bluuebunny/crossref_metadata_2025 huggingface dataset:
Readability of Online Foot & Ankle Patient Resources
Authors: Cush Coleman , Foster Brian , Zhang Hui , Cush Gerard J.
Published: January 2022

Category:

Other

Introduction/Purpose:

The internet is a popular source of health information for patients. Professional organizations, such as the American Orthopaedic Foot & Ankle Society (AOFAS) and the American Academy of Orthopaedic Surgeons (AAOS) have created patient-directed websites containing high quality information. However, previous studies have demonstrated that these sites are often written at a level that is too complex for the average reader. We aimed to investigate the current landscape of the readability of these websites.

Methods:

Online patient resources on foot and ankle topics published by the AOFAS and AAOS were reviewed. Each page was analyzed using the Flesch Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) formulas. Sites were noted if they were written at or below an 8th grade reading level, which corresponds to the average US reading level. An independent two-sample t- test or chi-square test, where appropriate, were used to compare resource characteristics between the two professional societies.

Results:

162 total sites were reviewed, including 113 from the AOFAS and 49 from the AAOS. Overall, the mean FKGL was 9.4 (range, 6.7 - 15.3) and the mean FRE was 56.3 (range, 24.4 - 73.1). Websites written by the AAOS had significantly lower FKGL scores than sites written by the AOFAS (9.0 vs 9.5, p=0.01). 31.3% of all sites were written at or below an 8th grade reading level. Websites published by the AAOS had significantly more sites published at this level than sites published by the AOFAS (44.9% vs 25.7%, p=0.02).

Conclusion:

Online patient information on foot and ankle topics published by professional organizations are often written at a level that is too complex for the average reader. There was a statistical but not clinically significant difference between sites published by the AAOS and AOFAS. Professional organizations should continue to develop their online patient resources, with emphasis on increasing their readability.
Percutaneous Fixation of Metatarsals Fractures with Kirchner’s Wire, Comparison of Antegrade and Retrograde Technique
Authors: Drago Sebastian R. , Zagal Alvarado Patricio Alfonso , Ugarte Jaime , Phillips Vicente , Contreras Martin , Bastias Gonzalo F.
Published: January 2022

Category:

Trauma; Midfoot/Forefoot

Introduction/Purpose:

The antegrade intramedullary nailing technique with Kirchner’s wire (K-wire) (EAK) for the management of metatarsal fractures (MTT) is recent and with few reports. Our objective was to evaluate and compare the clinical results among patients operated on in our center for MTT fractures using the EAK technique versus the traditional retrograde technique (ERK).

Methods:

Retrospective, analytical study. We reviewed the cases of patients with a diagnosis of MTT fracture and surgical indication operated with EAK or ERK between February 2010 and January 2016. First and fifth metatarsal fractures were excluded from the analysis, as well as patients in which a fixation method other than K-wire was used. Demographic data, clinical and radiological results were recorded. A total of 34 patients (34 feet, 70 metatarsals) were analyzed and were divided into two groups: Group 1, operated with EAK (15 feet, 22 metatarsals), and Group 2, operated with ERK (19 feet, 48 metatarsals). Statistical analysis was carried out with Fisher's exact test and Mann-Whitney U test for non-parametric variables, with fixed statistical significance at p <0.05.

Results:

The median age was 37 years [IQR = 51-25.25], p = 0.128. Both groups presented similar soft tissue involvement (p = 1,000), similar associated injury rate (20.0% vs 42.1%, p = 0.271), and similar proportions of diaphyseal and neck fractures (p = 0.659 and p = 0.733 respectively). The group operated with the EAK technique presented a lower report of metatarsalgia (6.7% (1) vs 47.3% (9), p = 0.020), shorter rest time since injury (94 days [IQR = 129-82] vs 144 days [IQR = 210-122], p = 0.002) and shorter time to full load (7 weeks [IQR = 9-6] vs 10 weeks [IQR 12.5-8.5], p = 0.002). EAK and ERK did not show differences in criteria for poor reduction (p = 1.00), number of re-interventions (p = 0.560), infections (p = 0.492), or metatarsophalangeal stiffness (p = 0.451).

Conclusion:

Metatarsal fracture fixation with EAK presented a lower rate of metatarsalgia and shorter rest time compared to ERK, demonstrating similarity in terms of quality of reduction and complication rate.
The Impact of Hallux Valgus on Function and Quality of Life in Females
Authors: Gordon David , Lewis Thomas L. , Ray Robbie
Published: January 2022

Category:

Bunion

Introduction/Purpose:

The effect of hallux valgus (HV) on health-related quality of life (HRQOL) and the relationship between radiographic severity of deformity and patient reported outcome measures (PROMs) is poorly understood. The aim of this study was to compare the HRQOL of female patients with HV to the UK population. The secondary aim was to assess the correlation between PROMs, including HRQOL, with radiographic severity of deformity.

Methods:

Weight bearing radiographic data (hallux valgus (HVA) angle; intermetatarsal (IM) angle) were measured in consecutive female patients presenting with symptomatic HV. Each patient prospectively completed the Euroqol EQ-5D-5L questionnaire (EQ- 5D), Visual Analogue Scale for Pain (VAS-Pain) and Manchester Oxford Foot Questionnaire (MOXFQ). Data were stratified into age ranges and compared with an EQ-5D United Kingdom general population reference dataset. Pearson R correlation values were calculated for the PROMs and radiographic deformity.

