bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effect of Exchanging a Mobile-Bearing into a Fixed-Bearing Total Ankle Replacement System in Patients with Coronal Plane Instability
Authors: Ruiz Roxa , Schweizer Christine , Krähenbühl Nicola , Hintermann Beat
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

The interface between the polyethylene (PE) inlay and the tibial component in mobile-bearing total ankle replacement (TAR) systems may allow the talus to seek its position according to the individual anatomy. However, chronic overload and/or incompetence of soft tissue may allow medial and/ or lateral translation of the talar component over time. This typically results in medial and/ or lateral gutter pain as well as pain along the syndesmosis. The purpose of this study was to assess the effect of tibial component exchange and conversion from a mobile-bearing into a fixed-bearing TAR system in patients with coronal plane instabilities TAR.

Methods:

A consecutive series of 30 ankles (29 patients; age 65.6 [48.9 – 86.1]; male, 23; female, 7) with coronal plane instabilities underwent revision TAR with exchange of a mobile-bearing (Hintermann Series, H3) into a fixed-bearing (Hintermann Series, H2) TAR system. Patients presented with a medial (n = 12) or lateral (n = 9) translation of the talar component, or a varus (n = 4) or valgus (n = 5) instability with subsequent tilt of the talar component. After removing the tibial component and PE inlay, a tibial osteotomy was performed and 1 to 2 mm of the distal tibia removed. A tibial component of the H2 total ankle system was inserted. While holding the foot in neutral position, the PE inlay was locked to the tibial component in the appropriate position. Functional outcome and pain were recorded to evaluate clinical outcome, and standard radiographs under fluoroscopy were taken for radiographic assessment.

Results:

All but one of the remaining 28 patient showed significant improvement of pain (P<0.05). Preoperative gutter pain disappeared completely in 20 ankles (71.4%), and partially in 8 ankles (18.6%). The AOFAS Hindfoot Score improved from 54.3 (range, 21 to 90) preoperatively to 74.0 (range, 48 to 92) at latest follow-up (P<0.05). Radiographic assessment showed firm osteointegration in all patients with the talar component centralized in the ankle mortise, and a free medial and lateral gutter without tilt of talar component (Figure 1). One patient with bilateral revision TAR was affected by a bilateral deep infection of both ankles 9 months after surgery subsequent to a severe pneumonia. Both ankles were removed and replaced by a cement spacer.

Conclusion:

Converting a mobile-bearing into a fixed-bearing TAR system has shown to be effective in the treatment of patients with coronal plane instabilities following TAR. Allowing the PE inlay to adapt its position according to the talar component before definitive fixation to the tibial component of the H2 series, saved having to replace the talar component. Future long-term studies however are needed to identify significant benefits of this novel total ankle concept in primary and revision TAR.
Early Outcomes Following Dorsal Denervation of the Midfoot for Management of Arthritic Pain
Authors: Shi Glenn G. , Kumar Arun , Williams Meredith A. , Wilke Benjamin K. , Whalen Joseph L. , Kraus Jonathan
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Debilitating midfoot arthritic pain is reported to affect up to 12% of adults over 50 years. After failure of nonoperative management, midfoot arthrodesis has been favored as the primary operative treatment producing acceptable outcomes with associated potentially long postoperative immobilization and 17% major complications rate. The aim of this study was to evaluate the pain and functional outcomes of dorsal midfoot surgical denervation by deep peroneal neurectomy as a safe alternative for management of dorsal midfoot pain.

Methods:

In this retrospective study, 18 patients (21 feet) who underwent dorsal denervation of the midfoot by deep peroneal neurectomy by a single surgeon were evaluated. There were 13 women and 5 men with mean age 70.4 (range, 47 to 88) at the time of surgery. Indications for the procedure include painful midfoot arthritis, lack of radiographic collapse, intact plantar protective sensation, failed nonoperative management for 6 months, and greater than 75% transient pain relief from preoperative diagnostic block of deep peroneal nerve. Preoperative and postoperative (3 months, 6 months) Visual Analog Scale (VAS), Short- Form 36 (SF-36), and Foot and Ankle Outcome Score (FAOS) were reviewed. Complications were recorded.

Results:

The mean VAS score improved from 7.4 +/-1.9 to 1.9 +/-1.9 at 3 months and 1.4 +/-1.9 at 6 months (p<0.001). Six patients reported being pain free (VAS=0) at 3 months. All subscales of FAOS showed significant improvement at both 3 and 6 months (Table 1). The mean SF-36 total score improved from 51.4 +/-17.9 to 72.5 +/-7.6 and 74.5 +/-7.5 at 3 and 6 months respectively (p<0.001). Available radiographs at 6 months showed no further collapse. Complications include one patient with delayed wound healing and another patient with inadequate pain relief. No patients reported symptomatic paresthesia.

Conclusion:

Deep peroneal neurectomy for dorsal midfoot denervation is a safe and effective alternative to arthrodesis for management of dorsal arthritic midfoot pain showing significant improvements in both pain and functional outcomes at early follow up. Our study demonstrated clinical and function outcomes similar to those previously reported for arthrodesis yet with the advantages of earlier postoperative weightbearing and lower complication rate.
Patients with History of Intravenous Drug Use (IDU) with Septic Arthritis of the Foot and Ankle Have Suboptimal Hospitalization Outcomes Compared to Patients Without IDU
Authors: Shields Margaret , Toppo Alex , Furrer Mariano Menendez , Dewire Peter , Salzler Matthew
Published: October 2019

Category:

Infection

Introduction/Purpose:

Although intravenous drug use (IDU) is a known risk factor for septic arthritis of the foot and ankle (F&A), little is known about its influence on hospitalization outcomes. This study evaluated differences in demographic characteristics and hospitalization outcomes of septic arthritis of the F&A according to IDU status.

