. The cohort was queried for postoperative infections within 90 days, subsequent irrigation and debridement, and failure of TAR. Failure of TAR was defined was a revision, conversion to tibiotalar arthrodesis, lower extremity amputation, or implant removal. A diagnosis of preoperative PVD only included those patients who had PVD as an ICD-9 diagnosis code and underwent a preoperative lower extremity angiogram prior to TAR. Preoperative co-morbidities including prior corticosteroid injections, diabetes mellitus, smoking, rheumatoid arthritis, congestive heart failure, hypertension, obesity, and end-stage renal disease requiring dialysis were taken into consideration. Three multivariable logistic regression models were then developed in order to identify risk factors associated with postoperative infections and failure after TAR.

Results:

10,698 Medicare patients who underwent a primary TAR were identified. 334 patients had a postoperative infection within 90 days of their TAR and 95 of those patients required an irrigation and debridement. Patients with a preoperative diagnosis of PVD had the highest acute infection rate at 10.5% as well as the highest incidence of failure at 12.3%. Multivariable logistic regression modeling demonstrated that patients with PVD had the greatest risk of developing a postoperative infection within 90 days (OR 2.85, 95% CI 1.45-5.13, P<0.01). Preoperative PVD was the most important risk factor for requiring an irrigation and debridement postoperatively (OR 4.87, 95% CI 1.94–10.6, P<0.001) (Table 1) and placed patients at the highest risk of TAR failure (OR 2.67, 95% CI 1.43–4.63, P<0.001).

Conclusion:

Our study suggests that a preoperative diagnosis of PVD has significant negative effects on outcomes following TAR. Preoperative PVD is an independent risk factor for an acute postoperative infection, postoperative irrigation and debridement, and failure of the implant.
Using TSF Multi-Planar External Fixation for Overcorrection of Severe Equinus Contractures of the Ankle joint
Authors: Dabash Sherif , Potter Eric , McGarvey William
Published: October 2019

Category:

Ankle, Hindfoot, Trauma

Introduction/Purpose:

Equinus deformity is a debilitating condition which interferes with the activity of daily living. Correction of the deformity ranges from conservative (heel cord stretching, orthotics) to surgical treatment (Baumann, Strayer, Achilles lengthening, soft tissue releases). Severe contractures need surgical intervention with extensive dissections to release soft tissues. This study investigated the clinical outcomes of gradual equinus contracture overcorrection using a Taylor Spatial Frame with tendo-Achilles lengthening or toe flexor tenotomy as necessary.

Methods:

This retrospective chart review evaluated patients with significant equinus treated with a Taylor Spatial Frame at a single large tertiary referral center. Data collected included: diagnosis; patient demographics; laterality; time in frame; additional procedures; complications. Patients were assessed preoperatively and were followed at one-week, three-week, six-week, three- month, and six-month intervals, and yearly after.

Results:

24 patients (26 procedures) were treated with a Taylor Spatial Frame for equinus and had complete preoperative and eighteen-month follow-up measurements. The angle of deformity increased from a preoperative -21.5 (range, -69.0 to -1.0) degrees to a postoperative 4.9 (range, -17.0 to 17.0) degrees (z = -4.4573, p = 0.0001, N = 26, Wilcoxon signed rank test). Four complications occurred during the follow up (two pin site infections, one broken pin, and one plantar abscess). Three patients had recurrence of of equinus deformity at time of last follow-up.

Conclusion:

Taylor Spatial Frame is a successful method for correcting severe, fixed equinus contractures of the ankle joint with minimal soft tissue related complications. Over correction should be achieved in order to compensate for the loss of some dorsiflexion after frame removal.
Radiographic Outcomes of Lisfranc Injuries Treated with a Suture Button Device
Authors: Delman Connor , Kreulen Christopher , Shelton Trevor , Roster Brent , Boutin Robert , Giza Eric
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Controversy exists regarding the optimal treatment of Lisfranc injuries of the midfoot. There has been increasing interest in using a suture button device in lieu of traditional screw fixation. Biomechanical studies comparing screw fixation with suture button devices have demonstrated conflicting results. This study evaluates the radiographic outcomes of patients with Lisfranc injuries treated with a suture button device or a hybrid technique with supplemental fixation.

Methods:

Forty-three patients with a Lisfranc injury were treated operatively with either a suture button device (Tightrope, Arthrex, Naples, FL) or a hybrid technique with supplemental hardware fixation. The distances between the first and second metatarsal (M1-M2) and the medial cuneiform and second metatarsal (C1-M2) were measured on weightbearing radiographs. These measurements were used to assess the accuracy of reduction, maintenance of reduction, and magnitude of reduction. The accuracy of reduction was determined by comparing weightbearing AP radiographs of the uninjured foot with weightbearing radiographs of the operatively treated foot at 6 weeks postoperatively. The magnitude of reduction was assessed via a comparison of weightbearing AP radiographs of the injured foot preoperatively to the operatively treated foot at 6 weeks postoperatively. The maintenance of reduction was determined by comparing radiographic measurements at 6 weeks postoperatively to measurements taken at 12 weeks postoperatively.