Results:

Between July 2015 and March 2020, 425 consecutive female patients presented with symptomatic HV for consideration for surgery. EQ-5D-5L data were prospectively collected for 396 of these patients (93.2%). EQ-5D-5L Index scores were significantly worse for females with HV when compared with females in the general population. There was a moderate correlation with MOXFQ Index score and EQ-5D-5L Index (R=-0.51, p<0.001) and VAS-Pain scores (R=0.54, p<0.001). There was no correlation between radiographic HV deformity and HRQOL measures or MOXFQ scores.

Conclusion:

Female patients presenting with HV deformity have a significantly reduced quality of life compared with the UK general population. The radiographic severity of deformity did not correlate with health-related quality of life measures or foot and ankle specific PROMs. Foot and ankle specific clinical PROMs do correlate with HRQOL and may be a better marker of the negative effect of symptomatic hallux valgus deformity on quality of life.
Effect of Achilles Tendon Repair on Performance Outcomes Following Return to Play in NCAA Division I Basketball Athletes
Authors: Hodgens Blake H. , Sanchez Rafael A. , Geller Joseph S. , Huntley Samuel R. , Kaplan Jonathan R. , Aiyer Amiethab A.
Published: January 2022

Category:

Sports; Ankle

Introduction/Purpose:

Achilles tendon ruptures are devastating injuries highly prevalent among athletes. Despite our understanding of the impact of Achilles tendon rupture in professional athletes, and in particular its relationship to basketball, no study has examined the effect of Achilles tendon rupture on performance metrics in National Collegiate Athletic Association (NCAA) Division I basketball players.

Methods:

NCAA Division I basketball players who sustained a surgically repaired Achilles tendon rupture between the 2000 and 2019 seasons were identified by systematic evaluation of individual injury reports from the NCAA career statistics and individual school statistics databases. 65 male and 41 female players were identified. Athletes were included if they participated in at least one collegiate season before tearing their Achilles tendon, and at least one season after operative repair. A total of 50 male and 30 female athletes were ultimately included in the analysis. Each injured athlete was matched to a healthy control by conference, position, starter-status at time of injury, class year, and number of games played. Matched controls were healthy players and experienced no significant injuries during their NCAA careers.

Results:

Following Achilles tendon rupture and subsequent surgical repair, male athletes played significantly more minutes per game (19.7 vs. 22.6, p=0.017), scored more points per game (6.7 vs 7.9, p=0.024), and had more assists per game (1.4 vs. 1.7, p=0.036), when compared to their pre-injury statistics. The only area of worsened athletic performance following injury was total blocks, which significantly decreased post-injury (18.1 vs. 10.2, p=0.004). Matched healthy controls demonstrated a higher percent change in assists per game (+39.0% vs +21.8%, p=0.036) and total blocks (+55.1% vs -43.5%, p=0.031) between the matched pre- injury and post-injury periods. Female athletes scored significantly more points per game after returning from injury (7.6 vs 6.3, p=0.032) but demonstrated a significantly lower 3-point shooting percentage (10% vs. 20%, p=0.047).

Conclusion:

Male athletes who returned to play following Achilles tendon rupture demonstrated significant increases in various offensive performance metrics, while suffering a significant decrease in total blocks. Female athletes demonstrated a significant improvement in points per game following Achilles tendon rupture, but suffered a significant decline in 3-point shooting percentage. Despite suffering an Achilles tendon rupture, 14% of the male cohort reached the NBA, and 16.7% of the female cohort reached the WNBA.
Ankle-Hindfoot Reconstruction by Tibiotalocalcaneal (TTC) Arthrodesis Using Multiple Cannulated Screws: 32 Cases
Authors: Im Jemin , Jung Hong-Geun , Lim Jung-Won , Song Won Tae
Published: January 2022

Category:

Ankle; Ankle Arthritis

Introduction/Purpose:

Tibiotalocalcaneal (TTC) arthrodesis is a salvage procedure that can be used as an alternative to amputation for various pathologic conditions of the ankle-hindfoot. The aim of this study is to evaluate the clinical-radiological outcome of TTC arthrodesis performed using the multiple cannulated screws.

Methods:

From 2003 to 2018, 32 ankles (31 patients) underwent TTC arthrodesis. The mean follow-up period was mean 32.5 (12-92) months and the average patient age at surgery was 59.6 years (43-75). The etiologies of TTC arthrodesis included posttraumatic osteoarthritis (18.8%), Charcot arthropathy (18.8%), paralytic deformity (21.9%), failure of total ankle arthroplasty (9.4%), and failure of arthrodesis (9.4%). For all of 32 cases, transfibular approach was used with or without auto fibular cancellous bone graft. 7.3mm cannulated screws were used for fixation of arthodesis for all of 32 cases, and in 23 of 32 cases (71.9%), screw- fixation was used exclusively without any additional plate or Ilizarov fixator. Especially for 11 of 32 cases with large bony defect, fresh-frozen allo-femoral head structural bone graft was used. Pre- and postoperative visual analog scale (VAS) pain, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot functional score, and radiographs including CT images were assessed.