Methods:

Using the Nationwide Inpatient Sample for the years 2000 to 2013, we identified all patients aged 15-64 with a principal discharge diagnosis of septic arthritis of the F&A. Applying previously published algorithms, septic arthritis of the F&A was classified as related or unrelated to IDU. We assessed differences in demographic characteristics and in-hospital outcomes including length of hospital stay (LOS), leaving against medical advice (AMA), hospital charges, and presence or absence of surgical intervention.

Results:

Of the 14,198 hospitalizations, 11% were associated with IDU. Patients with IDU were more likely to be younger, black, and have Medicaid or no insurance coverage. Patients with IDU were more likely to leave AMA (9.7% vs 1.4%, p<0.001), have longer LOS (9.2 vs 6.8 days, p<0.001), and incur increased hospital charges ($58,628 vs $38,876, p=0.005). In addition, patients with IDU were significantly less likely to receive an arthroscopy (1.5% vs 6.5%, p<0.001) or arthrotomy (2.2% vs 11.0%, p<0.001) of the foot.

Conclusion:

IDU-related septic arthritis of the foot and ankle is associated with suboptimal hospitalization outcomes and greater resource use. Given the disparity in outcomes, there is potential to improve outcomes of septic arthritis of the foot and ankle in patients with IDU via enhanced physician communication skills among disenfranchised patient populations and proactively addressing substance abuse issues early during hospital admission.
Comparison of Functional and MRI Outcomes of Microfracture with and without BioCartilage for Osteochondral Lesions of the Talus
Authors: Shimozono Yoshiharu , Huang Hao , Deyer Timothy , Kennedy John G
Published: October 2019

Category:

Ankle, Arthroscopy, Sports

Introduction/Purpose:

Microfracture (MF) remains a dominant treatment strategy for symptomatic osteochondral lesions of the talus (OLT). Micronized cartilage allograft (BioCartilage) is a biologic scaffold and is utilized for MF augmentation to improve the quality for cartilage regeneration. However, there is still lack of evidence on efficacy of BioCartilage as an adjunct to MF, as no comparative studies have been reported to date. The purpose of this study is to clarify the effectiveness of BioCartilage as an adjuvant to MF compared to MF alone in the treatment of OLT.

Methods:

A retrospective cohort study comparing patients treated with MF with BioCartilage and MF alone between 2014 and 2017 was undertaken. Patients with a minimum follow-up time of 12 months were included. All patients received concentrated bone marrow aspirate injection at the time of surgery. Clinical outcome was evaluated with the Foot and Ankle Outcome Score (FAOS) pre- and postoperatively. Postoperative MRIs were evaluated using a modified Magnetic Resonance Observation of Cartilage Tissue (MOCART) score. Comparisons between groups were made with the Man-Whitney U test for continuous variables and the Chi-squared test or Fisher exact test for categorical variables.

Results:

Twenty-four patients underwent MF with BioCartilage (MF-BC group) and 24 patients underwent MF alone (MF group). The mean age was 40.8 years in MF-BC group and 47.8 years in MF group (p=0.068). The mean follow-up time was 19.2 months in MF-BC group and 24.5 months in MF group (p=0.042). Both groups showed significant improvements in all FAOS subscales. No significant differences between groups were found in postoperative FAOS subscales including symptoms, pain, daily activities, sports activities and quality of life (MF-BC; 72.8, 77.8, 87.4, 60.8, 56.6, MF; 73.3, 79.3, 86.0, 60.9, 60.6, respectively, p>0.05). The mean MOCART score in MF-BC group was higher (73.2vs64.1), but not statistically significant (p=0.315). When assessing each MOCART parameter individually, MF-BC group had significant better infill in the defect (p=0.028).

Conclusion:

MF with BioCartilage is an effective treatment strategy for the treatment of OLT and results in similar functional outcomes compared with MF alone in the short-term. However, MF with BioCartilage provides better cartilage infill in the defect on MRI. This finding suggests that the repair seen in a cartilage defect treated with BioCartilage augmentation may be superior to treatment with MF alone. Further long-term follow-up studies are warranted.
Tendoscopic Groove Deepening for Subluxation or Stenosis of the Peroneal Tendons
Authors: Shimozono Yoshiharu , Kennedy John G
Published: October 2019

Category:

Ankle, Arthroscopy, Sports

Introduction/Purpose:

Peroneal tendon disorders frequently result in refractory posterolateral ankle and hindfoot pain which disables patients from daily activity and sports. Diagnosis can be challenging in certain cases of peroneal tendon pathology, such as subluxation and stenosis. Additionally, traditional open surgery is associated with complications including surgical scarring and injury to the sural nerve. Therefore peroneal tendoscopy has gained popularity as an effective diagnostic and treatment procedure. Recently tendoscopic groove deepening technique has been reported for the treatment of chronic subluxation or stenosing tenosynovitis of peroneal tendons. In this case series, we present the effectiveness of tendoscopic groove deepening procedure for subluxation or stenosis of the peroneal tendons.

Methods:

A retrospective cohort study investigating patients treated with tendoscopic groove deepening the fibular groove and concentrated bone marrow (CBMA) injection for the treatment of peroneal subluxation or stenosing peroneal tenosynovitis. Retrospective chart review was performed, and clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS) and Short-Form 12 (SF-12) preoperatively and at final follow-up.