Results:

An accurate reduction was obtained in both treatment groups with no significant difference in the M1-M2 and C1-M2 measurements at 6 weeks postoperatively compared to the uninjured foot. The magnitude of reduction was greater and statistically significant for the hybrid fixation group but was not maintained (Hybrid fixation M1-M2 magnitude of reduction: -1.39, p < .001; C1-M2 magnitude of reduction: -1.77, p < .001). The suture button treatment group attained a satisfactory reduction that was maintained with no statistically significant difference in the M1-M2 and C1-M2 distances at 6 weeks and 12 weeks postoperatively (Tightrope M1-M2 maintenance of reduction: 0.04, p=0.88; C1-M2 maintenance of reduction: 0.39, p=0.21).

Conclusion:

After open reduction of Lisfranc injuries, the suture button device appears to adequately maintain the reduction when patients have returned to full activity. Based on radiographic parameters, the suture button construct provides an effective alternative to traditional screw fixation for the treatment of Lisfranc injuries.
Degenerative Pathology of the Ankle, Hindfoot, and Midfoot is as Limiting to Patient Mobility as Congestive Heart Failure
Authors: Erwood Amalie , Kurkis Gregory , Maidman Samuel David , Cole Robert , Tenenbaum Shay Ariel , Bariteau Jason Tyler
Published: October 2019

Category:

Ankle, Ankle Arthritis, Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

Degenerative conditions of the ankle, hindfoot, and midfoot can markedly limit mobility. The Life-Space Assessment (LSA) is a questionnaire quantifying how patients mobilize after a medical event as they return to their previous daily settings. Current outcome measures do not accurately assess mobility in the geriatric foot and ankle population. In contrast, the effect of congestive heart failure (CHF) on patient mobility is routinely assessed via the New York Heart Association (NYHA) functional classification. The NYHA classification is stratified by limitation of physical activity: I (no limitation), II (some limitation), III (marked limitation), and IV (unable to carry out without discomfort). We hypothesized that degenerative conditions of the foot and ankle would be as mobility limiting as CHF.

Methods:

Patients over the age of 50 were included in this study. LSA data was prospectively collected from patients with degenerative ankle, hindfoot, and midfoot diagnoses at their preoperative visit and NYHA-classified CHF patients at a cardiology clinic. The degenerative foot and ankle cohort included Achilles tendonitis, ankle joint cartilage defects, ankle arthritis, subtalar arthritis, and midfoot arthritis. Patient demographics and comorbidities were recorded from the electronic medical record. Mean LSA data was analyzed and compared using a Student’s t-test.

Results:

28 degenerative foot and ankle patients and 44 CHF patients met inclusion criteria for the study. Patient demographics, including age, gender, and BMI, were not significantly different between the two groups. The foot and ankle cohort had a mean LSA score of 68. Mobility of the foot and ankle group was significantly less compared to NYHA class I patients, who had a LSA score of 103 (p=0.008). There was no significant difference in mobility compared to class II or III congestive heart failure patients, who recorded a mean LSA score of 62 (p=0.60). There was insufficient data available on NYHA class IV patients to make comparisons to this group.

Conclusion:

Degenerative ankle, hindfoot, and midfoot pathology is associated with similar mobility limitation to that of NYHA class II and III congestive heart failure.
Gender-Related Reporting Within Foot and Ankle Subspecialty Orthopaedic Literature is Lacking
Authors: Gianakos Arianna L. , George Nicole , Merklein Meghan , Chambers Lori , Daniel Joseph , DiGiovanni Christopher , Kennedy John G
Published: October 2019

Category:

Ankle, Arthroscopy, Hindfoot, Midfoot/Forefoot, Trauma

Introduction/Purpose:

Differences in the prevalence of foot and ankle injuries between men and women have been established within the orthopedic literature, but reporting of these differences in treatment outcomes is lacking. The purpose of this study was to determine the trends in reporting of gender-specific outcomes in major orthopaedic foot and ankle related journals over the last 8 years.

Methods:

The five highest impact orthopaedic foot and ankle and sports specialty journals were selected for review. These included: Foot and Ankle International (FAI), Foot and Ankle Surgery (FAS), American Journal of Sports Medicine (AJSM), Arthroscopy, and Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA). All published issues in 2011 and 2016 were evaluated for the presence of gender-specific analyses by two independent reviewers. Studies were included if they met the following criteria: clinical randomized control studies, prospective studies, and retrospective studies. Case series, review articles, cadaveric studies, biomechanical studies, and animal studies were excluded. Journal article, percentage of female patients, body part evaluated, type of gender-specific analysis, and results of the analysis were recorded and analyzed.

