bluuebunny/crossref_metadata_2025 huggingface dataset:
Prevalence of Proximal Tarsal Disruption in Lisfranc Fracture-Dislocations
Authors: Fashandi Ahmad , Anciano Victor , Cooper M. Truitt , Park Joseph
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Lisfranc fracture/dislocations comprise of spectrum of injury including simple disruption of the lisfranc articulation to more complex tarsometatarsal fracture/dislocations. A further known variant of lisfranc injuries involves proximal tarsal disruption, specifically through the articulation of the medial and middle cuneiform. In the absence of polytrauma and high energy injury it is unknown what proportion of patients with sport or primary axial loading injury have proximal medial column variants of the lisfranc fracture. Recognizing and stabilizing this disruption is critical to establishing a stable medial column and restoring appropriate biomechanics of the foot.

Methods:

After IRB approval a retrospective cohort of patients was established at a single instutition utilizing CPT codes consistent with fixation of lisfranc/tarsometatarsal fracture-dislocations. Surgical encounters over a 3 year period were identified and retrospective chart review of operative reports and independent evaluation of imaging was used to determine medial column/proximal variants within the included subset of patients. Low energy fracture mechanisms with adequate imaging and operative reports were included in the study.

Results:

A total of 52 low energy lisfranc fracture-dislocations were included in the study for evaluation of injury patter. Based on imaging studies, intra-operative findings and fixation modalities 30 medial column variants (58%) were identified in this cohort. This subset of patients showed instability through the medial ray extending proximal to the lisfranc articulation and requiring intercuneiform fixation.

Conclusion:

Tarsometatarsal fracture-dislocations represent a spectrum of injury from disruption of the lisfranc joint to multiple midfoot dislocations. A proximal variant of this injury pattern with intercuneiform disruption is often noted, but prevalence has not been established. In low energy tarsometatarsal fracture-dislocations this study notes a 58% prevalence of medial column disruption requiring additional proximal fixation. Recognizing this injury pattern and appropriately addressing the pathology is critical for obtaining a stable foot and favorable outcome.
Virtual Scribe Services Are Associated with Higher Physician Satisfaction than Traditional Documentation
Authors: Hamid Kamran , Nwachukwu Benedict , Keating Timothy
Published: September 2018

Category:

Other

Introduction/Purpose:

Introduction of a novel virtual scribe service is theorized to eliminate waste from clinic operations. The iScribes virtual scribe application is activated in clinic and records audio proceedings of patient encounters. Recordings are transmitted to a remotely located medical scribe who translates patient-physician discussions into comprehensive clinic notes per the physician’s preferences. We hypothesize that virtual scribe services result in accurate notes, simple integration and high satisfaction.

Methods:

A modified version of a previously validated survey on physician documentation quality and satisfaction was digitally distributed to 193 orthopaedic surgeons who were using the iScribes system. The survey consisted of 16 domains relating to implementation, ease-of-use, efficiency, integration with electronic medical records, information quality, overall satisfaction and comparison to prior documentation systems.

Results:

Of the 193 physicians surveyed, 94 responded (49%). The majority (85%) were in private practice with the remaining in private-academic hybrids (2%), university systems (5%) and hospital employment (7%). Prior documentation modes were standard dictation (80%), Dragon voice-recognition (14%) and self-written/typed notation (6%). The average practice duration was 15 years (range: 1-34 years), and the average time utilizing the virtual scribe service was 12 months (range: 1-48 months). Providers rated the following domains as “agree” or “strongly agree”: easy to use (96%), fast (92%), integrates with workflow (94%), acceptable security (90%), allows me to perform work well (95%), reliable (90%), information is complete/accurate (88%), satisfaction with technical support (92%), overall satisfaction (92%) and prefer iScribes over previous system (93%) (Figure 1).

Conclusion:

The iScribes virtual scribe service was associated with high physician satisfaction in all tested domains and was preferred over traditional documentation in the present cohort of orthopaedic surgeons. Prospective analysis of time, quality and cost metrics is warranted.
Arthroscopically-assisted reduction and percutaneous screws fixation of Sanders type Ⅱ of calcaneal fractures
Authors: Hong Jinsong
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Compared the clinical effect of arthroscopy assisted reduction and application of sinus tarsal approach reduction when treating Sanders Ⅱ calcaneal fractures.

Methods:

It was a retrospective comparative study since August 2014 to February 2017.There are 68 cases with Sanders type Ⅱ displaced calcaneal fractures which was divided into two groups. Group 1 with 31 cases was treated with arthroscopy assisted reduction and percutaneous headless screws fixation. Group 2 with 37 cases was treated with reduction and internal fixation.

Results:

No statistically significant difference was found between the two groups compared with the time of fracture healing, the Maryland foot score and AOFAS, and the differences was not statistically significant(P>0.05). Compared with the open reduction group, arthroscopy group had lower VAS, the healing time of incision was significantly less, intraoperative and postoperative blood loss was less, and it had higher SF-36 score, the difference had statistical significance(P<0.001).

