bluuebunny/crossref_metadata_2025 huggingface dataset:
Potential Contribution of Abnormal Talar Dome Lateral-Wall Geometry to Development of Ankle Osteoarthritis
Authors: Tochigi Yuki , Ogawa Masato , Kakihana Masataka , Ozeki Satoru
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Abnormal tibial plafond geometry, varus deformity and insufficient talar anterior coverage in particular, is well recognized as congenital factors predisposing ankles to osteoarthritis (OA), both primarily and after lateral ligament injury. Presumably, abnormal geometry of the gutter articulations (for the medial and lateral malleoli) also increases a risk of ankle OA, though this concept has not been well addressed to date. The talar side-wall surfaces, which appears to be less affected by degenerative deformity in ankle OA, may leave the congenital characteristics of the gutter articulation geometry. To identify a type of ankles at higher risk of OA development in this context, the present study explored characteristics of the talar side-wall geometry in OA ankles.

Methods:

Clinical CT images, from 21 moderate to advanced OA ankles without critical preceding pathologies and from 29 age- matched non-OA ankles, were subjected to 3-D morphometric evaluation of the talar dome side-wall geometry. Using a DICOM viewer (AquariusNET®, TeraRecon, Foster City, CA, USA), a local coordinate system for each ankle was manually established using talar landmarks. Then, on a transverse section at 3-5 mm distal to the superior aspect of the talar trochlea, the angle between the medial and lateral side-wall tangential lines (regressed from five cortical surface reference points for each) was measured as the “anterior opening angle.” Similarly, the “inferior opening angle” was measured on a mid-coronal section. Differences between groups were statistically tested using a t-test, with the significant level of p set at 0.05.

Results:

The anterior opening angle was significantly larger (p = 0.006) in the OA ankles (mean +/- SD: 11.9 +/- 6.0 degrees) than in the non-OA ankles (8.5 +/- 3.2). The inferior opening angle was also significantly larger (p = 0.007) in the OA ankles (30.7 +/- 11.1) than in the non-OA ankles (25.2 +/- 5.5). Defining the range of mean +/- 2SD as “normal” (Figure), 13 out of 21 (62%) OA ankles had both or either abnormally large anterior and/or inferior opening of the talar side-wall surfaces.

Conclusion:

Anterior and inferior opening trapezoidal shapes are common characteristic of the talar dome geometry. It is also well recognized that the degrees of opening substantially vary across individuals. The present study documented frequent occurrence of excessive anterior and/or inferior opening in OA ankles. Assuming that these abnormalities are inherent characteristics rather than results of degeneration, excessive anterior and inferior openings of the talar dome side-walls could be pathogenetical factors that increase a risk of ankle OA. Clinically, when ankles with excessive anterior and/or inferior opening talar dome side-walls would have ligament insufficiency, surgical repair or reconstruction should be considered to minimize a risk of future OA development.
Male Hallux Valgus Corrected by Translational Osteotomy of First Metatarsal
Authors: Dixon Alexis E. , Myer David , Elkins Jennifer E. , Brodsky James W.
Published: October 2016

Category:

Bunion

Introduction/Purpose:

Male hallux valgus (HV) is less common and more severe than in females, and has been reported to be associated with higher Distal Metaphyseal Articular Angle (DMAA). Although valgus-producing osteotomies should increase DMAA, this has not been documented. This study evaluated the results of a translational osteotomy that counter-rotates the distal metatarsal articular surface in a varus direction to re-align the articular surface, and correct the DMAA.

Methods:

Prospectively collected pre-op and post-op data on 26 males with HV were retrospectively reviewed, at a minimum one-year followup. Radiographic data included hallux valgus (HVA), first-second intermetatarsal (IMA) angles, DMAA, medial sesamoid position (MSP), and first MTPJ congruence. Clinical outcomes included Visual Analog Score (VAS), SF-36, and AOFAS forefoot score. MTP range of motion (ROM) was measured. Preoperative radiographic and clinical data were compared to previously published cohort of female patients for the same measures. Paired t-tests compared clinical and radiographic outcomes pre- and postoperatively. Bowker’s Test was used to compare the rate of joint congruence. An alpha of 0.05 was considered significant. Student t-test and Fisher’s Exact Test were for comparison between males and females. Mean age of males with HV was 53.8 (SD=17.7), mean follow-up was 1.68 years.