Results:

Overall union rate was 81.3% (26/32). Mean VAS score decreased from 6.92 preoperatively to 1.46 postoperatively and the AOFAS score improved from 27.0 to 53.7 (Max=68) at the final follow-up. Complication of TTC arthrodesis included nonunion (18.8%, 6/32), infection (12.5%, 4/32), and one case of skin necrosis. Most frequent nonunion site was tibiotalar joint (6/32). For 3 of 7 cases with nonunion, patients were painless and could ambulate without severe functional impairment. There were two cases with infective nonunion and one case with active Charcot arthropathy after artrhdesis. Union rate of two groups with/without allo-femoral head bone graft were similar to each other (81.8%, 81.0%, respectively), however, final AOFAS scores were significantly superior in 'without' femoral head bone graft group.

Conclusion:

This study achieved a fusion rate comparable to other previous studies and obtained favorable clinical outcomes. Realignment TTC arthrodesis using multiple cannulated screws is a valid surgical option as a salvage procedure for various deformed or arthritic conditions of ankle-hindfoot. Allo-femoral head structural bone graft can be selected as useful option for TTC arthrodesis with large bone defect.
Endoscopic Insertional Achilles Reconstruction with Double Row Suture Bridge Reconstruction: A Technique Tip
Authors: Miller Christopher P. , Acevedo Jorge I. , McWilliam James R. , Michalski Max
Published: January 2022

Category:

Ankle; Arthroscopy

Introduction/Purpose:

Insertional Achilles tendinopathy can be a debilitating condition that often fails to improve with non- surgical management such as bracing and physical therapy. Traditional surgical techniques include an open debridement of the diseased tendon and resection of calcaneal spurs. This is followed by repair of the tendon. Suture anchors are often used to secure the tendon, but recent advances in tendon fixation, including the advent of double row repairs, has allowed better biomechanical repairs and faster rehabilitation. Additionally, minimally invasive surgery (MIS) and endoscopic techniques have advanced to allow successful treatment of all aspects of the condition while minimizing wound complications and infection

Methods:

The authors present a technique to treat insertional Achilles tendinopathy and calcaneal bone spurs using MIS techniques while also incorporating a percutaneous double row suture anchor repair. The technique utilizes four portals to access two endoscopic working planes. The burr is inserted deep to the tendon and the calcaneoplasty is performed. Subsequently, the endoscope is inserted alongside a shaver to remove bony debris and debulk the anterior aspect of the Achilles areas of tendinopathy. Following this, the portals are used to place a double row suture anchor repair.

Results:

With over 75 surgeries performed, there have been zero wound complications and patients have been able to return to full weight bearing within 10 days after surgery. Follow up outcome data is currently being collected and will be reported as a case series once sufficient patients have completed their follow up.

Conclusion:

This study presents double-row repair following an endoscopic assisted MIS calcaneoplasty and Achilles debridement. The technique combines the benefits of the double row suture bridge repair with a minimal incision technique to debride the insertional tendinosis. In order to adequately debride the tendon and the posterior calcaneal tuberosity, the tendon foot print is elevated as the burr removes the bone at the insertion. The anterior portion of the tendon, which may be a pain generator as well, isdebrided endoscopically with the shaver. Finally, a double row suture bridge repair is performed in order to allow early weight bearing and rehabilitation.
Comparing Infection Rates from Using Different Surgical Preparation Solutions and Techniques in Foot & Ankle Elective Surgery
Authors: Molloy Andrew P. , Tangirala Ravishanker , Lyle Shirley A. , Heyes Gavin
Published: January 2022

Category:

Other

Introduction/Purpose:

Surgical site infection (SSI) after Foot & Ankle surgery ranges from 1.2% to 13.2%, higher than any other elective orthopaedic procedure. Infection is of concern for the patient and expensive for the healthcare system. SSI is multifactorial and can be divided into host-related and perioperative factors. Skin preparation is one of the key peri-operative factors in reducing SSI. The current literature supports a combined chlorhexidine and alcohol preparation technique, although there is some conflicting evidence. Most studies to date have used proxy outcomes such as growth from swabs shortly after skin preparation. There are no large scale studies which have looked at definitive clinical outcomes such as the rate of postoperative SSI.

Methods:

A retrospective review of data was undertaken for two longitudinal cohorts which were using two different skin preparation solutions and techniques due to a change in hospital protocol. Each cohort was continuous and derived from the same overall populationIn cohort 1, Povidine-Iodine (Betadinetm) followed by Alcoholic Chlorhexidine was used on swabs (Double prep group). In cohort 2, 2 Alcoholic Chlorhexidine was used in a prep stick applicator. Standard criteria for diagnosing surgical site infection were used. All open injuries, procedures for ongoing infection, amputations for osteomyelitis /diabetic foot and COVID- 19 positive cases were excluded.

Results:

After applying standard exclusion criteria, 919 elective F&A procedures in the Double prep group and 491 procedures were included for the Single prep groupAs these were continuous longitudinal cohorts of large scale from the same population, there is a justifiable presumption of group matchingIn cohort 1 there were 15 superficial infections (1.6%) and 3 deep (0.3%). In cohort 2 there were 18 superfical infections (3.6%) and 1 deep (0.3%). The total infections in cohort 1 were 18 (2%) and 19 in cohort 2 (3.9%)There was an increase in superficial, and therefore total infection rates, in the single prep group compared to the double prep group. These increases were statistically significant; p <0.05 with regards to superficial infection and total infection rates in the single prep group.