Conclusion:

Two different kinds of surgical treatment of Sanders type Ⅱ calcaneal fractures had good clinical outcomes, but the treatment of arthroscopy group had less injury, less pain after surgery, less complications of incision, and it was more helpful to improve patients quality of life.
Comparison of Midfoot and Metatarsal Dorsal Wedge Osteotomy to Treat Cavovarus Foot Deformity in Adolescents
Authors: Hong Jinsong
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

To compare the clinical result of midfoot and metatarsal dorsal wedge osteotomy for the treatment of cavovarus foot deformity in adolescents.

Methods:

A comparative retrospective study of 24 patients with cavovarus foot deformity in adolescents was conducted between March 2012 and March 2015 in the Guangzhou Orthopaedic Hospital. All patients were flexible deformity. 10 patients were treated with midfoot dorsal wedge osteotomy, while 14 patients received metatarsal dorsal wedge osteotomy. The clinical curative effects, complications and image differences were compared between the two groups. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Visual Analogue Scale (VAS) score were evaluated for each patient during the follow-up. All statistics were analyzed using the SPSS software system.

Results:

No early stage soft tissue complications occurred in all patients. All the patients obtained an average 21.5 months (ranged,10-30 months) follow-up.X-ray demonstrated that bone healing was obtained, the midfoot dorsal wedge osteotomy group at an average of 11.2 weeks (ranged,10-13 weeks). the metatarsal dorsal wedge osteotomy group at an average of 13.4 weeks (ranged,12-15 weeks). By AOFAS foot score and VAS pain score: There is no significant difference between the two groups (P=0.138). No complications of nonunion, recurrence of de-fortuity or implant failure were seen during follow-up.

Conclusion:

The midfoot and metatarsal dorsal wedge osteotomy are the effective methods for the treatment of cavovarus foot deformity in adolescents. For severe deformity midfoot metatarsal dorsal wedge osteotomy can provide more powerful correction.
Range of Motion Following Total Ankle Replacement and Subtalar Fusion Through Lateral Versus Anterior Approach. Biomechanics Analysis
Authors: Indino Cristian , Leardini Alberto , Manzi Luigi , Maccario Camilla , Usuelli Federico Giuseppe
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

A gait analysis of patients who underwent simultaneous total ankle replacement (TAR) and subtalar fusion allows to assess the ankle range of motion (ROM) with precision. In healthy subjects or in patients who underwent isolated TAR this is not possible because it is influenced by the subtalar ROM and it is not possible to analyse the two joints separately. Excluding the role of the subtalar joint, it is possible to analyse the consequences of different prosthetic designs and different surgical approaches on joint kinematics. The aim was to evaluate and compare with a gait analysis the effects of two different TAR designs on the functionality of the tibiotalar joint by exploiting the exclusion of the subtalar effect determined by the subtalar fusion simultaneously performed.

Methods:

Minimum follow-up was 12 months. 16 patients underwent a fix-bearing TAR through lateral approach (Zimmer Trabecular Metal Total Ankle), 7 patients underwent a mobile-bearing TAR through anterior approach (Hintegra). A six-camera motion capture system was used to measure foot static posture and foot segment kinematics. Rotations in the sagittal, frontal, and transverse planes between shank and the whole foot, shank and calcaneus, calcaneus and midfoot, midfoot and metatarsus, and calcaneus and metatarsus were calculated. Sagittal and transverse plane rotations of the first matatarso-phalangeal joint, medial longitudinal arch deformation, transverse plane angle between first and second metatarsal bone and between second and fifth metatarsal bone, and sagittal plane orientation of the first and second metatarsal bone with respect to the ground were also calculated. The following spatio-temporal parameters were calculated: stance time, swing time, stride length, normalized stride length, cycle time, cadence, walking speed, and normalized walking speed.

Results:

On average, the lateral approach group walked at a faster speed and with a longer stride length than the anterior approach group. However, spatio-temporal parameters in both groups were generally lower than the control values. No major differences were detected between the two groups in terms of ROM in any foot joint, with the exception of the frontal-plane motion of the midfoot with respect to the calcaneus (midtarsal joint) which was larger in the anterior approach group.

Conclusion:

patients with TAR through lateral approach seem to walk at a faster speed and with a longer stride length than patients with TAR through anterior approach; the midtarsal joint ROM was larger in the anterior approach group and this could mean that mobile bearing TARs through an anterior approach could lead to an overload of the midtarsal joint with respect to fixed-bearing TARs through a lateral approach. However, further studies with larger samples of patients are needed to confirm these results.
Consideration of Medial Anatomical Structures at Risk when Placing Quadricortical Syndesmotic Fixation
Authors: Kaiser Philip , Riedel Matthew , Ghorbanhoseini Mohammad , Qudsi Rameez , Kwon John
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Surgical fixation of ankle fractures with syndesmotic instability using quadricortical fixation through the fibula and tibia is commonly performed to maintain mortise congruency. Quadricortical fixation can be achieved by screws or suture buttons however both involve unprotected drilling and placement of hardware through the medial distal tibia which places anatomic structures at iatrogenic risk. These structures may include the anterior tibialis tendon, the saphenous neurovascular bundle (SNVB) and posteriorly, the posterior tibialis tendon (PTT). This study aims to radiographically map the anatomic course of these structures at risk on a lateral radiograph as would be used intraoperatively during syndesmotic fixation.