Results:

Mean radiographic improvement: HVA 36.5º to 15.3º (P=0.0001); IMA 15.9 to 8.1 (P=0.0001); DMAA 13.3º to 6.4º (P=0.0003); MSP 2.8 to 1.2 (P=0.0001); congruence 4/26 to 22/26 (P=0.0001). Mean clinical improvements: VAS 5.7 to 1.0 (P=0.0001); AOFAS 49.6 to 84.7 (P=0.0001); SF36-P 44.7 to 51.2 (P=0.0004). MTP dorsiflexion decreased 58.3º to 51.8º (P=0.0276); plantarflexion 5.8º to 3.0º (P=0.0217). Higher mean preoperative angles in males versus females: HVA 35.8º versus 29º (P=0.0016); IMA 15.9º versus 13.0º, (P=0.0002), MSP 2.7 versus 2.5 (P=0.2012). No difference in DMAA, 13.6 versus 16.4 (P=0.2551). Congruence in males lower (5/27 versus 22/40, P=0.0048). No difference in VAS (5.6 versus 6.3, P=0.1767), AOFAS (50 versus 47.9, P=0.5085), SF-36p (45.1 versus 42.4, P=0.2656), dorsiflexion (57.9º versus 49.4º, P=0.0728), plantarflexion (5.8º versus 4.8º, P=0.7204).

Conclusion:

Prior studies reported the results of mixes of surgical procedures. This is the first large series of adult male HV treated with a single procedure, and the first using this counter-rotational modification of the Scarf osteotomy. The modified Scarf osteotomy combines translation varus counter-rotation to direct the articular surface more medially, explaining decreased DMAA, and with excellent radiographic and clinical outcomes. We demonstrate excellent radiographic and clinical outcomes in a large group of male HV treated with translational osteotomies.
Sparing the Naviculocuneiform Joint during Medial Column Stabilization for Rigid Flatfoot Deformity
Authors: Huh Jeannie , Lampley Alexander J. , Gross Christopher E. , Adams Samuel B. , Nunley James A. , Easley Mark E.
Published: October 2016

Category:

Midfoot/Forefoot

Introduction/Purpose:

Combined arthrodesis of the talonavicular (TN) and 1st tarsometatarsal (TMT) joints is a treatment option for the patient with both a rigid flatfoot and hallux valgus deformity or 1st TMT joint arthritis. In these cases, the naviculocuneiform (NC) joint is spared, as long as no evidence of joint collapse or instability is present. The purpose of this study was to assess the effect of this medial column stabilization construct on the spared NC joint over time and its ability to improve the radiographic parameters in the flatfoot deformity.

Methods:

Patients who underwent concomitant TN and 1st TMT joint arthrodesis, while sparing the NC joint, in the setting of a rigid flatfoot deformity, between January 2006 and December 2014, were identified. The medical records, including preoperative and postoperative radiographs were retrospectively reviewed. Outcomes included radiographic correction gained by surgery (AP and lateral talo-first metatarsal angles), union rate, complications, and need for subsequent surgery. Specific radiographic attention was paid to development of subsequent collapse and/or arthritis at the NC joint at the time of final follow-up.

Results:

21 consecutive combined TN and 1st TMT joint arthrodeses were performed. Average age at time of surgery was 61 (range, 23-82) years. 17 patients had a mean follow-up of 35 (range, 12-88) months. Union was achieved at both arthrodesis sites in 16/17 patients (94.1%). One patient (5.9%) had a nonunion at the TN joint, requiring revision arthrodesis. The mean lateral talo- first metatarsal angle correction was 24.5 (range, 12-36) degrees. The mean AP talo-first metatarsal angle correction was 11.6 (range, 0-33) degrees. One patient (5.9%) developed NC joint collapse and underwent subsequent arthrodesis at that level. There was radiographic evidence of NC joint arthritis to varying degrees in all cases by the time of final follow-up, however, none were symptomatic to warrant arthrodesis.