Conclusion:

Double skin preparation, with Povidone-Iodine followed by alcoholic Chlorhexadine, statistically significantly decreases foot and ankle surgical infection rates as compared to a single alcoholic chlorhexidine skin preparation
Plantar Plating in the Modified Lapidus Procedure: Evaluation of Function and Impairment of the Tibialis Anterior Tendon
Authors: Niehaus Richard , Hodel Sandro , Eid Karim , Lenz Christopher G.
Published: January 2022

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

Plantar Plating in the Modified Lapidus Procedure (MLP) to treat severe Hallux Valgus deformities (HVD) or hypermobility of the first ray has become more popular. Due to biomechanical considerations, early weightbearing can be achieved. The surgical procedure and some plate designs make a release of the Tibialis Anterior tendon (TAT) necessary and screws have to be placed through or close to its insertion. We investigate if there are detectable changes of the tibialis anterior tendon or the function of the tibialis anterior muscle (TAM).

Methods:

We retrospectively reviewed 22 Feet (17 patients) after plantar plating for a modified Lapidus procedure. All patients underwent a MRI at an average of 27 months (range 12-49 months) postoperatively for evaluation of the tendon. Clinical outcome was evaluated using the EFAS score. Dorsiflexion strength was measured and compared to the healthy contralateral extremity. Complications and union rates were assessed.

Results:

The subjective satisfaction was rated at a mean of 8.2 (range, 5 - 10; SD +-1.5) on a scale from 0 to 10. Fourteen (82%) patients would undergo the same surgical treatment again. MRI images showed signs of tendinopathy of the TAT in 13 feet (59%). There were no ruptures, signs of thinning of the tendon or fatty infiltration detected. Complication rate was low with only on case with performed revision surgery. Regarding the Range of Motion, the force data comparing both feet of the patients is statistically close in comparison to the other side without any statistical differences.

Conclusion:

The MLP using a plantar-positioned locking plate leads to high patient satisfaction rates and provides significant improvement of preoperative deformity in severe HVD at midterm follow-up. Inversion strength was reduced, and MRI showed signs of tendinopathy in more than half of the cases. However, these findings did not seem to have any effect on the clinical outcome. None of the present patients had a high degree of fatty infiltration of the TAM in accordance with the Goutallier grading. Plantar-positioned locking plates do not seem to impair the TAM or the TAT.
Porous Titanium Wedges in Revision First Metatarsophalangeal Arthrodesis
Authors: Noble David M. , Small Benjamin , Cooper M. Truitt , Park Joseph S. , Perumal Venkat
Published: January 2022

Category:

Midfoot/Forefoot; Other

Introduction/Purpose:

First metatarsophalangeal (MTP) arthrodesis is a common procedure for hallux MTP pathology. In the setting of prior procedures with resultant bone loss, porous titanium wedges provide an alternative to allograft or autograft. The purpose of this study was to report clinical and radiographic outcomes achieved with titanium wedges used in 1st MTP arthrodesis in a revision setting.

Methods:

A retrospective analysis was performed in 10 patients (mean age 65.8) with prior 1st MTP procedures who underwent 1st MTP arthrodesis with use of porous titanium wedges from February 2014 to March 2020. Outcomes were assessed using both clinical (Visual Analogue Scale, Foot and Ankle Ability Measure, Mental Health Continuum Short Form, 36-Item Short Form Survey, need for revision) and radiographic parameters. Patients were followed from a minimum of 6 months up to 6 years (mean 31.4 months).

Results:

Average Foot and Ankle Ability Measure (FAAM) score was 91.1 +/- 14.7 (75.1 +/- 5.3 FAAM Activities of Daily Living; 17.9 +/- 9.9 FAAM Sports). Average pain visual analogue scale was 1.9 +/- 1.7. Average Mental Health Continuum-short form score was 34.2 +/- 8.5. Postoperative computed tomography (CT) imaging demonstrated lack of osseous integration in two of six CT scans obtained. Four patients underwent subsequent revision procedures, 3 for hardware prominence and 1 for failure of fusion.

Conclusion:

To our knowledge, these data represent the first reported clinical and radiographic outcomes in patients undergoing revision 1st MTP arthrodesis with use of porous titanium wedges. Further research should focus on comparative data with other commonly performed operative techniques.
Treatment of Complex Hindfoot Trauma with Hindfoot Nail
Authors: Patch David A. , Lameka Megan , Halstrom Jared R. , Quade Jonathan H. , Spitler Clay A. , Johnson Michael D.
Published: January 2022

Category:

Hindfoot; Trauma

Introduction/Purpose:

Pilon fractures are often associated with severe bone comminution and soft tissue compromise. As a result, surgical salvage procedures such as hindfoot nailing may be indicated for patients who are not candidates for standard fixation techniques such as open reduction and internal fixation (ORIF). The purpose of this review was to access outcomes associated with complex hindfoot trauma acutely treated with hindfoot nailing.

Methods:

A case series at a Level I trauma center was performed to identify trauma patients with complex hindfoot fractures who underwent hindfoot nailing as definitive treatment after initial external fixation between 2012 and 2020. Indications included a combination of patient comorbidities, fracture severity, and soft tissue injury. Exclusion criteria included follow-up less than 3 months. Post-operative radiographs were interpreted by a fellowship-trained foot and ankle surgeon. Primary outcome measures included unplanned reoperation/revision and deep infection. Deep infection was defined as any patient requiring surgical debridement after definitive fixation with positive cultures or the presence of positive cultures at the time of planned surgery. Fractures were classified using the AO/OTA classification and injury characteristics and postoperative complications were recorded via chart review.