Results:

A total of 529 studies evaluating a total of 103,099 patients were included in this review (Table 1). In all included studies, an average of 44.7% (46,116 patients) of the population were female. Only 13.6% (72/529) of studies included gender as variable in a multifactorial statistical model. 229 studies were included from 2011 and 300 studies were included from 2016 with only 10.4% (24/229) and 16.0% (48/300) of studies reporting gender specific statistical analysis, respectively (Table 2). There were no journals that demonstrated significant improvements in gender-reported rates from 2011 to 2016 (p=0.07). Twenty-four percent of the studies that performed gender-based statistical analysis demonstrated significant differences between male and female outcomes with the most common difference reported following management of ankle fractures (Table 3).

Conclusion:

The reporting of gender-specific differences in foot and ankle literature is lacking. Only 13.6% of studies analyzed for gender-specific differences. Within these studies, there has been significant differences in outcomes reported. Understanding these differences is important in order to more effectively manage and treat the male and female populations.
A New ‘Approach’ to Reduce Wound Complications Following Ankle Arthroplasty
Authors: Halai Mansur , Pinsker Ellie , Khan Ryan , Daniels Timothy R.
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

Despite advancements with instrumentation and implant design, total ankle arthroplasty (TAA) is still associated with a high rate of wound complications, which can lead to poorer outcomes. The aim of this study was to evaluate all wound complications following TAA and to determine any demographic or operative associations.

Methods:

A retrospective review of 660 consecutive TAAs was performed between November 2001 and May 2017. Data was collected on wound complications and potential risk variables, including age, sex, body-mass index, diabetes, smoking, and inflammatory arthritis. All wounds were seen at the clinic by the surgical team and a wound specialist nurse who independently recorded any issues. Major wound complications were those that required consultation with plastic surgeons, debridement by the nurse specialist, use of negative pressure therapy, or return to the operating room. All major complications were treated initially with oral antibiotics. Minor wound complications included any mention of discoloration, swelling, or clinical concern that merited the patient returning for further review. Minor wound complications were not treated with oral antibiotics. Operative notes were also reviewed to collect data on the surgical approach and additional incisions.

Results:

Fifty-nine patients (8.9%) had wound healing issues: 19 major (2.9%) and 40 minor (6.1%). All issues became evident <21 days postoperatively. Major wound complications were associated with a history of inflammatory arthritis, smoking, or coronary heart disease. Four patients were treated with negative pressure therapy, four with debridement in the operating room, and two were eventually converted to fusions. Fourteen (83%) patients with major complications had an ancillary procedure to balance the TAA through a separate incision. From 2001 to 2010, the standard surgical approach for TAA was performed anteriorly. All TAA patients with major wound complications were operated via an anterior surgical approach as their primary incision. No major wound complications were reported among the 22 anteromedial approaches.

Conclusion:

Potential TAA patients with a history of smoking, heart disease, or inflammatory arthritis should be considered with caution. A multidisciplinary team is valuable for evaluating wounds, as the majority of wound complications can be managed in the outpatient clinic with debridement, bespoke dressings, or negative pressure therapy from a specialist nurse. The anteromedial approach (see attached figure), which we have previously described, has great potential for patients who have a higher risk of developing a wound complication. Further investigation is necessary to evaluate its role in reducing the incidence of wound complications.
Iatrogenic Avascular Necrosis of the Talus Following Subchondroplasty
Authors: Hanselman Andrew , Cody Elizabeth , Easley Mark , Adams Samuel , Parekh Selene
Published: October 2019

Category:

Ankle, Basic Sciences/Biologics

Introduction/Purpose:

Subchondroplasty® (SCP®) (Zimmer Holdings, Inc, Warsaw, IN) is a relatively new procedure that was developed in 2007 for the treatment of bone-marrow lesions (BMLs). It involves the injection of flowable nanocrystalline calcium phosphate (CaP) synthetic bone substitute into the BML using fluoroscopic-guidance, in order to promote healing and reinforce the effected region. Although a newer technique, SCP has been shown promising results in the knee through several different small case-series. The foot and ankle literature is sparser, with only a few documented case-reports or case-series. As a result, we wanted to report our small case-series of patients who underwent talar SCP and went on to develop avascular necrosis (AVN).

Methods:

A retrospective review was conducted of patients who underwent SCP for a talar BML at our facility or were referred to our facility after undergoing SCP at an outside institution. Patients who developed iatrogenic talar AVN postoperatively were included in the study. Patient characteristics, comorbidities, imaging, and need for further surgery was analyzed.

Results:

Four patients were identified who had previously undergone talar SCP and went on to develop iatrogenic talar AVN. Two patients had their original SCP performed at our facility, whereas the other two patients were referred from outside institutions. All four patients were symptomatic from their AVN. Two patients have undergone revision surgical intervention, while the other two patients are pending surgical intervention.