Conclusion:

Simultaneous arthrodesis of the TN and 1st TMT joints, while sparing the NC joint, is a reliable treatment in the carefully selected patient who presents with both a rigid flatfoot and hallux valgus deformity or 1st TMT joint arthritis. Good results in terms of union rate and radiographic correction, as well as a low complication rate were found in this study. Subsequent joint collapse and symptomatic arthritis at the spared NC joint was rare. Longer term follow-up and inclusion of functional outcomes are warranted in future studies on this topic.
Surgical Anatomy of a Novel Medial Gastrocnemius Recession versus the Proximal Medial Gastrocnemius Recession
Authors: Oh Irvin C. , DiGiovanni Benedict F. , Kaplan Nathan B. , Fowler Xavier
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

Isolated gastrocnemius contracture (IGC) is associated with various foot and ankle pathologies. To address the problem of IGC, a number of gastrocnemius lengthening procedures have been described. Decreased power and endurance with plantar flexion activities have been reported in patients after the Strayer procedure. Although proximal medial gastrocnemius recession (PMGR) has shown to be an effective surgical treatment for IGC, it poses risks to various anatomic structures around the knee joint and requires the patient to be positioned prone. The aim of this study was to describe an anatomic basis for a novel medial gastrocnemius recession (MGR) at the mid-level of the gastrocnemius muscle and to investigate the anatomical structures at risk in comparison to PMGR.

Methods:

Ten fresh frozen cadaveric lower leg specimens were employed for the study. The standard PMGR and the novel MGR were performed on each specimen. For the MGR procedure, we made a 2 cm incision over the mid-level of the medial gastrocnemius muscle region and performed complete release of the medial gastroncnemius fascia. After completion of the two procedures, complete dissection was performed to investigate the distances between surgically released fascia margins and surrounding anatomic structures including the greater saphenous vein, small saphenous vein, saphenous nerve, medial sural cutaneous nerve, semimembranosus tendon, tibial nerve and popliteal artery. These distances were recorded and compared statistically.

Results:

Proximities of anatomic structures to surgically released gastrocnemius fascia were significantly different between the two techniques. Major neurovascular structures were closer to the surgical margin than anticipated and at greater risk with the PMGR. In particular, popliteal artery (average distance 6.62 mm) and the tibial nerve (8.04 mm) were in close proximity with the PMGR margin, whereas these structures were deeply embedded and farther away from the MGR margin. For the PMGR, the semimembranosus tendon (average distance of 4.16 mm), small saphenous vein (6.71 mm), medial sural cutaneous nerve (3.66 mm), were also in close proximity to the surgical margin. For the MGR, the structures closer to the surgical margin and thus at greater risk of injury were the greater saphenous vein (12.22 mm) and saphenous nerve (11.87 mm).

Conclusion:

Medial gastrocnemius recession (MGR) at the central level of the gastrocnemius muscle may be an attractive surgical option and method when addressing IGC associated with various foot and ankle disorders. It can easily be performed in either the supine or prone position and may allow for less risk of injury to major surrounding neurovascular structures than a more proximal release. The biomechanical and clinical efficacies of the proposed MGR warrant further investigation.
Arthroscopic Treatment of Osteochondral Lesions of the Talus with Allograft Cartilage Matrix
Authors: Ahmad Jamal , Jones Kennis
Published: October 2016

Category:

Arthroscopy

Introduction/Purpose:

The purpose of this study is to prospectively evaluate the clinical and radiographic outcomes of using allograft cartilage extracellular matrix (ECM) as an adjuvant when arthroscopically treating osteochondral lesions of the talar dome (OLT).