Results:

Twenty-six of 29 of identified patients met inclusion criteria. The most common AO/OTA classification was 43C (62%). The average age was 55 years (range, 31-94) and the most common mechanism of injury was motor vehicle crash (38%). Thirteen fractures (50%) were open with Gustilo Anderson grade IIIA fractures being the most common (38%). The overall deep infection rate was 15% with fifty percent of cases positive for a history of diabetes mellitus or smoking. Unplanned reoperations occurred in seven (27%) cases. Among these, a total of four (57%) occurred due to the development of deep infection, two (29%) were nonunions, and one (14%) was indicated for hardware failure. Below the knee amputation occurred in one patient with nonunion (4%), which was a grade IIIA open pilon fracture with significant bone loss. Union was achieved in the majority of patients (92%).

Conclusion:

Treatment of complex hindfoot trauma with intramedullary nailing has a high union rate as a salvage procedure in a poor host. Surgeons should consider this treatment in patients that are not candidates for standard open reduction and internal fixation techniques.
Early Failure of Paragon28 Phantom Hindfoot Fusion Nail: A Case Report
Authors: Pattisapu Naveen , Bettin Clayton C. , Friedmann Elizabeth , Sims Michael L.
Published: January 2022

Category:

Diabetes; Hindfoot; Trauma

Introduction/Purpose:

Tibio-talar-calcaneal (TTC) fusion nails are commonly used to treated acute ankle fractures in patients with diabetes, Charcot arthropathy or other comorbidities. Recently, Paragon28 released the Phantom Hindfoot Fusion Nail (Phantom nail) with a unique design feature-a proximal coil.

Methods:

We present the case of a diabetic patient with an ankle fracture-dislocation treated with the Paragon28 nail who experienced early implant failure.

Results:

A 48-year-old male with HIV, end-stage renal disease requiring hemodialysis, and insulin-dependent diabetes mellitus with severe peripheral neuropathy presented a trimalleolar ankle fracture-dislocation treated with a TTC nail. At his first follow- up, he presented with early implant failure at the nail-coil interface.

Conclusion:

The integrity of the Phantom nail, appropriate length, and placement of the flex coil require further evaluation. Unstable pathologies such as fractures may be better stabilized with a solid nail construct.
Fusion Rates Following First Metatarsophalangeal Arthrodesis using a Dynamic Nitinol Staple-Plate Construct, Minimum 1-Year Follow-Up
Authors: Philbin Terrence M. , Malloy McCoy Antonio M. , Chandra Amar , Consul Devon , Thompson Mitchell , Nguyen Kevin N.
Published: January 2022

Category:

Midfoot/Forefoot

Introduction/Purpose:

Arthrodesis has long been the procedure of choice for end-stage arthritis of the first metatarsophalangeal joint (MTP). Multiple constructs have been described through literature with good fusion rates and patient outcomes. Methods allowing for ease of application and reduction of OR time without sacrificing surgical outcomes and fusion rates are therefore of considerable interest.

Methods:

In this study, we retrospectively reviewed a cohort of 33 patients undergoing arthrodesis of the first MTP utilizing a dynamic Nitinol staple and plate construct. The primary focus of our study was to evaluate the fusion rates following the aforementioned procedure. All patients within the study received a compression staple-plate construct placed across the first MTP and underwent the same post-operative protocol with radiographs taken at set intervals to evaluate fusion across the joint.

Results:

Our results demonstrated a 100% fusion rate with 3 delayed unions and no incidences of hardware failure. The time to fusion and fusion rates seen in this study are comparable to those previously reported in literature.

Conclusion:

We conclude that utilization of this construct is a viable option for arthrodesis of the first MTP, and its ease of application may decrease overall operating time which could prove advantageous over other, more commonly used methods.
Diabetic Kidney Disease is Associated with Increased Complications Following Operative Management of Ankle Fractures
Authors: Polachek William S. , Baker Hayden P. , Dahm James S. , Strelzow Jason , Hynes Kelly K.
Published: January 2022

Category:

Trauma; Ankle; Diabetes

Introduction/Purpose:

Diabetes mellitus and peripheral neuropathy are established risk factors for complications in operatively treated ankle fractures. Generally, the presence of peripheral neuropathy and diabetic nephropathy have been used as dependent variables in studies of diabetic ankle fracture cohorts, but these factors are typically treated as binary risk factors. Thus, we sought to quantify additional risk factors for complication specific to diabetic patients undergoing fracture fixation.

Methods:

We identified 617 rotational ankle fractures treated operatively at a single academic medical center from 2010-2019, of which 160 were identified as diabetic. Of these, 91 ankle fractures in 90 diabetic patients met criteria for retrospective review of clinical and radiographic data. Criteria included perioperative laboratory studies, including Hemoglobin A1c and estimated glomerular filtration rate (eGFR), as well as follow-up radiographs in the electronic record. We defined complications in this surgical cohort as deep surgical site infection, unplanned return to the OR and failure of fixation. Logistic regression was performed, and odds ratios (OR) calculated.