Methods:

Eighteen fresh-frozen cadaveric feet were dissected with preservation of all soft tissue and neurovascular structures over the medial distal tibia. While preserving fascial and tendinous sheath attachments, the SNVB and the PTT were identified and marked with metal wiring. Standardized and calibrated lateral radiographs were obtained to determine the anatomic course of these structures. Lateral radiographs of the distal tibia and fibula were analyzed by a grid system comprised of 1 cm row-increments moving cranially from the ankle joint up to 5 cm and by 3 evenly distributed parallel columnar zones from anterior to posterior (see Figure). The anterior boundary of the columnar zone was placed at the anterior tibial shaft and the posterior boundary was placed at the posterior malleolus of the tibia. The position of respective metal wires placed within the SNVB and the anterior portion of the PTT were charted according to this grid system and results compiled.

Results:

The SNVB was located in zone 1 or 2 (or anterior to zone 1) in 97.3% of specimens (107/110). The SNVB traversed from proximal-posterior to distal-anterior. For the 16 specimens that crossed a columnar zone, the most common crossover was from zone 2 to zone 1 at 3-4 cm above the ankle joint which occurred in 43.8% (7 of 16) specimens. The PPT was found in zone 3 in all specimens (n=18) with only one specimen demonstrating crossover of a columnar zone into zone 2 at its most distal extent (0-1 cm). The PTT was noted to pass behind (radiographically overlap) with the tibia in 83.3% (15 of 18) of specimens between 1 and 3 cm above the ankle joint.

Conclusion:

Inappropriate placement of quadricortical syndesmotic fixation may place structures on the medial ankle at risk given blind drilling and hardware placement. The SNVB is at considerable risk along the anterior course of the distal tibial while the PTT is only at risk in zone 3 at the distal extent of the tibia when a true lateral radiograph is obtained. This grid system allows a simple intra-operative check to guide safer placement of quadricortical syndesmotic fixation.
Iatrogenic Fracture Gapping During Fixation of Jones Fractures
Authors: Kaiser Philip , Riedel Matthew , Qudsi Rameez , Kwon John
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Surgical fixation of Jones fractures is often recommended to facilitate recovery and achieve union. Iatrogenic fracture displacement during intramedullary screw fixation is a commonly encountered technical issue. This may be related to fracture location in relation to the surrounding ligamentous attachments, namely the robust intermetatarsal ligaments found at the proximal articulation of the 4th and 5th metatarsals. This study examines the relationship between fracture line and its location in regards to the surrounding ligamentous structures and its effect on Jones fracture displacement, reduction and fixation in a cadaveric model.

Methods:

Eighteen fresh-frozen cadaveric feet were dissected with preservation of all ligamentous attachments. Given the similar anatomic distal extent of the dorsal and plantar intermetatarsal ligaments on the 5th metatarsal, measurements were obtained detailing the anatomic position of the dorsal intermetatarsal ligament (DIL) only. The specimens were divided into two groups with modelled fractures created at the 4th & 5th metatarsal articulation proximal to the distal extent of the DIL (Group 1) or just distal to the DIL (Group 2). Fractures were fixed in standard fashion with serial fluoroscopic images obtained to study fracture gapping and rotation.

Results:

There was approximately 5 mm of fracture gapping created iatrogenically during tapping with no statistically significant differences between Group 1 and Group 2 (4.53 mm versus 5.25 mm, p=0.5430). The distal aspect of the DIL was anatomically located 2.77 mm (Range 1.58 mm – 4.46 mm) distal to the 4th & 5th metatarsal articulation.

Conclusion:

Considerable iatrogenic fracture gapping occurs during intramedullary screw fixation of Jones fractures in a cadaveric model regardless of fracture location in relation to the intermetatarsal ligamentous attachments. Intraoperative displacement may be related to iatrogenic distraction caused by canal tapping when utilizing a common surgical method. Specific techniques may be required to maintain anatomic alignment during tapping and screw fixation to prevent iatrogenic displacement.
Dorsal Suspension for Morton’s Neuroma
Authors: Kang Chan , Song Jae-Hwang , Ahn Ki jun , Choi Bo Sung , Hwang Sungjin , Lee Gi-Soo , Lee Jeong-kil , Seo Gangwon , Kim Dong Yeol
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

We performed a dorsal suspension of neuroma using the dorsal transverse ligament for the treatment of Morton’s neuroma. The purpose of this study was to investigate and compare the functional outcomes and complications of dorsal suspension with those of neurectomy.

Methods:

We conducted a retrospective study of thirty-eight (40 feet, 40 neuromas) and thirty-six (36 feet, 36 neuromas) patients who underwent dorsal suspension and neurectomy, respectively. At twenty-four month follow-up, the visual analog scale was used to evaluate pain, and the Foot and Ankle Ability Measure (FAAM) was used to investigate patient-reported function of activities of daily living and sports. Satisfaction analysis was performed using the Coughlin scale, and postoperative complications were also evaluated.