Results:

Twenty patients diagnosed with subluxation and/or stenosis were included. The mean age was 35.1±9.2 years and the mean follow-up time was 32.5±12.4 months. Mean symptoms, pain, daily activities, sports activities and quality of life scores in FAOS significantly improved from 56.8, 74.1, 72.3, 36.2 and 22.7 preoperatively to 86.5, 83.2, 92.3, 70.2 and 63.8 postoperatively, respectively at final follow-up (p<0.001). The mean SF-12 significantly improved from 48.7 to 75.8 postoperatively (p<0.001). No superior peroneal retinaculaum repair was perfumed in all subluxation cases. No complications were reported.

Conclusion:

The current study demonstrates that endoscopic groove deepening of the fibular groove was a reproducible and minimally invasive technique that provided a good clinical outcome for subluxation of the peroneal tendons and stenosing peroneal tenosynovitis.
Efficacy of a Knee Walker for Foot and Ankle Patients: Comparative Study with an Axillary Crutch
Authors: Song Jae Hwang , Kang Chan , Lee Gi Soo , Won You Gun , Kim Tae Gyun
Published: October 2019

Category:

Ankle, Orthosis, rehabilitation

Introduction/Purpose:

An axillary crutch is the most commonly used assistive device in foot and ankle patients who require nonweightbearing. On the other hand, its use frequently induces axillary or wrist pain and critical neurovascular injuries have been reported in several studies. Recently, knee walker was introduced, which minimized these weaknesses and yielded favorable results in some clinics. To the best of our knowledge, there have been no previous original article comparing the clinical results of the knee walker and axillary crutch in foot and ankle patients who require nonweightbearing. This study compared the clinical outcomes of patients using the knee walker and axillary crutch.

Methods:

A retrospective analysis was performed comparing the utility of a knee walker and axillary crutch as a nonweightbearing ambulatory aid for 62 foot and ankle patients treated between November 2016 and March 2018. A comparative study of the two orthosis could be performed because all the patients temporarily used an axillary crutch before or after the use of a knee walker. Jin Bae He Wheel Chair X 01 (JBH Medical Apparatus, Nanjing, China) was used for the knee walker and standard axillary crutch was used. A demographic study and comparative analysis based on the visual analogue scale (VAS) satisfaction score (0˜100), complications, and fall down history were evaluated. Furthermore, under the assumption of having retreatment, their preference of orthosis between the knee walker and axillary crutch was investigated.

Results:

The mean age of the patients was 36.5 and the mean duration of ambulation with a knee walker and axillary crutch were 5.2 and 2.4 weeks. The VAS satisfaction score of the knee walker and crutch was 88.8 and 27.5, respectively (p<0.05). The most frequent complications of the knee walker and crutch were ipsilateral knee pain (6 cases) and axillary or wrist pain (56 cases), respectively. No case of falling down occurred during knee walker ambulation, but there were two cases of crutch ambulation. Fifty-eight patients (93.5%) preferred the knee walker and four patients (6.5%) preferred a crutch.

Conclusion:

Compared to the axillary crutch, the knee walker afforded lower complication and higher satisfaction. Most patients preferred the knee walker to a crutch. Therefore, the knee walker is an efficient and safe orthosis for foot and ankle patients who require nonweightbearing.
The Ponseti Method in Children with Clubfoot after Walking Age: Systematic Review and Metanalysis
Authors: Stéfani Kelly Cristina , Haje Davi de Podestá , Nogueira Monica Paschoal
Published: October 2019

Category:

Clubfoot

Introduction/Purpose:

The prevalence of untreated congenital clubfoot among children older than walking age is higher in developing countries due to limited resources for early care after birth. The Ponseti method represents an intervention option for older, untreated children.

Methods:

A metanalysis was conducted of observational studies selected through a systematic review of articles included in electronic databases (Medline, Scopus, Embase, Lilacs, and the Cochrane Library) until June 2017. A pooling analysis of proportions with 95% confidence intervals (CIs) and a publication bias assessment were performed as routine. Estimates of success, recurrence, and complication rates were weighted and pooled using the random effects model.

Results:

Twelve studies, including 654 feet diagnosed with congenital clubfoot in children older than walking age (older than 1 year old), were included for analysis. The rate of satisfactory outcomes found via a cluster metanalysis of proportions using the random effects model was 89% (95% CI = 0.82–0.94, p < 0.01), relative to the total analysed. The recurrence rate was 18% (95% CI = 0.14–0.24, p = 0.015), and the rate of casting complications was 7% (95% CI = 0.03–0.15, p = 0.19).

Conclusion:

Application of the Ponseti method in children with untreated idiopathic clubfoot older than walking age leads to satisfactory outcomes, has a low cost, and avoids surgical procedures likely to cause complications. The results obtained exhibited considerable heterogeneity.
Tuber-to-Anterior Process Angle (TAPA): A Cadaveric Study and Surgical Technique for Placing Axial Calcaneal Screws
Authors: Stupay Kristen L. , Briceno Jorge , Velasco Brian , Kwon John Y.
Published: October 2019

Category:

Ankle, Hindfoot

Introduction/Purpose:

Operative management of displaced intra-articular calcaneus fractures frequently involves placement of P: A screws in order to maintain calcaneal length and axial alignment. While plate fixation may still be more commonly utilized, screw-only fixation for the treatment of these fractures has been demonstrated by several authors to be safe and effective. Directing fixation from the tuber into the anterior process can be challenging. Understanding the calcaneal long-axis as it relates to the long-axis of the foot, a measurement we call the Tuber-to-Anterior Process Angle (TAPA), can facilitate the ease and accuracy of guide-wire and cannulated screw placement. The goals of this study are to define the TAPA, and to report a surgical technique which uses this angle to facilitate axial screw placement.