Results:

The overall the complication rate was 24.2% (22/91) in this cohort. Median follow-up was 29 weeks (range: 5-520 weeks). Mean perioperative Hemoglobin A1c in patients who experienced postoperative complications was 7.6% (Range: 5.1%- 14.2%) compared to 7.8% (Range:5.6%-13.5%) who did not (p=0.69). Diabetic patients with chronic kidney disease (eGFR<60 ml/min/BSA) (OR=5.29, p=0.006) and peripheral neuropathy (OR=4.61, p=0.003) were at significantly higher risk of all complications compared to diabetic patients without these comorbidities. Of note, we did not find an association between perioperative Hemoglobin A1c or Body Mass Index and complication rate.

Conclusion:

Patients with diabetes complicated by chronic kidney disease are at significantly higher risk of complications following operative management of ankle fractures. Our study also corroborated previous reports that within this high-risk cohort, the presence of peripheral neuropathy is a significant risk factor for complications. These sequalae of diabetic disease extends beyond simple glycemic and are manifestations of microvascular disease, glycosylation of soft tissues and impaired metabolic pathways. Identifying these risk factors in diabetic patients allows for patient specific risk stratification, education, and management decisions of ankle fractures.
Preoperative Opioid Prescription is a Risk Factor for Extended Opioid Filling After Ankle Arthroscopy
Authors: Polachek William S. , Lee Cody , Scott Bryan L. , Hynes Kelly K.
Published: January 2022

Category:

Arthroscopy; Ankle; Sports; Other

Introduction/Purpose:

Opioids can be an important tool in the management of postoperative pain, however, increased prescribing of these medications following orthopaedic procedures has significantly contributed to the current opioid crisis. Post- operative opioid utilization and duration varies greatly among surgeons, procedures, and patients. We sought to investigate patterns of opioid prescription following ankle arthroscopy and determine patient factors associated with increased postoperative opioid prescribing.

Methods:

A national claims-based database was queried for patients undergoing first-time ankle arthroscopy. Only patients with continuous database inclusion for at least one year prior to and one year after index ankle arthroscopy were included. Patients carrying an International Classification of Diseases (ICD)-9 or ICD-10 code(s) for diagnosis of septic ankle joint or a CPT code for total ankle arthroplasty prior to index ankle arthroscopy were excluded from the study. Patients who filled at least 1 opioid prescription between 1 and 4 months prior to surgery were defined as preoperative opioid-use group. Monthly relative risk ratios for filling an opioid prescription were calculated for the first year after surgery. Multiple logistic regression analysis was performed to identify factors associated with opioid prescription refills at 3, 6, 9, and 12 months after ankle arthroscopy. For analysis, P<0.05 was defined as significant.

Results:

We identified 6,039 patients who underwent primary ankle arthroscopy. The preoperative opioid-use group consisted of 1,514 patients (25.1%), of which 24 (1.6%) filled opioid prescriptions at 6 months postoperatively compared to 39 (0.9%) of opioid-naive patients (relative risk [RR], 1.84 95% confidence interval [CI], 1.11-3.05). Multivariate analysis determined that the preoperative opioid-use group was at increased risk of filling prescriptions at 3 (odds ratio [OR], 2.22; 95% CI 1.42-3.48) and 6 months (OR, 1.74; 95% CI, 1.01-2.95) postoperatively. Patients with Body Mass Index (BMI) > 30 were also at increased risk at 3 months (OR, 1.65; 95% CI, 1.04-2.62) and 6 months (OR, 2.01; 95% CI, 1.17-3.49) postoperatively. Comorbidities such as diabetes, hypertension, fibromyalgia, alcohol, and tobacco abuse were not associated with opioid filling (P>0.05).

Conclusion:

Preoperative opioid prescription filling and BMI 30 were associated with an increased risk of extended opioid prescription utilization following ankle arthroscopy. Overall, prolonged opioid prescribing was not widespread in either group postoperatively. This may represent the indications and outcomes of ankle arthroscopy. Patients presenting with preoperative opioid-use and increased BMI may benefit from multimodal pain management and additional perioperative education around non- pharmacologic pain-management strategies to decrease risk of prolonged opioid use.
Mortality in Patients after Diabetic Charcot Foot-Related Procedures
Authors: Ptasinski Anna , Koroneos Zachary , Stauch Chris M. , Martinazzi Brandon , Aynardi Michael C.
Published: January 2022

Category:

Diabetes; Hindfoot; Midfoot/Forefoot

Introduction/Purpose:

Diabetic Charcot foot is a chronic and progressive disease, following neuropathic loss of protective sensation and causing destruction of the joints. It is classically identified through a rocker-bottom deformity and may also present with a collapse of the medial arch, bony prominences, and ligamentous instability. Charcot leads to further morbidities, and patients may require surgeries including below the knee amputations or limb salvage reconstruction to treat the disease if conservative treatments fail. Previous literature demonstrated that foot ulceration is associated with mortality in diabetic patients, but no clear association between Charcot diagnosis and mortality has been identified. The purpose of this study was to investigate the mortality in patients diagnosed with acute diabetic Charcot foot.

Methods:

After institutional review board approval, all patients at a single institution that underwent an orthopaedic surgery for the treatment of Charcot during 2015-2020 were queried using hospital and public records. Demographic data, as well as the 30- day, 90-day, 1-year, and 5-year mortality were recorded.