Results:

Both groups reported significant pain relief, and there were no significant differences between the groups with respect to postoperative pain (dorsal suspension group, mean, 12.0; neurectomy group, mean, 25.8; p = .99). The postoperative FAAM outcomes showed no significant between-group differences in activities of daily living (dorsal suspension group, mean, 89.5, neurectomy group, mean, 77.2; p = .22) or sports subscales (dorsal suspension group, mean, 85.5; neurectomy group, mean, 69.4; p = .97). Satisfaction analysis showed ‘excellent’ and ‘good’ results in the dorsal suspension and neurectomy groups (95% and 77.7%, respectively). Complications reported in the dorsal suspension and neurectomy groups were numbness (5% vs 61.1%, respectively, p < .05) and paresthesia (5% vs 33.3%, respectively, p < .05).

Conclusion:

Compared with neurectomy, dorsal suspension provided comparable pain relief and improvement in terms of functional outcomes, as measured by the FAAM. With its lower rate of complication and high satisfaction, dorsal suspension can be another operative option for the treatment of Morton’s neuroma.
The Influence of Diabetes on Acute Achilles Tendon Rupture Repair
Authors: Kaplan Jonathan , Hillam Jeffery , Aiyer Amiethab , Smyth Niall
Published: September 2018

Category:

Sports

Introduction/Purpose:

Diabetes Mellitus (DM) is an epidemic affecting millions of individuals in the United States. Multiple studies have demonstrated an increase in complications in foot and ankle surgery in patients with DM, including wound healing complications, surgical site infections (SSI), or surgical failure. The goal of this study was to retrospectively review outcomes data from the National Surgical Quality Improvement Program (NSQIP) to determine the impact of DM on operative treatment of achilles tendon ruptures.

Methods:

Using the NSQIP from 2006-2015, patients were identified using common procedure terminology (CPT) for Achilles tendon ruptures. Diabetic and non-diabetic cohorts were evaluated to compare demographics, comorbidities, perioperative details and 30-day outcomes. Statistical evaluation included a power analysis for the primary outcome measure of wound disruption as well as univariate analysis was performed using chi-squared or Fisher’s exact and Wilcoxon signed-rank tests.

Results:

A total of 2,014 patients were identified having sustained an Achilles tendon rupture. There were 1,981 patients without DM and 33 patients with DM. There were no significant differences in postoperative complications, including SSI, medical complications, and 30-day outcomes between patients with DM and non-DM patients undergoing surgical repair of acute Achilles tendon ruptures. The power analysis for wound disruption showed a P=0.9 with an alpha of 0.05, sample size of n=2014, and Pearson correlation coefficient of r=0.0721

Conclusion:

While DM has been shown to have an increase in complications in various foot and ankle procedures, this study demonstrates that there is no significant difference in postoperative complications and 30-day outcomes between patients with DM and non-DM patients undergoing surgical repair of acute Achilles tendon ruptures using the NSQIP database from 2006-2015. Based on this data, patients with diabetes mellitus can be considered adequate surgical candidates for acute Achilles tendon rupture repair.
Clinical significance and morphological analysis of the os subfibulare using radiologic assessment in patients with chronic lateral ankle instability
Authors: Lee Doo Jae , Lee Dong Yeon , Lee Jae Hee
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Although os subfibulare has been associated to various clinical problems in patients with chronic lateral ankle instability (CLAI), there are a few studies on the analysis of morphological characteristics of os subfibulare. The purpose of this study is to analyze morphologic characteristics of the os subfibulare and to evaluate the clinical significance of the os subfibulare in patients with CLAI.

Methods:

Among 252 patients who visited our training hospital with the symptom of lateral ankle instability for more than 1 year after sustaining ankle injury, 71 patients with os subfibulare who underwent magnetic resonance imaging (MRI) of the ankle were included in this study. For each patient, the simple radiologic assessment was also performed. The shape and size of ossicles were measured on a sagittal MR images. The location of the subfibular ossicle was classified into 3 zones by relation with the attachment site of the anterior talofibular ligament. The talofibular impingement, in which ossicles impinged to the talar articular surface.

Results:

The most common shape of ossicles was oval, and the most common site of ossicles was ATFL attach site. 61% of patients showed talofibular joint impingement on axial MR images, whereas 28 cases showed normal congruency of the talofibular joint. Forty-eight cases in 71 patients with CLAI had an enlarged fibular shape instead of a contralateral fibula on simple radiographs. The age; sex; the shape, location, and size of the ossicle; talofibular articular impingement; and history of major trauma were associated with surgical treatment in statistical analysis.

Conclusion:

The morphological analysis of the os subfibulare revealed that the ossicle manifested radiographic differences based on its size, location, and morphology. Based on the findings of our study, we suggest it is crucial to understand the morphologeical characteristics of the os subfibulare in patients with CLAI and to establish the treatment plan accordingly.
Screw fixation of the posterior malleolar fracture
Authors: Lee Gi-Soo , Kang Chan , Cho Byung-Ki , Won Yougun
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Posterior malleolar fracture is known to be an indication for surgery when the size of the fragment is greater than 25% to 30% of the joint surface. The purpose of this study was to compare the results of cannulated screw fixation and early joint motion in patients with ankle fracture with posterior malleolar fracture of less than 25%, and we do cadaver experiments.