Methods:

Eight cadaver feet were utilized. A longitudinal pin was placed from the center of the posterior calcaneal tuber to the 2nd metatarsal heads. Next, the calcaneocuboid joint was exposed, and a wedge of cuboid was removed. A calcaneal pin was then placed, exiting at the center of the anterior process. The tips of two small K-wires were impacted into the medial and lateral-most aspects of the articular surface. A true axial view of each specimen was obtained. On these images, a digital line was drawn from the posterior tuber starting point and the central calcaneal pin, representing the calcaneal long-axis. The angle subtended by this line and the long-axis of the foot represents the TAPA. Digital lines were drawn between the posterior tuber starting point and the medial and lateral K-wires, and the range between their subtending angles represents the axial plane tolerance for screw placement within the anterior process.

Results:

The average TAPA measured 10.9 ± 1.3 degrees (range: 8.4-13.0). The average angle, as measured to the medial extent of the anterior calcaneus, measured 2.8 ± 1.3 degrees (range: 0.4-4.3). The average angle, as measured to the lateral extent of the anterior calcaneus, measured 19.0 ± 2.7 degrees (range: 15.7-22.7).

Conclusion:

Knowledge of the Tuber-to-Anterior Process Angle (TAPA), found to be 10.9 degrees (± 1.8 degrees) laterally deviated from the long-axis of the foot, simplifies placement of posterior-to-anterior screws in the calcaneus. Understanding this relationship reduces reliance on intraoperative axial fluoroscopy and increases operative efficiency. Furthermore, this knowledge can be applied during other procedures in which axial screw placement is performed, such as with corrective calcaneal osteotomy.
The Use of Structurally Augmented 3D Printed Cages in Segmental Defects of the Tibial Shaft
Authors: Tracey Joseph , Parekh Selene
Published: October 2019

Category:

Trauma, Emerging Technology

Introduction/Purpose:

Modern day management of segmental defects of the tibia shaft (SDTS) involve autologous nonvascularized grafts, autologous vascularized contralateral fibula grafts, as well as bone transport distraction osteogenesis, however single stage titanium cages with adjuvant biologics continue to demonstrate advantages. With the development of advanced additive manufacturing further modalities such as complex variable lattice structure and submicron texture may be incorporated into custom fit implants. We aim to further investigate the potential of this technology on osteoinduction, and hypothesize early bone in-growth.

Methods:

A retrospective analysis was performed on 3 patients undergoing custom cage implantation for SDTS. All three patients were male with an average age of 60, 2 patients were diabetic, and one was a smoker. All three cases were performed in the setting of post-infection salvage. Pertinent demographic and clinical history was retrieved through the medical record.

Results:

All three cases were uncomplicated in the post-surgical period, and early bone in-growth was demonstrated in successive follow-ups. One case was single-staged and built into a prior total ankle arthroplasty, the next was a deformity correcting intramedullary rod that became infected requiring two-stage salvage with an antibiotic spacer and subsequent custom cage with Intramedullary rod supplementation, and the third case was a two-stage trauma salvage initially using an antibiotic spacer with subsequent custom cage implantation.

Conclusion:

3D printed custom cages were found to be a safe and efficacious option for management of SDTS, with demonstrated early bone in-growth. Considering the incorporation of advanced additive manufacturing techniques, strong implementations may be present for salvage cases.
Online Ratings and Reviews of American Orthopedic Foot and Ankle Surgeons
Authors: Velasco Brian T. , Chien Bonnie , Kwon John Y. , Miller Christopher P.
Published: October 2019

Category:

Practice Management

Introduction/Purpose:

Utilization by patients of physician rating websites continues to expand. There is limited information on how these websites function and influence patient perception and physicians’ practices. No study has specifically investigated online ratings and comments of orthopedic foot and ankle surgeons. In this study, we identified what factors impact online ratings and comments for this subset of surgeons.

Methods:

A total of 210 orthopedic foot and ankle surgeons in or near metropolitan areas were randomly selected from the American Orthopaedic of Foot & Ankle Society (AOFAS) website. Demographic information, ratings (number of stars), and comments were reviewed on the three most visited public domain physician ratings websites: HealthGrades.com (HealthGrades), Vitals.com (Vitals), and Ratemds.com (Ratemds). Content differences between positive and negative comments were evaluated.

Results:

Orthopedic foot and ankle surgeons had a mean rating of 4.03 ± 0.57 out of 5 stars. A high percentage (84%) of the total number of ratings were either 1-star (17%) or 5-stars (67%). Most positive comments related to outcome, physician personality, and communication while most negative comments related to outcome, bedside manner, and waiting time. Chi-square analysis revealed statistically significant proportions of positive comments pertaining to surgeon-dependent factors (eg, physician personality, knowledge, skills) and of negative comments concerning surgeon-independent factors (eg, waiting time, logistics).