Conclusion:

This case-series is the first study, to our knowledge, to report iatrogenic talar AVN after undergoing SCP for talar BMLs. Although early studies in the Foot and Ankle literature are promising for use of this technology, these studies have been small and surgeons should be aware of this potential complication.
Risk Factors of Arthropathy Change of the Lateral Side of Subtalar Joint After Calcaneal Fracture Surgery
Authors: Hio Naohiro , Hasegawa Atsushi , Monden Satoshi , Taki Masanori , Tsunoda Kazuhiko , Omae Hiroaki
Published: October 2019

Category:

Hindfoot, Trauma

Introduction/Purpose:

As a result of arthropathy change on the lateral side of subtalar joint after intra-articular calcaneal fracture, the secondary disorders such as pain or restricted range of motion occasionally occur. The purpose of this study is to examine factors that cause such arthropathy change.

Methods:

We divided 23 joints into two groups according to arthropathy change of the lateral side of subtalar joint: the existence of such arthropathy (O) group included 8 joints, the absence of arthropathy (N) group included 15 joints. The patients’ mean age at the time of surgery were 49.1 years and 54.9 years respectively, and the mean follow-up period were 16.1 months and 12.4 months respectively. The anterolateral approach or the sinus tarsi approach was used for both groups, and the medial approach was combined as needed. The fixing materials were a plate or screws, and in some cases, staples and Kirschner wires were used in combination. We assessed Sanders classification, postoperative clinical evaluation using Creighton-Nebraska scale, and the width, height and dislocation of subtalar joint surface of calcaneus.

Results:

The breakdown of the Sanders classification is as follows: N group consists of 3 joints of type 2A, 7 of type 2B, 3 of type 2C, 1 of type 3BC, 1 of type 4. O group consists of 5 joints of type 2A, 2 of type 2B, 1 of type 2C. The proportion occupied by Sanders classification type 2A in O group was larger than in N group. The average of the postoperative clinical evaluation was 94.9points in N group, 86.9points in O group. In postoperative image evaluation, the mean width in the was 106.2% in N group, 117.1% in O group, the mean dislocation of the subtalar joint surface was 0.4 mm in N group and 1.1 mm in O group.

Conclusion:

It was suggested that Sanders type 2A and the residual dislocation of the subtalar joint surface may be a cause of arthropathy change on the lateral side of subtalar joint.
Tarsal Coalition of the Cuneiforms in an Elite Athlete: A Case Report
Authors: Johnson Alexander J. , Gokcen Eric
Published: October 2019

Category:

Midfoot/Forefoot, Sports

Introduction/Purpose:

Tarsal coalitions are a relatively common, often asymptomatic disorder with an incidence of 1-6% in clinical studies and 11-13% in cadaver studies. Calcaneonavicular, followed by talonavicular, are the most common forms of coalitions, but a variety of other coalitions have been described in radiographic, anatomic, and clinical literature. Despite the varied research that has focused on the topic in recent decades, there are no identified reports of cuneiform to cuneiform coalition in the literature.

Methods:

The authors present the unique case of medial and intermediate cuneiform coalition in a young female track athlete. A 19 year old female Division 1 hurdler presented with 1 year of atraumatic midfoot pain limiting her ability to compete. Despite evaluation by multiple orthopedic surgeons, the etiology of the pain was undetermined, and she had failed multiple conservative treatment options. Her exam revealed diffuse midfoot tenderness and increased midfoot pain with twisting motion. MRI and CT evaluation showed coalition between medial and intermediate cuneiforms with early degenerative changes. Ultrasound guided injection in this area resulted in relief of symptoms, confirming the diagnosis. The patient underwent coalition release and medial- intermediate cuneiform arthrodesis.

Results:

Postoperatively the patient underwent a period of nonweightbearing then progressed back to activity. CT scan confirmed solid arthrodesis and she was cleared to return to track competition. She successfully returned to competitive collegiate hurdling 11 months after surgery while noting only occasional discomfort in the foot.

Conclusion:

With no previous reports identified in the literature, cuneiform to cuneiform coalitions are a rare clinical entity. It is likely that the patient in the current case experienced symptoms related to this pathology because of her high level athletic participation. After failing conservative management, the patient experienced a good outcome after coalition release and arthrodesis. Although it is likely that patients with similar pathology who fail conservative management may expect similarly positive outcomes, review of future cases will help further define the optimal treatment for this condition.
Comparison of Drain Versus No-Drain for Intra-Articular Calcaneal Fixation via Sinus Tarsi Approach: Randomized Controlled Trial Study 33 Cases
Authors: Khongphaophong Methee , Kungwan Supoj
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Sinus tarsi approach for intra-articular Calcaneal fracture fixation has been popular recently and brought lower rate of would complications compared to extensile lateral approach. Post -operative drains are routinely used as precaution again hematoma and would complications, but still no study explained the importance of drains in sinus tarsi approach recently.The objectives of this study is to compare the outcome and complications between drain vs. without drain in sinus tarsi approach for intra-articular Calcaneal fixations.