Results:

79 patients were identified, with 57 (72%) males and 22 (28%) females with Charcot-related surgeries between 2015 and 2020. At the time of surgery, the average age was 58.2 (28-83) years. At the time of analysis, 61 (77%) patients were still living, but 18 (23%) patients were deceased with mortality within 30 days (1), 90 days (5), 1 year (9), and 5 years (18) of the Charcot-related procedure. For deceased patients, the average age of death was 59.6 years (30-83 years). The average number of days post- operation until death was 460 days (23-1613 days).

Conclusion:

Diabetic Charcot foot is a serious and debilitating complication of diabetic neuropathy. This data demonstrates that 23% of patients analyzed expired an average of 1.26 years after Charcot-related surgery. In addition, patients that were deceased were an average of 59.6 years of age, suggesting that Charcot may be associated with early mortality. Future studies will include an analysis of possible predictors of mortality for patients diagnosed with Charcot foot to evolve clinical and surgical management of patients.
Anatomy of the Intermetatarsal Facets of the Fourth and Fifth Metatarsals
Authors: Qatu Mossub , Jastifer James R.
Published: January 2022

Category:

Basic Sciences/Biologics

Introduction/Purpose:

The intermetatarsal joint between the fourth and fifth metatarsals (4-5 IM) is important in defining fifth metatarsal fractures. The purpose of the current study was to quantify this joint in order to determine the mean cartilage area, the percentage of the articulation that is cartilage, and to give the clinician data to help understand the joint anatomy as it relates to fifth metatarsal fracture classification.

Methods:

Twenty cadaver 4-5 IM joints were dissected. Digital images were taken and the articular cartilage was quantified by calibrated digital imaging software.

Results:

For the lateral fourth proximal intermetatarsal articulation, the mean area of articulation was 188 + 49 mm, with 49% of the area composed of articular cartilage. The shape of the articular cartilage had 3 variations: triangular, oval, and square. A triangular variant was the most common (80%, 16 of 20 specimens). For the medial fifth proximal intermetatarsal articulation, the mean area of articulation was 143 + 30 mm, with 48% of the joint surface being composed of articular cartilage. The shape of the articular surface was oval or triangular. An oval variant was the most common (75%, 15 of 20 specimens).

Conclusion:

This study supports the notion that the 4-5 IM joint is not completely articular and has both fibrous and cartilaginous components.
Ankle Fractures Involving the Posterior Malleolus: 7-Year Results in 100 Cases
Authors: Rammelt Stefan , Neumann Annika P.
Published: January 2022

Category:

Ankle; Trauma

Introduction/Purpose:

The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate and new concepts continue to emerge. The aim of this study was to assess the medium- to long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population treated with an individualized treatment approach.

Methods:

One hundred patients with ankle fractures involving the PM were identified retrospectively and reevaluated at an average follow-up of 7.0 years. Fixation of the PM was tailored to the individual fracture pattern. Bartoníček-Rammelt type I PM fractures (extraincisural shell-like fragments) were not fixed surgically. Displaced Type II (posterolateral fragments) and type III PM fractures (two-part with medial extension) were mostly fixed with direct posterior screw or plate fixation. Intercalary joint fragments were fixed with lost K-wires or resorbable pins. Type IV PM fractures (large triangular fragments) were treated with either posterior screw / plate fixation or indirect anteroposterior screw fixation with direct transfibular control of reduction, if feasible.

Results:

Internal PM fragment fixation was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p=0.010). At 7 years, the mean Foot Function Index was 16.5, the Olerud Molander Ankle Score averaged 80.2 and the American Orthopaedic Foot & Ankle Society ankle/hindfoot score averaged 87.5. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 and 50.5, respectively. Range of motion was within 3.4 degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with anterior or posterior shift of the distal fibula of 1 mm within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p=0.031). Two patients (2%) needed secondary ankle fusion following deep infection.

Conclusion:

With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected. The mere size of the PM fragment is just one of the factors guiding treatment, other important criteria are fragment displacement, impaction of the tibial plafond and incisura involvement. PM fixation provides direct bone-to-bone fixation of the syndesmosis and significantly reduces the need for additional transsyndesmotic fixation with a screw or flexible implant.
Thirty Days vs One-Year Complications and Reoperations after Foot Amputation and Below Knee Amputation: A Large Database Study
Authors: Riepen Dietrich , Sambandam Senthil , Mounasamy Varatharj , Wukich Dane K.
Published: January 2022

Category:

Diabetes; Midfoot/Forefoot

Introduction/Purpose:

Below knee amputation (BKA) and Foot amputation (AA) are two commonly performed procedures for diabetic foot conditions. Aim of this study was to analyze the characteristics of the complications and reoperations at 30 days and 1 year in a matched sample of BKA and FA in diabetic patients in a large database population.

Methods:

Commercially available patient database record (PearlDiver) was used for this study. Diabetic Patient undergoing BKA and FA were identified using CPT code. After matching two groups for smoking, obesity and comorbidities scores, the differences in the risk of complications at 30 days, 90 days and 1 year and the risk of reoperation at 1 year were noted in both groups.

Results:

There were 8555 patients in each matched group. Most patients were male (71.6%) and 6891 patients were smokers and 5292 patients were obese. More than 50% of general and systemic complications happened after 30 days. Incidence of 30 days, 90 days and 1 year general complications including Acute kidney injury, cardiac arrest, Cerebrovascular event, myocardial infarction, Pulmonary embolism, Pneumonia, sepsis and transfusion were higher in the BKA group. AKI was the most common general complication and PE was the least common general complication observed at 30 days, 90 days and 1 year. The risk of wound dehiscence, surgical site infection and overall wound complications were higher in FA group. One year reoperation for infection and dehiscence were higher in the FA group and reoperation for hematoma formation was higher in BKA group. The risk of revision to a BKA in the FA group at 1 year was 16.4% (1410 patients).