Conclusion:

This is the first study examining online ratings and written comments of orthopedic foot and ankle surgeons. Surgeons had a generally favorable rating and were likely to have positive comments. Patients were likely to write positive comments about surgeon personality and communication, and negative comments pertaining to bedside manner and waiting time. Knowledge and management of online content may allow surgeons to improve patient satisfaction and online ratings.
The Captain’s View: A Novel Radiographic View to Assess Axial Alignment of the Calcaneus
Authors: Velasco Brian , Moura Bruno , Kwon John
Published: October 2019

Category:

Hindfoot, Trauma

Introduction/Purpose:

The axial alignment of the calcaneus has paramount importance in the management of these fractures. The Harris view has long stood as the recommended radiograph to assess axial alignment. However, given the obliquity at which the radiograph is obtained, it doesn´t represent a true axial view and is subject to inaccuracies secondary to rotational malpositioning of the foot and mismeasurement of angulation. Multiple reports have described the axial alignment as a surgical outcome, but usually this assessment of the residual deformity have no described method. The objectives of this study are to evaluate the capacity of Harris view to assess axial alignment in a cadaveric model and to describe the use of a true AP view of the calcaneus that we have named Captain´s view.

Methods:

Five below knee amputated fresh-frozen cadaveric specimens were used in the study. For each specimen, the soft tissues over the lateral side were removed to access to the lateral wall. A small wedge of the cuboid was removed to visualize the center of the calcaneocuboid articular surface. LCA-guide and a cannulated drill were used to create a tunnel in the axis of the calcaneus. An oblique osteotomy was performed in order to simulate a non-comminuted fracture. Varus deformity was created by inserting solid radiolucent wedges into the osteotomy to create models of 10, 20, and 30 degrees of varus angulation. Harris and Captain views were obtained for each specimen with 0 (control), 10, 20, and 30 degrees of varus malalignment. Measurements of the deformity were made digitally on each fluoroscopic image.

Results:

The average degrees of varus in Harris views were 10,9 (5,5-16); 11,5 (8,2-13,6); and 18,3 (13,3-23,6) for 10,20 and 30 degrees of deformity respectively. The average degrees of varus in Captain´s view were 13,0 (7,3-20,9); 18,4 (11,7-23,5); and 28,2 (24,4-31,1) for 10,20 and 30 degrees of deformity respectively. The average degrees of error for varus deformity in Harris views were 4,1 (41%); 8,4 (42%) and 11,6 (39%) for 10,20 and 30 degrees of deformity respectively. The average degrees of error for varus deformity in Captain´s views were 4,8 (48%); 3,6 (18%) and 2,8 (8%) for 10,20 and 30 degrees of deformity respectively.

Conclusion:

The results of this study show a high rate of mismeasurement for both radiographic views. Despite the average angles have a clear correlation with the severity of varus, the wide range of error observed between specimens make this assessment unreliable and inaccurate. We observed an improvement of accuracy of captain´s view for more severe deformities, but not with Harris views which maintain a 40% mismeasurement in all the settings. Therefore, intraoperative Harris views should not be used in isolation to evaluate axial alignment and Captain´s view provides an additional perspective that can be useful to rule out severe deformities.
Biomechanical Evaluation of a Novel Lisfranc Injury Cadaveric Model Using Supination and Pronation Testing
Authors: Wagner Emilio , Wagner Pablo , Baumfeld Daniel , Baumfeld Tiago , Prado Marcelo , Nery Caio
Published: October 2019

Category:

Basic Sciences/Biologics, Sports, Trauma

Introduction/Purpose:

Lisfranc joint injuries occur due to direct or indirect trauma, where twisting forces are applied. Cadaveric models have been used to evaluate injury patterns and fixation methods, but a frequent limitation has been historically the small amount of joint displacement after injury, which hinders a correct evaluation of the damage degree and reconstruction effectiveness. Our hypothesis was that adding pronation and supination motion to a cadaveric model would produce reliable and measurable joint displacements.

Methods:

24 fresh frozen lower leg cadaveric specimens were utilized. The medial (C1), intermediate (C2) cuneiforms, first (M1) and second (M2) metatarsal bones were marked. A complete ligament injury was performed between C1-C2 and C1-M2 in 12 specimens (Group 1), and between C1-C2, C1-M2, C1-M1 and C2-M2 in 12 matched specimens (Group 2). Supination and pronation motion of the forefoot relative to the hindfoot was obtained through internal and external rotation of the tíbia, using an Instrom machine. A 3D Digitizer was used to measure distances between the bones already mentioned.

Results:

Distance C1-C2 increased 3 mm after ligament injury with supination motion (p<0.05). Distance C1-M2 increased 4 mm after ligament injury with pronation motion (p<0.05). Distances between C1-M1 and C2-M2 only changed in Group 2, increasing 3 mm and 2 mm respectively (p<0.05).

Conclusion:

Pronation and supination motion of the forefoot relative to the hindfoot produces measurable joint displacements in a cadaveric Lisfranc injury model. We believe this new method for testing cadaveric lisfranc injuries will allow a better understanding of injury patterns and repair or reconstruction techniques.
Radiographic Analysis of Pronation in Operated Hallux Valgus: Short Term Follow-Up
Authors: Wagner Emilio , Wagner Pablo , Keller Andres , Bernal Nazira , Lopez Mario , Caicedo Nathaly , Etchevers Gaston , Mococain Pablo , Zanolli Diego
Published: October 2019

Category:

Bunion

Introduction/Purpose:

Hallux Valgus (HV) is a multiplanar deformity with metatarsal varus and pronation. Pronation is a frequently undiagnosed and/or untreated deformity parameter being a recognized postoperative relapse factor. The objective of this research is to estimate the pronation prevalence in HV and evaluate the pronation correction after conventional Hallux Valgus surgery.