Methods:

The clinical portion of the study evaluated 70 patients with fracture of the posterior malleolus that comprised less than 25% of the articular surface. After fixation for lateral and/or medial malleolar fractures, cannulated screw fixation was performed for posterior malleolar fractures in 34 cases. (A group) In other 36 cases, fixation was not performed for posterior malleolar fractures. (B group) One week after the operation, ankle range of motion exercise was performed. Cadaver studies were evaluated both cannulated screw fixed and non-fixed in less than 25% fractures of the posterior malleolar. The stability of the ankle joint was measured in 12 cases. In 6 cases, the posterior malleolar was fixed and the other 6 cases were not fixed.

Results:

There was no significant difference in clinical outcome between Group A and B and functional score at 2 years follow up. However, the ankle function score at 6 months and 1 year after the follow - up was significantly higher in group A than in group B. In the cadaver study, the group with screw fixation was significantly stable in external rotation.

Conclusion:

In case of less than 25% posterior fracture, screw fixation is considered to have a significant effect on recovery and clinical outcome in the short term due to stability.
Effects of walking speed and slope on foot pressure in young healthy adults
Authors: Lee Kyoung Min , Min Byung-Cho , Koo Seungbum
Published: September 2018

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Although pedobarographic measurement is increasingly used for clinical and research purposes, relatively few published studies have investigated regarding effects of walking speed and slope. This study examined pedobarographic findings in young healthy adults with regard to different walking speeds and slopes.

Methods:

Twenty young healthy adults (mean age 22.4 years, SD 1.2 years; 10 males and 10 females) were recruited. Dynamic pedobarographic data were obtained during treadmill walking with different walking speeds (3.2 km/hr, 4.3 km/hr, and 5.4 km/hr) and slopes (-8°, -4°, 0°, 4°, and 8°). Pedobarographic data including peak pressure and pressure-time integral were measured on five plantar segments: medial forefoot (MFF), lateral forefoot (LFF), medial midfoot (MMF), lateral midfoot (LMF), and heel. Distribution of foot pressure between medial and lateral sides, and between anterior and posterior aspects were calculated as varus/valgus index and forefoot/heel index, respectively. Walking speed of 4.3 km/hr on 0° of slope was considered as standard walking condition.

Results:

Varus/valgus index of peak pressure showed significant increase on the slope of 8° and the walking speed of 4.3 km/hr (p=0.036) and 5.4 km/hr (p=0.007). Forefoot/heel index of peak pressure significantly decreased on downhill walking. Varus/valgus index of pressure-time integral showed significant increase when uphill and downhill slope was greater and walking speed was faster compared with standard with walking condition. Forefoot/heel index of pressure-time integral showed significant increase in downhill walking while significant decrease was observed during uphill walking.

Conclusion:

Changes of walking speed and slope caused those of foot pressure distribution. Therefore, combination of walking speed and speed might be associated with pressure related symptoms and disorders of the foot.
Transfixing Screw Placement for Syndesmotic Injury
Authors: Lee Si Wook
Published: September 2018

Category:

Trauma

Introduction/Purpose:

The strategy of transfixing screw fixation including screw number, size, material, the number of cortex involved, and penetrating angle is controversial. The purpose of this fresh frozen cadaveric study is to demonstrate the optimal degree of transfixing screw insertion after syndesmotic reduction in the Pronation External Rotation (PER) type ankle fractures, and to study reliable parameters to evaluate the syndesmotic reduction.

Methods:

Twenty paired fresh frozen anatomic specimens of the ankles were obtained. Before dissection, CT scans were taken preoperatively. Then, preparation was performed by cutting and dissection of anterior interior tibiofibular ligament (AITFL), interosseous ligament and membrane. Two types of screw placement were set. Ten screws were inserted into right ankle at an angle of 25 to 30 degrees from neutral position. The other 10 screws were inserted into the left ankle at a 0 degree angle from neutral position. Postoperative CT scan was performed after screw insertion. Anterior fibular distance(AFD), posterior fibular distance(PFD), anterior translation distance(AT), diastasis, anterior-posterior translation(APT) were measured in 2D axial section and volume of the syndesmotic space were measured in 3D reconstruction data of preoperative and postoperative CT scan.

Results:

The transfixing screw fixation induce the significant difference in syndesmotic space regardless of insertion angle. There was significant difference only in fibular diastasis between both ankle model. There was no statistically significant difference in AFD, PFD, AT, APT and 3D reconstructed volume according to transfixing screw insertion angle when each measured value was compared through left and right ratio and absolute volume value.