Methods:

Prospective randomize controlled study (RCT) of 33 intra-articular calcaneal fractures treated by open reduction and internal fixation with mini-calcaneal locking plate (Normed, Florida) use sinus tarsi approach between 2014, December to 2018, March by one surgeon. 15 cases were not applied post-operative radivac drain vs. 18 cases were applied radivac drain no. 8. Operative times, post -operative maximum body temperature (degree Celsius), duration of hospital stay (day), wound complications (dehiscence, infection, hematoma), nerve injury were recorded, post-operatively.

Results:

Compared demographic datas for age, gender and Sander’s classifications, both groups were not significantly different. Mean operative time were 84.73 minutes in no drain group vs. 92.06 mins in drain group, p-value = 0.202. Mean post-operative maximum body temperature were 37.31 degree C. in no drain vs. 37.46 degree C. in drain group, p value =0.46. Hospital stay were 5.53 days in no drain group vs. 7.28 days in drain group, p-value = 0.224. There were 1 superficial wound complications in each groups and were cured by intravenous antibiotic, no hematoma and nerve injury in both groups.

Conclusion:

Post-operative radivac drain application did not bring different outcome and wound complications when compared to no radivac drain group in open reduction and internal fixation (ORIF) via sinus tarsi approach. But no drain group brought shorter mean operative time and hospital stay, although there were not significantly different (p>0.05). Continue our study for larger numbers of patient may bring different results.
Automatic Grading of Ankle Osteoarthritis Based on Takakura Staging System: A Deep Learning- Based Approach
Authors: Kim Hwiyoung , Choi Jiyun , Jang Chul-Young , Lee Jin Woo , Kim Sungjun , Han Seung Hwan
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

The Takakura staging system has been used for the stratification in ankle osteoarthritis(OA). Patient’s OA stage is determined by visual examination on the status of talar and distal tibia in anteroposterior ankle radiograph. Clinical decisions about whether to treat conservatively or to treat with operation such as supra-malleolar osteotomy or arthroplasty may depend on this grading system. However, this is not completely reproducible between examiners and it makes a debating situation about different treatment method to a same ankle radiograph. If highly reproducible measurement method may be suggested this debating may no longer need. Therefore, the purpose of this study was to suggest a deep learning-based algorithm that automatically grades ankle osteoarthritis and to present feasibility of the provided automatic grading system.

Methods:

2529 AP both-ankle radiographs were collected and graded for OA by a radiologist and orthopedic surgeon. We converted Takakura staging system into 3 grades(Grade1: stageI, Grade2: II-IIIa, Grade3: IIIb-IV) according to treatment plan. To confine the region of interest(ROI), a rectangle encompassing ankle portion was automatically generated using an object detection model(YOLOv2). The data oversampling was done to overcome small data and class imbalance. Four pre-trained convolutional networks(One Inception-v3 and three ResNet models) were fine-tuned using augmented data. We tried two different ensemble methods: voting ensemble and gradient boosting. Voting ensemble adjusts the decision through selecting majority votes among trained models. Gradient boosting(XGboost model) trains new classification model to focus on the cases that previous model mis- classified. The evaluation of trained models and ensemble model were performed in terms of average classification accuracy. Gradient-class activation map(CAM) method was utilized to present CAM highlighting the location where highly affected the network for the decision.

Results:

A total of 3836 original ROIs were obtained and as follows: grade 1, 1382; grade 2, 1927; grade 3, 527. The number of oversampled ROIs was 16398 like follows: grade 1, 5528; grade 2, 7708; grade 3, 3162. The performance of each classifier was ranged 71.0% ˜ 77.3% in terms of average classification accuracy. Ensemble methods yielded average classification accuracies of 78.1% and 79.2% for voting ensemble and XGboost, respectively.

Conclusion:

Deep learning-based algorithm application for automatic grading of ankle osteoarthritis based on Takakura staging system is feasible. This approach is expected to be applied to various staging system for arthritis assessment through radiographs.
Functional and Radiographic Outcomes after the Removal of Suture-Button Fixation Device in the Treatment of Syndesmosis Diastasis
Authors: Kim Jae Young , Cho Jaeho
Published: October 2019

Category:

Trauma

Introduction/Purpose:

Suture-button fixation device (TightRope, Arthrex, Naples, Florida) is devised to obviate the need for second operation for removal in the treatment of syndesmosis diastasis, but considerable removal rate has been reported. Nevertheless, functional and radiographic outcomes after suture-button fixation device removal has not yet been well documented. Therefore, the purpose of this study is to investigate the functional and radiographic outcomes of syndesmosis fixation treated with suture-button device before and after device removal.