Methods:

105 patients with operated Hallux Valgus were followed between 2010 and 2016. Mean age and follow up (months) was 53 and 23 respectively. For all patients, pre and postoperative angular measurements (Pronation angle, hallux valgus angle, HVA, and intermetatarsal angle, IMA) and the operative technique used was recorded. For pronation measurements, a 4-stage classification was used by means of 4 metatarsal templates with different degrees of pronation (0, 10, 20, 30 degrees). Surgical techniques used were Chevron, Scarf and Poscow.

Results:

Regarding pronation angle, 95 out of 105 patients (90%) had some degree of metatarsal pronation (10% had no pronation). The most common pronation value was 20 degrees (60%). No change in metatarsal pronation angle was observed at final follow up with any technique used. Regarding HVA and IMA pre/postoperatively: HVA: 29/11, IMA: 14/8. Chevron, Scarf and Poscow were used in 15, 67 and 23 patients respectively. 66% of cases decreased sesamoid position in one or more stages.

Conclusion:

Metatarsal pronation is a frequent finding in Hallux Valgus patients (90%). The most common pronation deformity is 20 degrees. It was not corrected with any technique used (Chevron, Scarf, Poscow). This fact is explained probably because these osteotomies are purely translational aiming to correct the metatarsal varus and not the metatarsal pronation.
Predictors of Wait Time in the Orthopaedic Foot and Ankle Clinic
Authors: Wakefield Connor J. , Wu Kevin , Skipor Joe , Ravanam Angad , Benko Savannah , Bohl Daniel D. , Lee Simon , Hamid Kamran S.
Published: October 2019

Category:

Health Sciences Research

Introduction/Purpose:

Wait times represent a critical component of the patient experience, and prolonged waits are correlated with decreased patient satisfaction. We hypothesized that time spent waiting for radiology is the largest contributor to total patient wait time in our orthopedic foot and ankle clinic.

Methods:

A prospective, observational study was conducted in the outpatient orthopaedic foot and ankle clinic at a tertiary medical center. A total of 210 new and follow-up adult patients were enrolled. Patients were tracked from arrival until checkout with multiple time points being recorded by a trained observer. The time between patient arrival and first contact with the orthopaedic surgeon was broken down into five distinct categories. Total time between patient arrival and first contact with the orthopaedic surgeon was tested for association with patient and appointment characteristics using Student’s t-test.

Results:

The average total time spent waiting for first contact with the orthopaedic surgeon was 57.1±30.4 minutes. The largest contributor was time spent waiting for an exam room (33.1±25.5 minutes), followed by time spent waiting for radiologic imaging (21.7±19.9 minutes), time spent waiting for resident/PA (12.2±10.9 minutes), and time spent waiting for attending surgeon after seeing resident/PA (11.7±9.3 minutes). Factors contributing to a longer overall wait included obtaining x-rays at the visit (+15.4±4.2 minutes, 95% confidence interval [CI]=+7.0 to +23.8, p<0.001) and failure to complete patient paperwork beforehand (+36.9±5.3 minutes, CI=+26.4 to +47.4, p<0.001; Table 1). In contrast, overall wait time was not associated with age≥50 years, female sex, late arrival, or outside medical records needing review.

Conclusion:

Time spent waiting for assignment to an exam room was the largest contributor to the time between patient arrival and first contact with the attending surgeon. In order, the other contributors were time spent waiting for radiology, time spent waiting for the resident/PA, and time spent waiting for the attending surgeon after seeing the resident/PA. Obtaining x-rays increased patient wait time and completing patient paperwork beforehand decreased patient wait time. Orthopaedic foot and ankle surgeons should work to avoid unnecessary x-rays and encourage completion of patient paperwork before arrival in order to optimize clinic flow and decrease patient wait times.
Deformity and Clinical Outcomes Following Surgical Correction of Charcot Ankle
Authors: Wallace Stephen , Liskutin Tomas E. , Schiff Adam P. , Pinzur Michael S.
Published: October 2019

Category:

Ankle, Ankle Arthritis, Diabetes, Hindfoot, Trauma

Introduction/Purpose:

Deformity associated with Charcot Foot Arthropathy leads to a poor quality of life in affected individuals. Deformity in the midfoot appears to be predictive of clinical outcomes following surgical correction. The goal of this retrospective study was to determine if that same methodology could be applied to patients treated for Charcot Foot Arthropathy involving the ankle joint.

Methods:

Fifty-six consecutive patients underwent surgical reconstruction of Charcot Foot deformity involving the ankle joint by a single surgeon over a fourteen year period. Preoperative patient characteristics and tibiotalar alignment, were recorded. Surgical treatment included single stage debridement of active infection and ankle arthrodesis with application of a circular external fixator when infection was present (39 of 56, 69.6%) or retrograde locked intramedullary nailing in the absence of infection (17 of 56, 30.3%). Clinical outcomes were graded based on limb salvage, resolution of infection and chronic wounds, and the ability to ambulate with therapeutic footwear or accommodative orthoses. The average follow-up was 7.5 (range 1.1-14.0) years.

Results:

One patient died at 134.3 weeks following surgery of unrelated causes and 8 underwent amputation. Twenty eight of 56 patients (50.0%) achieved a favorable (excellent or good) clinical outcome. There was no significant association between preoperative or postoperative alignment and clinical outcomes. Insulin-dependent diabetics were approximately 3 times more likely to have a poor clinical outcome.