Conclusion:

In ankle syndesmotic injury, transfixing screw insertion should be considered for the ankle stability. But, regardless of the insertion angle, transfixing screw insertion would have a significant therapeutic effect on ankle syndesmotic injury. Fibular diastasis would be the reliable parameters to evaluate syndesmotic reduction.
Hallux MTP Arthrodesis for Treatment of Severe Hallux Valgus Using a Dorsal Locking Plate
Authors: Lee Wonyong , Truitt Cooper M. , Perumal Venkat , Park Joseph
Published: September 2018

Category:

Bunion

Introduction/Purpose:

First metatarsophalangeal (MTP) joint arthrodesis is widely accepted as a treatment option for severe hallux valgus deformities. Although successful results of first MTP joint arthrodesis for hallux valgus have been reported in previous studies, the reported rates of fusion have been lower than for the general hallux rigidus population. The purpose of this study was to demonstrate the failure rate of first MTP joint arthrodesis for severe hallux valgus deformities and to evaluate radiographic correction of hallux valgus parameters after the surgery.

Methods:

From January 2014 to June 2017, 34 patients underwent first MTP joint arthrodesis surgery for severe hallux valgus deformity and were included in this retrospective study. Severe hallux valgus was defined as having a hallux valgus angle (HVA) of greater than 40 degrees and an intermetatarsal angle (IMA) greater than 15 degrees. For radiographic evaluation, the patients were evaluated by measuring the IMA and HVA in preoperative and postoperative weight-bearing AP foot x-rays. We defined failure after first MTP joint arthrodesis as non-union, incomplete union, or implant breakage or migration leading to a symptomatic recurrence of hallux valgus deformity.

Results:

The mean preoperative IMA and HVA were 16.7 ± 4.2 degrees (range 8.4 to 26.5) and 45.2 ± 8.6 degrees (range 28.7 to 71.1) respectively, and the postoperative IMA and HVA were 11.3 ± 3.8 degrees (range 4.1 to 20.4) and 20.9 ± 11.8 degrees (range 0.4 to 51.1) respectively. The postoperative IMA and HVA were significantly improved after surgery (< 0.001). Among the 34 patients in this study, a 14.7% failure rate was reported (n=5). For fusion procedures performed without lag screw fixation, there was a 12.6-fold increase in failure risk when we used the small dorsal locking plate compared with the medium dorsal locking plate (Odds ratio = 12.571).

Conclusion:

First MTP joint arthrodesis is an effective and reliable option for severe hallux valgus correction. However, for this challenging cohort, the 14.7% failure rate in this study is consistent with other studies in the literature. For severe hallux valgus deformities, selection of implant may play a more significant role. The use of longer plates to gain additional purchase in the diaphyseal bone, lag screw augmentation, and utilizing flat cuts instead of cup and cone reaming to realign the joint may help mitigate the increased stresses placed on the fixation constructs for MTP arthrodesis.
The Common Peroneal (High Fibular) Nerve Block
Authors: Maiyuran Harinee , Harris Thomas
Published: September 2018

Category:

Ankle

Introduction/Purpose:

The bifurcation of the sciatic nerve results in the common peroneal nerve, along with the tibial nerve. A commonly block used before foot and ankle surgery is the sciatic block. This block requires an ultrasound or neurostimulation for accurate placement and can take time to administer effectively. We believe that the common peroneal, or high fibular nerve block, may be equivalent in some clinical circumstances to the sciatic block and does not require additional imaging for accurate placement.

Methods:

In this study, a mixture comprised of 5 mL 0.5% bupivacaine and 5 mL 1% lidocaine was used for each patient. Certain surface anatomic landmarks were used to place the block without ultrasound or neurostimulation. The time spent administering the block was recorded. Patients were not given pain medicines in the recovery unit unless the block did not work. A follow-up questionnaire was completed within 24 hours following surgery, and this was used to assess aspects of the patient’s post-operative experience. These include the number of hours following surgery that the patient: 1) first felt pain, 2) first took pain medication, 3) first felt tingling, 4) fully regained feeling in his/her leg, and 5) could wiggle his/her toes. Also, any complications were recorded.

Results:

This study involved 21 patients with an average age of 51. The most common procedures used with the block were hardware removal of the fibula and open reduction internal fixation of the fibula. The block took on average less than 3 minutes to administer and ultrasound was not used in any cases. No patients were given pain medicines in the recovery unit. None of the patients reported any complications, specifically, there were no cases of foot drop or any persistent paresthesias. The average time it took for patients to first feel pain after the block was approximately 8 hours. On average, patients first took pain medication approximately 11 hours after surgery, and regained sensation in their leg 15 hours after surgery.

Conclusion:

The benefits of the common peroneal block are multifold, as their clinical outcomes were positive and patients did not experience any complications. Also, from a surgeon perspective, the block is quick to administer and does not require ultrasound or neurostimulation.
Sport and physical activities in patients with Chronic Achilles tendon rupture reconstruction using flexor hallucis longus transfer
Authors: Manzi Luigi , Maccario Camilla , Palanca Ariel , Di Silvestri Claudia , Usuelli Federico Giuseppe
Published: September 2018

Category:

Sports

Introduction/Purpose:

Neglected or chronic Achilles tendon ruptures can be significantly disabling to patients if the muscle-tendon unit is stretched beyond its normal passive limit. Chronic rupture of the Achilles tendon (delayed diagnosis of more than 4 weeks) can result in retraction of the tendon and inadequate healing. Direct repair may not be possible and clinical results may not be satisfactory especially if the distal stump is grossly tendinopathic and when the defect exceeds 5-6 cm.