Methods:

The records of 30 patients with syndesmosis injury who underwent suture-button fixation and later device removal between August 2009 and September 2017 were investigated. The mean postoperative time to device removal was 11.9 months (range, 7-19). In plain radiograph, tibiofibula clear space (TFCS), tibiofibula overlap (TFO), and medial clear space (MCS) were measured at three specific follow-up period; immediate postoperative (F1), just before device removal (F2), and at least three months after device removal (F3). For subgroup of 18 patients with CT scans, the Anterior to posterior (A/P) ratio (Normal range: 0.8 -1.2) was measured to investigate malreduction of syndesmosis and they were divided into two groups according to their accuracy of reduction. Additionally, functional outcomes were recorded and compared using American Orthopedic Foot and Ankle (AOFAS) score. Repeated measurement analysis of variance was performed to statistically compare the data and statistical significance was set at P < 0.05.

Results:

In plain radiographs, TFCS, TFO, MCS at three specific follow-up period showed no significant differences. In CT analysis at immediate postoperative period, 6 cases (30%) revealed malreduction, but 5 of them showed spontaneous reduction at follow- up just before device removal. Malreduced patients (n = 6) had a mean A/P ratio of 1.28 (range, 0.78 -1.52) at F1, 1.08 (range, 0.81- 1.21) at F2, and 1.08 (range, 0.83 -1.22) at F3 (F1, F2: p = 0.021, F1, F3: p = 0.032, F2, F3: p > 0.05). Patients with initial adequate reduction (n = 12) continued to have a reduced syndesmosis during the follow-up period and after the device removal. The AOFAS score did not change significantly before and after removal.

Conclusion:

Our investigation showed that the removal of suture-button device for syndesmosis fixation at average 1-year postoperative time does not bring out reduction loss or functional changes. Thus, removal is advisable for the patients with irritation or discomfort related to device. Furthermore, malreduced syndesmosis after tightrope fixation may have possibility of spontaneous reduction during the follow-up period.
Screw Fixation of the Posterior Malleolus Fragment in Ankle Fracture: Cadaveric and Clinical Studies
Authors: Lee Gisoo , Kang Chan , Won Yougun , Song Jae Hwang , Cho Byungki
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Previously, a posterior malleolus fragment (PMF) covering 25–30% of the articular surface was a known indication for surgical fixation for ankle fractures. This study aimed to compare the outcomes of screw fixation for PMF comprising <25% of the articular surface and to evaluate the results of cadaver experiments.

Methods:

The clinical study enrolled ankle fracture patients with PMFs who planned to undergo surgery between March 2014 and February 2017. Among them, 62 with type 1 PMF comprising <25% of the articular surface were included: 32 patients underwent cannulated screw fixation for PMF after fixation for lateral and/or medial malleolar fracture (A group), whereas the other 30 patients underwent internal fixation for lateral and/or medial malleolar fracture but no screw fixation (B group). Clinical outcomes were determined at the 3-, 6-, 12-, and 18-month visits. Additionally, cadaver studies were conducted to evaluate cannulated screw fixation or no fixation in cases of PMFs comprising <25% of the articular surface and >1 mm displacement. Ankle joint stability was measured under external torque on the ankle in the neutral position. The level of significance was set at P < .05.

Results:

Clinical outcomes at 6 and 12 months after surgery were significantly higher in group A than in group B. However, there was no significant intergroup difference in clinical outcomes at 18 months of follow-up. In the cadaver study, PMF screw fixations were significantly more stable under external rotation force.

Conclusion:

Screw fixation was significantly useful during early recovery and in short-term clinical outcomes owing to stabilization of ankle fractures with PMF involving <25% of the articular surface.
Changes in the Mechanical Axis and Weight-Bearing Line of the Ankle After Varus Knee Correction
Authors: Lee Seung Yeol , Kwon Soon-Sun , Lee Kyoung Min
Published: October 2019

Category:

Ankle, Hindfoot

Introduction/Purpose:

Varus limb malalignment results in an imbalance of force transmission to the knee joint, resulting in a concentrated load in the medial compartment. A varus knee correction may affect the ankle and subtalar joint, because the weight-bearing load on the lower extremity extends from the hip to the foot. A previous study suggested that the true mechanical axis of the lower limb should be calculated with a line from the center of the femoral head to the lowest point of the calcaneus, not to the center of the tibial plafond. Therefore, we performed this study to evaluate changes in the mechanical axis and weight- bearing line of the ankle after varus knee correction.