Conclusion:

Surgical correction of Charcot deformity involving the ankle joint was associated with a high complication rate and risk for failure. The lessons learned from this highly co-morbid patient population with complex deformities can be used as a benchmark for applying modern surgical techniques.
Outcomes of Endoscopic Treatment for Plantar Fasciitis: A Systematic Review
Authors: Ward Leona , Shimozono Yoshiharu , Kennedy John G
Published: October 2019

Category:

Arthroscopy, Hindfoot

Introduction/Purpose:

Open plantar fascia release is an established surgical treatment for plantar fasciitis traditionally. However, it has long recovery period and complications with conflicting late results. Recently, endoscopic plantar fascia release has gained popularity, providing good outcomes with early return to activity. However, there is still a paucity of overall clinical data regarding outcomes and complication rates following endoscopic procedure for the treatment of plantar fasciitis. The purpose of the current study was to systematically review the outcomes of endoscopic plantar fascia release in the treatment of plantar fasciitis.

Methods:

A systematic review was preformed using, MEDLINE, EMBASE and Cochrane library databases based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies included were evaluated with regards to level of evidence (LOE) and quality of evidence (QOE) using the Coleman methodological score. Clinical outcomes and complications were also evaluated.

Results:

Twenty-one studies including 601 feet were included in this systematic review. The mean patient age was 48.5±5.2 years, and the mean follow-up time was 26.9±22.7 months. Sixteen studies used the AOFAS score for clinical outcome measure. The mean preoperative AOFAS score was 52.3±24.1 and the postoperative score was 88.8±4.1. The VAS score was utilized in 10 studies. The mean preoperative score was 7.8±0.8 and the postoperative score was 1.8±0.7. In total 111 of 601 (18.7%) patients had complications. The most common complication was recurrence of pain with 45 patients (7.5%). Twenty-two patients (3.7%) experienced paraesthesia and numbnesss. Seventeen patients (2.8%) required subsequent operations including gastrocnemius release, hematoma drainage, and baxter nerve release.

Conclusion:

The current systematic review demonstrates that overall there were good clinical and functional outcomes following endoscopic procedure for the treatment of plantar fasciitis. However, there was a relatively high complication rate (18.7%) associated with the endoscopic procedures. Due to the low level of evidence and poor qualities of evidence, further well designed studies are necessary to determine the clinical outcomes and complications of endoscopic plantar fasciotomy.
Local Delivery of Antibiotics in the Context of Chronic Diabetic Foot Infection with Bony Involvement: A Case Series of 102 Patients
Authors: Widnall James , Harvey David , Evans Paul , Jackson Gillian , Platt Simon
Published: October 2019

Category:

Diabetes

Introduction/Purpose:

Diabetic foot infection (DFI) is a devastating condition which poses risk to both life and limb. Treatment principles revolve around surgical debridement, dead space management, delivery of both local and systemic antibiotics and soft tissue cover. Dead space management and local antibiotic delivery can be achieved simultaneously by using an antibiotic loaded bone substitute. We report our retrospective case series of patients treated with surgical management involving local antibiotic delivery via calcium sulphate bone substitute (Stimulan™; Biocomposites, Keele, UK).

Methods:

All patients between January 2015 and June 2018 with DFI and proven bony involvement presenting to our university teaching hospital were treated via our extensive MDT approach. A total of 102 patients were included. Surgical debridement was performed along with simultaneous insertion of 10 ml calcium sulphate with 1 g vancomycin and 240 mg gentamycin. Outcome was classified as resolved, requiring prolonged treatment from other medical (endocrinologist) or surgical (plastic surgery, limb reconstruction) services or salvage surgery in the form of proximal amputation.

Results:

45.1% of patients had a partial amputation at the index surgery. 52% had bony debridement and just 2.9% had soft tissue debridement in conjunction with calcium sulphate insertion. The surgical wound was primarily closed in 56.8% of patients. 7 patients had delayed wound closure and 36.2% of patients healed via secondary intention. 74 patients (72.5%) had resolution of their DFI with bony involvement following surgical intervention. 21 (20.6%) patients needed further treatment from allied specialties. 7 (6.9%) patients required salvage surgery in the form of a below knee amputation. There was no correlation between either closure type (2 p-value 0.75) or index surgery type and outcome (2 p-value 0.64).

Conclusion:

DFI is a difficult clinical scenario to treat effectively. An MDT approach is undoubtedly key to a good outcome. We believe that the use of calcium sulphate can be a useful adjunct at the time of surgical debridement to aid in both dead space management and allow local antibiotic delivery.
Arthroscopic Repair of Acute Rupture of the Deltoid Ligament
Authors: Wircker Patrícia , Silva Miguel Duarte , Caetano João , Dias Rafael , Figueiredo João , Sousa João Vieira , Alçada Rita , da Silva Teresa Alves , Côrte-Real Nuno
Published: October 2019

Category:

Ankle, Arthroscopy, Trauma

Introduction/Purpose:

An ankle dislocation represents a high-energy traumatic injury that often occurs in traffic accidents or during jumping sports and usually it is associated with bi or trimalleolar fractures. Rupture of the deltoid ligament can occur alone or combined. There is currently extensive literature advocating LCL repair (assisted) by arthroscopy. However, the ruptures of the deltoid ligament are repaired by open technique: direct suture in acute cases and ligamentoplasty involving the Spring ligament in chronic cases. The possibility of repairing by arthroscopy allows an improvement in morbidity and complication rate. Undiagnosed and improperly treated medial collateral ligament (MCL) injuries can lead to disabling conditions.

Methods:

This study presents three cases of fracture-dislocation of the ankle with rupture of both collateral ligaments.

Results:

In addition to the usual osteosynthesis, it was also performed a ligament repair of the LCL with the arthroscopic Brostrom procedure. In the presence of medial instability, suture anchors were used to repairing the deltoid ligament and inferior extensor retinaculum via an arthroscopic technique. All patients presented a good functional recovery, two of them with AOFAS above of 83 at the end of the 6-month follow-up and with a complete return to daily living activities.