Methods:

We evaluated 9 patients (mean age 63) who underwent flexor hallucis longus transfer for treatment of chronic Achilles tendinopathy between May 2014 and January 2017 at a 12 months follow-up. Our results were measured with the SF-12 survey, AOFAS Ankle-Hindfoot Scale and VAS. Activity levels were determined using the Halasi ankle activity scale and the UCLA score obtained preoperatively and 12 months after surgery. Wound complications and tip-toe stance were also assessed.

Results:

All patients had a significant improvement of AOFAS, VAS and SF-12 scores. The Halasi activity scale and UCLA score were 5.8 and 8.2 respectively 12 months after surgery. Patient reported outcome measures consistently demonstrated improvement in clinical putcomes at 12 months follow-up. The patients went back to full daily function, could single leg heel raise and were gradually returning to sport. No major complications were recorded.

Conclusion:

Reconstruction of chronic tears of the Achilles tendon with flexor hallucis longus transfer can achieve satisfactory improvements in clinical outcomes at 1 year follow-up.
Hindfoot alignment in total ankle replacement at 2 year follow-uo
Authors: Manzi Luigi , Indino Cristian , Gross Christopher , D’Ambrosi Riccardo , Usuelli Federico Giuseppe
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

End-stage ankle osteoarthritis frequently involves multiplanar malalignment both tibio-talar and subtalar joint. Restoration of the correct position of the tibial and the talar component and of the hindfoot is mandatory for the long-term survival of total ankle replacement. Since patients with ankle osteoarthritis often present concomitant hindfoot deformity, radiographic references are needed to describe deformities. However, the possible compensatory mechanisms of these linked joints are not well known.The aim of this study is to show if there is any difference regarding hindfoot position at 6 months, 1 year and 2 years follow-up.

Methods:

The study included 68 ankles who underwent Total Ankle Replacment through a later transfibuklar approach between May 2013 and December 2015. The main indications for TAR were: post-traumatic (55 patients, 80.9%) and reumathoid arthritis (5 patients, 7.4%). In these patients the hindfoot view angle was measured 6, 12 and 24 months postoperatively. Furthermore, clinical outcomes were recorded. Patients who underwent hindfoot/midfoot fusions were excluded.

Results:

The mean hindfoot alignment angle (HAV) was 0.4±0.0 pre-operatively and 0.1±6.2, 0.7±6.2, 1.2±7.0 at 6, 12 and 24 months postoperatively. There was no statistically significant difference in the HAV between follow-up. A statistically significant improvement in clinical scores (AOFAS, VAS and SF.12) was found at each follow-up. The main complications were: 6 hardware removal for intollerance (8,8%), 3 delayed wound healing (4,4%), 1 medial impingement (1,5%).

Conclusion:

Regarding the hindfoot alignment angle, TAA through a lateral approach showed a good reliability. Furthermore, hindfoot alignment remains stable over time.
Ankle Fracture Stability-based Classification
Authors: Michelson James , Delaney John
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Rotational ankle fractures are common in orthopaedic surgery, however existing classification systems are mostly descriptive in nature and do not explicitly guide surgical decision-making. A Stability-Based classification was developed recently to provide a more prognostic classification. The purpose of this study was to compare the reproducibility of existing ankle fracture classifications, and determine the ability of the Stability-Based classification to predict clinical treatment.

Methods:

One hundred ninety-three consecutive ankle fractures treated at our institution were retrospectively analyzed. Rotational type injury patterns in patients >18 years old were included. None of the subjects were clinically treated or evaluated by the study authors. The fractures were treated by attending physicians who were unaware of the Stability-Based classification system. Pathologic fractures were excluded. Three observers classified injury radiographs using the Lauge-Hansen, Weber/AO, and Stability-Based classifications systems. Reproducibility (inter-observer variation) of each classification system was calculated using kappa statistics. Prognostic values were evaluated by calculating the area under the curve (AUC) for the ROC curves (using surgery as the positive outcome) for each classification.

Results:

The Stability-Based classification was showed the excellent reproducibility (kappa .938, 95% CI .921-.952), along with the Weber/AO classification (kappa .97, 95% CI .961-.976), while the Lauge-Hansen had the lowest reproducibility (kappa .74, 95%CI .664-.795). The AUC for the three classifications were .883 (95%CI .852-.914), .626 (95%CI .576-.675), and .698 (95%CI .641-.755), respectively (Figure 1). The AUC was significantly better for the Stability-Based classification compared to the other 2 classifications (p<.001).