Methods:

Patients with a varus knee who were followed-up after they had undergone high tibial osteotomy (HTO) or total knee replacement arthroplasty (TKA) at an age of >20 years, and who had undergone preoperative and postoperative scanogram were included in this study. The hip-knee-ankle (HKA) angle, mechanical axis, and weight-bearing line (line from the center of the femoral head to the lowest point of the calcaneus) were measured on the radiographs. The point at which the mechanical axis and weight-bearing line passed through the tibial plafond was the ankle joint axis point. The postoperative change in the ankle joint axis point on the mechanical axis and weight-bearing line according to the HKA angle correction was adjusted by multiple factors using a linear mixed model.

Results:

A total of 257 limbs from 198 patients were included in this study. The preoperative HKA was 7.3 ± 4.7° and corrected to 0.4 ± 3.8°. Although the ankle axis points on both axes moved laterally after HTO and TKA, the ankle joint axis of the weight- bearing line showed a significant larger lateral movement (22.5±35.7%) (Fig.) than that of the mechanical axis (15.7±16.0%) in terms of rate of change (p = 0.006). The ankle joint axis point on the weight-bearing line moved laterally by 0.9% per degree of postoperative HKA angle decrease (p < 0.001). The change in the ankle joint axis point on the mechanical axis was not statistically significant after HTO and TKA (p = 0.223).

Conclusion:

The mechanical axis and weight-bearing line of the ankle moved laterally after the varus knee correction. The ankle joint axis on the weight-bearing line moved laterally as the HKA angle decreased after the surgery, whereas the varus knee correction did not significantly affect the ankle joint axis on the mechanical axis. The varus knee correction might affect the subtalar joint as well as the ankle joint. Therefore, we believe that our findings warrant consideration in pre- and postoperative evaluations using the weight-bearing line of patients undergoing varus knee correction.
Radiographic Analysis Between Two Commonly Used Measurements for Hallux Valgus Interphalangeus
Authors: Lever Caroline , Millward Graham , Mason Lyndon , Molloy Andrew
Published: October 2019

Category:

Bunion

Introduction/Purpose:

There is an increasing recognition of the contribution of hallux valgus interphalangeus (HVI) to the total deformity seen in hallux vallux valgus. The most commonly assessed radiological parameter is the hallux interphalangeus angle (HIA). Our aim in this study was to assess the reliability of the difference in medial and lateral proximal phalanx wall length (delta PP) in the assessment of hallux valgus interphalangeus in both the pre-operative and post-operative radiographs compared with the HIA.

Methods:

All patients undergoing scarf osteotomy for hallux valgus correction at our institution over a nine-month period were included. 40 feet in 36 patients were evaluated. Standard AP weight bearing radiographs preoperative and at 6 weeks post-surgery were evaluated by 2 independent observers. The standard PACS angular measurement tools were used for all measurements. The HIA and delta PP were measured along with hallux valgus angle (HVA) and intermetatarsal angle (IMA). Delta PP was calculated as the medial side length of the medial proximal phalanx minus the lateral side length of the proximal phalanx. SPSS 21 was used for statistical evaluation. Two-way random single measure intra-class correlation coefficient (ICC) was calculated to assess the interobserver agreement.

Results:

33 female and 3 male patients were assessed. The mean age was 58 years (range 26-80 years). 18 patients underwent an Akin osteotomy. Pre-operative mean HVA 33 degrees, IMA 15 degrees, HIA 4 degrees and delta PP 1.64 mm. Post-operative mean HVA 17 degrees, IMA 9 degrees, HIA 7 degrees and delta PP 1.03 mm. In the sub group that underwent an Akin osteotomy the HIA increased from 5.2 degrees to 8.8 degrees in contrast to the delta PP that reduced from 2.04 to 0.26 mm. Pre-operatively the inter observer agreement using ICC was HVA 0.74, IMA 0.82, HIA 0.65 and Delta PP 0.70. Postoperatively the interobserver agreement was HVA 0.71, IMA 0.55, HIA 0.57 and Delta PP 0.64.

Conclusion:

The delta PP was more reliable than the HIA, with an improved interclass agreement on both pre and post- operative radiographs. The mean post-operative HIA increased, this was also present in the group where an akin osteotomy had been performed. In contrast the delta PP reduced. We feel pronation of the toe may alter the radiographic measures for HVI assessment and affect the validity of the HIA measurements, however the delta PP reliability was less affected. Pre-operative radiographs had greater interobserver agreement across all measures than postoperative radiographs, which may reflect difficulties in determining the bony landmarks for measurement following surgery.
Diabetic Ankle Fracture Complications: A Meta-Analysis
Authors: Lopez-Capdevila Laia , Ruh Juan Manuel Rios , Vidal Jorge Fortuño , Costa Andres Eduardo , Mata Mario Alexandre Sanchez , Fumas Alex Santamaria , Sevilla Alejandro Dominguez , Román-Verdasco Jorge , Perez Josep Miquel Sales
Published: October 2019

Category:

Ankle, Diabetes, Trauma

Introduction/Purpose:

Fractures in diabetic patients have a well-known increased risk of complications and this makes the decision to treat these fractures either surgically or conservatively a difficult choice. However, ankle fractures are mostly treated surgically because of their pattern and the postoperative management does not differ from those ankle fractures in non-diabetic patients. The following study aims to review the evident rate of complications following the treatment of an ankle fracture in diabetic patients and their matched controls.