Methods:

Between May 2012 and September 2014, 22 patients presented with an OLT amenable to arthroscopic surgery. All patients received an excision, micro-fracture, and injectable allograft cartilage ECM (BioCartilage, Arthrex, Naples, FL) at the OLT. Preoperative and postoperative function and pain was graded using the Foot and Ankle Ability Measures (FAAM) and a Visual Analog Scale (VAS) respectively. At 6 months from surgery, post-operative radiographs and computed tomography were assessed for osteochondral healing. Final radiographs were evaluated for OLT recurrence and ankle degenerative changes. Data regarding postoperative complications and revision surgeries were also recorded.

Results:

All 22 patients that received arthroscopic treatment of their OLT with allograft cartilage ECM were evaluated with a mean follow-up time of 20.2 months. The mean FAAM score increased from 51.4 of 100 preoperatively to 87.3 of 100 at the time of final follow-up. The mean VAS pain score decreased from 8.1 of 10 preoperatively to 1.9 of 10 at final follow-up. These differences between pre-surgical and post-surgical functional and pain scoring are statistically significant (P < 0.05). At 6 months from surgery, two patients (9.1%) received CT scans that revealed incomplete chondral formation at their OLT. One of these patients was symptomatic from this and ultimately required revision surgical treatment, involving an ankle arthrotomy and osteochondral autograft plugs from the ipsilateral lateral distal femoral condyle, to achieve full talar chondral healing. At final follow-up, one patient (4.5%) developed symptomatic and radiographic ankle degenerative changes at 1 year from surgery.

Conclusion:

Outcomes from arthroscopically treating OLTs with excision, micro-fracture, and application of allograft cartilage ECM has not been previously reported in the orthopaedic literature. This study demonstrates that using allograft cartilage ECM as an adjuvant to traditional ankle arthroscopic technique results in a high rate of improving ankle function and pain relief in patients with OLTs.
Comparison of Two Operative Techniques for Total Ankle Arthroplasty
Authors: Werner Shawn , Brage Michael
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Preoperative navigation and patient-specific instrumentation has many theoretical benefits in total ankle arthroplasty (TAA). Potential benefits over standard instrumentation include decreased surgical time, improved implant alignment, decreased surgical complexity, and decreased fluoroscopy exposure. The purpose of this study was to compare the differences of operative time and fluoroscopy exposure between two total ankle arthroplasty techniques utilizing the same implant, one using an intramedullary referencing system and the other a computed tomography (CT) scan-derived guide.

Methods:

Between 2011-2013, 74 TAA cases in 73 patients were retrospectively reviewed from a single foot and ankle fellowship-trained orthopaedic surgeon at a single center. TAA implants used included 65 intramedullary referencing implants (INBONE II, Wright Medical Technology) and 9 CT scan-derived patient-specific plans and guides (PROPHECY, Wright Medical Technology). Patients with the custom guide had a standardized preoperative CT scan before surgery that was used to create a custom surgical plan and 3-dimensional cutting guide. Patient demographics and the reason for TAA were recorded. Total anesthetic/surgical/tourniquet time and the number of fluoroscopy shots taken during the case were compared. This study also recorded additional procedures performed at the time of the TAA.

Results:

Average age for all patients was 62.7. This included 38 males and 35 females, most commonly having a TAA for osteoarthritis (N=34) closely followed by post-traumatic arthritis (N=33). When comparing all patients in the INBONE II to the PROPHECY group, surgical time was 151.6 vs 129 minutes (p-value 0.056) and fluoroscopy exposure was 38 vs 30 shots (p-value 0.01). There were 5 additional procedures (average 0.55 per case) in the PROPHECY group compared to 75 additional procedures (average 1.2 per case) in the INBONE II group. In a subset group of patients without additional bone work, comparing the INBONE II (N=25) and the PROPHECY group (N=8), fluoroscopy exposure was 31.3 vs 29 shots (p-value 0.2), respectively. In patients without any additional procedures, the average surgical time and fluoroscopy exposure of INBONE II (N=8) compared to PROPHECY (N=4) group was 125.3 vs 125.5 minutes and 32.8 vs 29.1 shots.