Conclusion:

FA is associated with higher risk of local complications at 30 days, 90 days and 1 years and higher reoperation rate at 1 year for local complications. However, BKA is associated with higher systemic major complications and higher risk of reoperation for hematoma formation. Most complications in the FA and BKA group happened after 30 days which highlights the fact that studies reporting 30 days complications after FA and BKA may underestimate the complications.
Outcomes of Bone Marrow Stimulation for Secondary Osteochondral Lesions of the Talus Equal Outcomes for Primary Lesions
Authors: Rikken Quinten , Dahmen Jari , Van Bergen Christiaan v. , Stufkens Sjoerd A. , Kerkhoffs Gino
Published: January 2022

Category:

Ankle

Introduction/Purpose:

To compare clinical, sports, work, and radiological outcomes between primary and secondary OLTs (<15mm) treated with arthroscopic BMS.

Methods:

Ethical approval was obtained before the start of the study. A power analysis was performed for the primary outcome measure, the Numeric Rating Scale (NRS) during activities. Secondary OLTs were matched to primary OLTs in a 1:2 ratio using lesion size, patient age, body mass index, and sex as prognostic covariates to control for confounding. Secondary outcomes included pre- and one-year postoperative clinical assessment of the NRS at rest, American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Outcome Score (FAOS) subscales, and the EQ-5D general health questionnaire. The rates and time to return to work and sports were collected. Radiological examinations were performed preoperatively and at final follow-up using computed tomography (CT). The postoperative outcomes were compared with a Wilcoxon rank-sum test; a univariate linear regression analysis was used to investigate the influence of covariates on clinical outcome scores.

Results:

After matching, 22 and 12 patients with smaller (<15 mm) OLTs were included in the primary and secondary group, respectively. The NRS during activities was not different between primary cases (median: 2, IQR: 1 - 4.5) and secondary cases (median: 3, IQR: 1 - 4), P= 0.5. Both groups showed a significant difference between all pre- and postoperative clinical outcome scores, except for the FAOS symptoms subscale in the primary group and NRS at rest in the secondary group. No significant differences in any clinical outcome scores were found between both groups at one-year follow-up, nor did any covariate significantly influence the clinical outcome scores. The return to sport rate was 90% for primary cases and 83% for secondary cases (P= 0.6). All patients returned to work. Lesion filling on CT was complete (67% - 100%) in 59% of primary cases and 67% of secondary cases (P= 0.6).

Conclusion:

No differences in outcomes were observed between arthroscopic bone marrow stimulation in primary and secondary OLT at one-year follow-up. Repeat BMS may therefore be a viable treatment option for failed OLTs in the short term.
Three-Dimensional Fluoroscopy Influence in Intraoperative Decision-Making Concerning Syndesmotic Reduction
Authors: Rivera Maximiliano , Cuchacovich Mikenberg Natalio R. , Bastias Gonzalo F. , Fuentes Patricio A.
Published: January 2022

Category:

Ankle; Trauma

Introduction/Purpose:

The use of intraoperative three-dimensional fluoroscopy to evaluate syndesmotic and articular reduction in ankle fractures is a relatively new tool demonstrating usefulness in the literature. It has been described that it can detect up to 32.7% of intraoperative malreduction. The objective of this prospective study is to observe if surgeons, when performing operative treatment in ankle fractures with three- dimensional fluoroscopy assistance, modify the syndesmotic reduction and/or fixation. The definitive syndesmotic reduction was assessed with bilateral ankle CT-scan postoperatively.

Methods:

Sixteen patients with ankle fracture and syndesmotic instability were analyzed. After malleolar and syndesmotic fixation, intraoperative three-dimensional fluoroscopy was performed. The surgeon then analyzed cross-sectional images to evaluate the reduction of the fracture and syndesmosis. In this scenario, the surgeon decided whether to make any changes in the reduction of the syndesmosis or in the configuration of the fixation strategy. Postoperative bilateral computed tomography was carried out to corroborate in detail if there was any syndesmotic malreduction.

Results:

Sixteen patients were included in this study (10 men) with a mean age of 40 years (range 25-60 years). 62% were supination-external rotation fractures according to Lauge-Hansen classification. Of all the patients evaluated, only 4 underwent any modification after performing intraoperative three-dimensional fluoroscopy. From the previous group, in 3 patients (19% of the total) there was a change in syndesmal reduction and in only one there was a change of any element of osteosynthesis. When evaluating syndesmal reduction with postoperative bilateral CT, there were 6 patients in the total group who presented syndesmal malreduction. In patients in whom a modification to syndesmal reduction was made, it persisted in 2 of the 3 cases.

Conclusion:

In our series, the use of intraoperative three-dimensional fluoroscopy did not motivate most surgeons to make changes in syndesmotic reduction, unlike other previously published studies. Even despite making changes in syndesmotic reduction, the percentage of patients who persists with poor reduction is considerable. In this study, the percentage of poor syndesmotic reductions was 32.7%. Despite being a figure that is within what is expected according to the literature, we consider that it is high even using intraoperative fluoroscopy as support.