Methods:

Searches of PubMed, Scopus, Cochrane and ISI Web of Knowledge were performed for studies published between the date of database inception and March 2018. An initial selection of 202 abstracts was performed by at least 2 different reviewers, of which 77 articles were selected to complete review. After following strict inclusion and exclusion criteria, only 17 papers were admitted to the final meta-analysis. Demographics patient characteristics and incidence of the overall and specific complications were extracted from each study selected and an odds ratio with a 95% confidence interval of each complication was calculated between the diabetic and non- diabetic groups. Major complications (infection, non-union, malunion, Charcot neuroarthropathy, amputation, death) were compared not only between the two main groups but also between subgroups (complicated diabetic and non-complicated diabetic patients, surgical and orthopaedic treatment). The statistics data was analysed by Stata 15.

Results:

There is a significant increased rate of complications after treating an ankle fracture orthopaedically or surgically in diabetic patients (OR 1.74, IC 95% 1.67 to 1.82). This risk is considerably higher when the ankle fracture is treated surgically (OR 5.14, IC 95% 2.79 -9.58). Among the complications in diabetic patients, the rate is greater in complicated diabetic patients (neuropathy, vasculopathy) compared to the non-complicated diabetic patients (OR 8, IC 95% 2.61 - 26.31). The main complication postoperative in ankle fracture described is infection, which is 7 times higher in diabetic patients in comparison to non-diabetic patients (OR 6.9, IC 95% 3.03 -15.73). The risk of amputation and/or non-union after an ankle fracture in diabetic patients is about 0.2%.

Conclusion:

This meta-analysis provides evidence that diabetic patients have a significant greater risk of presenting a complication after an ankle fracture. The rate of major complications (infection, malunion, non-union, amputation and death) is by far significantly higher among those diabetic patients treated surgically and even greater among complicated diabetic patients.
The Diagnostic Value of MRI for High Ankle Sprains with an Unstable Syndesmosis: Time to Scan Matters
Authors: Marsland Daniel , Randell Matthew , Ballard Emma , Forster Ben , Lutz Michael
Published: October 2019

Category:

Ankle, Arthroscopy, Sports, Trauma

Introduction/Purpose:

Early clinical examination combined with MRI following a high ankle sprain allows accurate diagnosis of syndesmosis instability. However, patients often present late, and for chronic injuries clinical assessment is less reliable. The aims of the current study were to describe MRI characteristics associated with diagnosed syndesmosis instability, and to assess if MRI characteristics change as the injury becomes chronic.

Methods:

Patients with a high ankle sprain and proven syndesmosis instability at arthroscopy were retrospectively identified from the logbooks of two fellowship trained foot and ankle surgeons over a five-year period. Patients were excluded if they had a distal fibula fracture or absence of an MRI report by a consultant radiologist. Associations between MRI characteristics and time from injury to MRI scan, categorised as acute (< 6 weeks), intermediate (6-12 weeks) and chronic (> 12 weeks) were examined using the Pearson’s chi-squared or Fisher’s exact tests (significance set at p<0.05).

Results:

Of the 164 patients, 108 had an MRI scan in the acute period, 32 were classified as intermediate and 24 as chronic. A posterior syndesmosis injury was detected in 93.5% of acute patients, 87.5% of intermediate patients and 54.2% of chronic patients. In the acute group, PITFL injury was detected in 78.7% of patients, posterior malleolus bone oedema in 60.2% and posterior malleolus fracture in 15.7%. The proportion of patients with injury to the PITFL in intermediate patients was 59.4% and 29.2% in chronic patients which was significantly lower than in acute patients (p<0.001). Twenty eight patients with posterior malleolus bone oedema had an apparently normal PITFL. The proportion of patients with posterior malleolus bone oedema or fracture were not significantly different between groups.

Conclusion:

The most important finding of the current study is that in acute high ankle sprains with syndesmosis instability, MRI detected a posterior syndesmosis injury in 93.5% of patients. Posterior malleolus bone oedema appears to be a marker of an unstable syndesmosis injury, regardless of time from injury to the MRI scan. The ability of MRI to detect a posterior syndesmosis injury reduces significantly if delayed more than 12 weeks. If suspicious of a high ankle sprain, we advocate early MRI assessment to help determine stable versus unstable injuries, as the ability of MRI to detect posterior injuries reduces over time.