Conclusion:

Results from this study suggest that there are no statistically significant differences between surgical time and fluoroscopy exposure, when comparing the INBONE II and PROPHECY TAA techniques. In one instance there was a statistically significant difference between fluoroscopy exposure, however, this compared groups with additional bone procedures, more likely to occur in the INBONE II group. Future studies are warranted to investigate larger sample sizes without co-founding variables and whether increased surgeon experience with the PROPHECY system will affect surgical time and fluoroscopy exposure, as it is a newer implant and our data could reflect the learning curve.
Does a Patient’s Self-Reported Ability to Weightbear Immediately after Injury Predict Stability for Ankle Fractures
Authors: Kwon John , Ghorbanhoseini Mohammad , Chien Bonnie Y. , Hofmann Kurt J.
Published: October 2016

Category:

Trauma

Introduction/Purpose:

Determining the stability of ankle fractures, particularly for apparent isolated Weber B fibula fractures, can be difficult. While the ultimate goal remains achieving an anatomic mortise, different techniques to predict ankle stability such as stress and weightbearing radiographs have been utilized with variable results. History of injury and the ability to walk after sustaining ankle trauma may be predictive of stability. Therefore, this study seeks to determine whether a patient’s ability to fully weight bear immediately after injury is an effective indicator for ankle stability following ankle fracture.

Methods:

A prospective review was conducted of patients sustaining isolated, unilateral ankle fractures presenting to two level I trauma centers. Aside from demographic data and fracture characteristics, a patient’s ability or inability to fully weightbear immediately after injury was elicited by interview at their initial assessment. This information was correlated with their ankle radiographs, which were deemed stable or unstable fractures based on commonly used indices to assess ankle stability.

Results:

102 consecutive patients sustaining ankle fractures were included. Mean age was 45. When analyzing the entire cohort, patients who were able to ambulate immediately after injury were 10 times more likely to have a stable ankle fracture than those who could not bear weight (odds ratio (OR) 9.9 (P < 0.001). The positive predictive value (PPV) for being able to fully weightbear as it relates to a stable ankle fracture was 77%. Additionally, inability to weightbear was 89% specific for an unstable fracture. When separately analyzing patients with apparent isolated fibula fractures (n=56), the PPV was 75%, specificity was 83%, while the OR was 5.8 (p=0.003) for those who could fully bear weight having a stable ankle fracture.

Conclusion:

This study demonstrates that patient’s self-reported ability to fully weightbear immediately after injury is a specific and convenient prognostic indicator for ankle stability across a range of ankle fracture subtypes. Future studies can analyze whether initial weightbearing accurately predicts ultimate management and good outcome.
Driving Reaction Time After Left Sided Foot and Ankle Procedures
Authors: Anthony Chris A. , Rungprai Chamnanni , Sittapairoj Tinnart , Phisitkul Phinit
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Previous authors have considered braking times using computer simulators in a effort to evaluate patient safety in returning to drive. Authors have considered brake response times after first metatarsal osteotomy, ankle fusion, ankle fracture as well as anterior cruciate ligament reconstruction and hip and knee arthroplasty. Brake reaction time (BRT), a commonly used parameter, is defined as time from a “stop” stimulus until a brake is depressed. Previous work suggested that a BRT of 0.47 seconds (s) was average for a healthy population and that a BRT > 0.7 s is potentially hazardous. To our knowledge, there is no previous study of left sided foot and ankle procedures and how these procedures may affect BRT and driving safety. The present pilot study aimed to evaluate postoperative BRT in patients at our institution who had undergone left sided foot and ankle procedures.