Conclusion:

Apart from having studied only three cases, the prospect of injury repaired by minimally invasive surgery in the acute phase seems advantageous in selected patients, avoiding evolution to a disabling chronic situation.
Introduction of a New Index as an Indicator for Achilles Tendon Tendinopathy
Authors: Wirth Stephan , Aregger Fabian , Jungwirth-Weinberger Anna , Jentzsch Thorsten , Hecker Andreas
Published: October 2019

Category:

Sports

Introduction/Purpose:

Achilles tendon tendinopathy is a common problem in our daily practice. The initial therapy consists of conservative treatment and usually leads to a reduction of pain. In some cases though, there is need for surgical treatment. The most common procedure is debridement of the tendon. If there is advanced damage of the tendon, a flexor hallucis longus (FHL) transfer may be indicated. In the current literature, there is a lack of hard criteria about the indications for such a transfer.

Methods:

We searched our radiologic database from the years 2016 and 2017 for magnetic resonance imaging (MRI) scans of the Achilles tendon. 60 patients were included in a tendinopathy group and 60 patients in a control group with no signs of tendinopathy. Inclusion criteria were severe tendinopathy for the tendinopathy group and a normal Achilles tendon for the control group. Exclusion criteria were other relevant morphologic changes or history of relevant surgery of the lower limb. Axial MRI scans were analyzed on a level of 4-5 centimeters above the ankle joint. The area of triceps surae (TS) and FHL were measured as well as the diameter of TS and an oblique diameter of FHL (from the medial corner of the fibula to the posteromedial corner of the FHL muscle). Then, quotients of the area of the FHL/TS and diameter of the FHL/TS were built and interobserver agreement was analyzed.

Results:

The quotients for area and for diameter of the FHL/TS showed significantly (p<0.001) higher values in the tendinopathy group. We also found strong to very strong interobserver agreements (rho=0.744). The median value for the quotient of diameter FHL/TS was 2.0 (interquartile range [IQR] 0.8) in the tendinopathy group versus (vs) 1.7 (IQR 0.3) in the control group. The median value for the quotient of area FHL/TS was 1.8 (IQR 1.3) in the tendinopathy group vs 1.3 (IQR 0.7) in the control group.

Conclusion:

The quotient of the diameter FHL/TS is easy to obtain in our clinical practice. It indicates a relevant FHL hypertrophy, which occurs in advanced Achilles tendon tendinopathy. A value of 2.0 and higher is indicative of symptomatic tendinopathy and may ultimately support the indication for a FHL transfer, which should be the topic of future research.
Genomic analyses of PMBL reveal new drivers and mechanisms of sensitivity to PD-1 blockade
Authors: Chapuy Bjoern , Stewart Chip , Dunford Andrew J. , Kim Jaegil , Wienand Kirsty , Kamburov Atanas , Griffin Gabriel K. , Chen Pei-Hsuan , Lako Ana , Redd Robert A. , Cote Claire M. , Ducar Matthew D. , Thorner Aaron R. , Rodig Scott J. , Getz Gad , Shipp Margaret A.
Published: October 2019

A deep dive into genomic aberrations in 37 new diagnoses of primary mediastinal B-cell lymphoma (PMBL) reveals a surprisingly high number of driver mutations as well as genetic and epigenetic explanations for immune evasion by the tumor.
Patent ductus arteriosus generates neonatal hemolytic jaundice with thrombocytopenia in Upshaw-Schulman syndrome
Authors: Fujimura Yoshihiro , Lämmle Bernhard , Tanabe Saori , Sakai Kazuya , Kimura Toshiyuki , Kokame Koichi , Miyata Toshiyuki , Takahashi Yukihiro , Taniguchi Shigeki , Matsumoto Masanori
Published: October 2019

Key Points

One third of patients with USS have a neonatal episode of severe hemolytic jaundice with thrombocytopenia induced by an unknown trigger. A USS patient with persisting PDA and recurrent neonatal hemolysis/thrombocytopenia suggests blood flow through the PDA as trigger.
Nano-metering of Solvated Biomolecules Or Nanoparticles from Water Self-Diffusivity in Bio-inspired Nanopores
Authors: Bergamasco Luca , Alberghini Matteo , Fasano Matteo
Published: October 2019

Taking inspiration from the structure of diatom algae frustules and motivated by the need for new detecting strategies for emerging nanopollutants in water, we analyze the potential of nanoporous silica tablets as metering devices for the concentration of biomolecules or nanoparticles in water. The concept relies on the different diffusion behavior that water molecules exhibit in bulk and nanoconfined conditions, e.g., in nanopores. In this latter situation, the self-diffusion coefficient of water reduces according to the geometry and surface properties of the pore and to the concentration of suspended biomolecules or nanoparticles in the pore, as extensively demonstrated in a previous study. Thus, for a given pore-liquid system, the self-diffusivity of water in nanopores filled with biomolecules or nanoparticles provides an indirect measure of their concentration. Using molecular dynamics and previous results from the literature, we demonstrate the correlation between the self-diffusion coefficient of water in silica nanopores and the concentration of proteins or nanoparticles contained therein. Finally, we estimate the time required for the nanoparticles to fill the nanopores, in order to assess the practical feasibility of the overall nano-metering protocol. Results show that the proposed approach may represent an alternative method for assessing the concentration of some classes of nanopollutants or biomolecules in water.