Conclusion:

The AO/Weber classification had excellent reproducibility, but did not predict the need for surgical stabilization accurately. In contrast, the Stability-Based classification system was both highly reproducible (kappa .938) with excellent prognostic ability to identify patients who got surgery (AUC .883). Furthermore, there were no patients who were classified as stable who failed non-operative treatment. The Stability-Based classification was found to have superior prognostic capacity compared to both the Lauge-Hansen and AO/Weber classification systems. This extends earlier studies by showing the reproducibility of the Stability-Based classification system and directly demonstrating its prognostic superiority to other classification systems.
MRI Analysis for Clarification of Mechanism of Ankle Osteoarthritis
Authors: Mitsui Hiroyuki , Hirano Takaaki , Niki Hisateru
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

We have previously studied the relationship between Takakura–Tanaka classification stages and bone-marrow edema (BME) in order to elucidate the pathology of ankle osteoarthritis (ankle OA) on magnetic resonance imaging (MRI). Moreover, we have investigated that BME onset on the talocrural joint can be predicted according to radiographic findings. In the present study, we focused on the changes around the subtalar joint to examine the relationship between talar lateral process impingement (TLPI) and foot and ankle joint alignment, and whether TLPI can be predicted on the basis of X-ray findings.

Methods:

We assessed 30 feet of 30 patients who had a diagnosis of ankle OA in our hospital and underwent MRI. Alignment was assessed radiographically by measuring the tibial anterior surface angle (TAS), the tibial lateral surface angle (TLS), the lateral talo-first metatarsal angle (LTMT), the lateral talocalcaneal angle (LTC), and the tibial axis–talar ratio (T-T ratio). MRI was obtained with the talocrural, subtalar and Chopart joints into 22 subdivided areas to examine the frequency of BME for each patient. TLPI was considered positive (+) when BME was found in the talar lateral process. The patients were divided into two groups according to TLPI positivity or negativity. Their BME frequency was examined, and significant differences in radiographically measured values were analysed with a t-test.

Results:

In the TLPI (+) group, BME development occurred at significantly higher frequencies in all areas except those surrounding the lateral process (p = 0.002). In addition, TLS was significantly lower (p = 0.02), and LTMT was significantly higher (p = 0.04). When the cut-off value on the ROC curve was set at TLS of =74° and LTMT of =19°, TLPI onset could be predicted with a sensitivity of 75% and a specificity of 71%.

Conclusion:

Our results revealed that in the TLPI (+) group, progression of the anteriorly opened talocrural joint and talar dorsiflexion may be causing the talar lateral process to hit the calcaneus. Furthermore, in the TLPI (+) group, BME in other areas also occurred at higher frequencies, and symptoms around the ankle joints may be occurring at multiple locations. The fact that TLPI could be predicted from radiography findings suggests that this may be a potential predictive tool of the severity of clinical symptoms.
Mechanically Superior Molybdenum Rhenium (MoRe®) Alloy provides an advanced option for Foot and Ankle Implants
Authors: Parekh Selene , Adams Samuel , Nunley James , Easley Mark , Pedowitz David , Hyer Christopher , Brigido Stephen
Published: September 2018

Category:

Other

Introduction/Purpose:

One of the most common complications in orthopaedic surgery of the foot and ankle is nonunion or delayed union and bone or implant fractures. Although foot and ankle surgery has improved dramatically over the past decades primarily due to the development of better techniques, little progress has been made in the development of new materials for implants. Titanium, the most commonly used alloy for foot and ankle implants, has limited strength and is notch-sensitive so repetitive stress leads to fatigue failure of implants and limits design options. Better materials with optimized biomechanical properties could result in the development of superior foot and ankle implants and surgical techniques. The mechanical properties of Molybdenum-Rhenium (MoRe®), a promising new alloy for foot and ankle implants were tested.

Methods:

Standard test methods (ASTM 1717) were performed to evaluate the mechanical properties of Molybdenum Rhenium (MoRe®) alloy compared to Titanium (Ti-6Al-4 V, ASTM F136-13 annealed bar, Ti-ELI).

Results:

MoRe® is composed purely (99.99%) of molybdenum and rhenium and does not contain Nickel. Molybdenum is found in food and is a cofactor to the enzymes xanthine oxidase and sulfite oxidase, which are essential to bone and connective tissue metabolism. Rhenium is an inert metal with no biological affect. Mechanical testing showed MoRe to be superior to Titanium: Yield Strength: MoRe® 280ksi, Titanium 115ksi, Ultimate Tensile Strength: MoRe® 300ksi, Titanium 125 ksi. Elongation and Reduction in Area: MoRe® 13%, 50%, respectively; Titanium 10%, 25%. Recoil: MoRe® <2%, Titanium 6%. Hardness Range: MoRe® 280-800HV, Titanium 350-400HV. Max Run-Out Load Bent Rod: MoRe® 4.0 mm rod 350 N, Titanium 5.5 mm rod 150 N. Decrease in Max Run-Out Load Bent, Unbent, Re-bent Rod: MoRe® -9%, Titanium -17%.

Conclusion:

The MoRe® alloy, with its advantageous mechanical properties, offers great promise for the design of a new generation of smaller, stronger and more fatigue resistant foot and ankle implants, resulting in less soft tissue disruption, quicker recovery and better outcomes for patients.