Methods:

Seventeen patients were enrolled in the study: 7 underwent ankle arthroscopy, 4 flatfoot reconstruction, 3 ankle arthroplasty, 2 ankle fusion, and 1 cavovarus foot reconstruction. Participants had their surgical procedures performed at a range of 6 weeks to 6 months prior to study enrollment. We utilized a standard software and hardware setup which included a steering wheel, gas and brake pedal and desktop computer which displayed the driving simulation (The Stationary Simple Reaction Timer, Vericom Computers, Inc, Rogers, MN). All participants had left sided surgery and had their right lower extremity tested in the driving simulation. All participants completed 4 driving simulations which were then averaged. Data was analyzed in two groups, those who underwent only ankle arthroscopy and those who underwent an open procedure (Flatfoot reconstruction, ankle arthroplasty, ankle fusion, cavovarus foot reconstruction). BRT was defined as the time from stop stimulus until brake depression of 5%.

Results:

Average BRT in patients undergoing ankle arthroscopy was 0.66 s (SD 0.06 s). Average BRT in patients undergoing any open procedure was 0.65 s (SD 0.08 s). In patients undergoing ankle arthroscopy, average BRT at 6 weeks was 0.65 s (N=2), 0.64 s at 3 months (N=3), and 0.69 s at 6 months (N=2). In patients undergoing an open procedure, average BRT at 6 weeks was 0.62 s (N=3), 0.65 s at 3 months (N=5), and 0.69 s at 6 months (N=2).

Conclusion:

We present driving simulation brake reaction time on patients undergoing common, left sided foot and ankle procedures at our institution. In both arthroscopic and open procedure populations BRT is greater than previously described healthy patient populations and is slightly below a previously defined “hazardous” cutoff of 0.7 s.
How Knowledge Relates to Confidence in Orthopaedics and Emergency Medicine Regarding Rehabilitation in Foot and Ankle Trauma
Authors: Johnson-Lynn Sarah E. , Townshend David
Published: October 2016

Category:

Sports

Introduction/Purpose:

The aim of this study was to survey the knowledge of registrars in emergency medicine and orthopaedics on five common injuries to the foot and ankle and compare this knowledge, and self-reported confidence in giving it, with that of consultants and physiotherapists of various levels of experience.

Methods:

An online survey was used to gather the information using scenario based open and closed questions. A total of 102 healthcare professionals, who regularly deal with sports injuries, were recruited. This included consultant orthopaedic surgeons with a subspecialty interest in foot and ankle surgery,. orthopaedic surgeons in other specialties, extended scope physiotherapy practitioners (ESPs) in foot and ankle and general musculoskeletal practice, emergency medicine consultants, emergency medicine registrars, orthopaedic registrars, senior physiotherapists and junior physiotherapists. The participants were drawn from the various healthcare institutions in the North East of England.

Results:

Consultant foot and ankle surgeons and extended scope practitioners in foot and ankle both scored significantly on knowledge of rehabilitation programme design than either set of registrars. For two of the case scenarios there was a significant difference in scores between either orthopaedic consultants or ESPs and registrars (p < 0.05). For total score there was a trend for extended scope practitioners to score higher than both sets of registrars but this did not reach significance. Correlation coefficients for knowledge and self-reported confidence ranged between 0.009 and 0.33, demonstrating only weak positive linear correlation between scenario score and reported confidence in advice given.

Conclusion:

The most significant area of gaps in knowledge amongst the two groups of registrars was in the specifics of rehabilitation programmes. There was markedly higher confidence with greater seniority, which correlated poorly with differences in specific knowledge. Registrars in emergency medicine and orthopaedics are likely to benefit from case based teaching in sports injury rehabilitation.
Mid- to Long-Term Follow Up of the Salto Mobile Bearing Total Ankle Arthroplasty with Radio Graphic Analysis
Authors: Puna Rupesh , Tomlinson Matthew P.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Total ankle arthroplasty (TAA) remains a relatively uncommon procedure in New Zealand compared to total hip arthroplasty (THA) and total knee arthroplasty (TKA). Survivorship and clinical results of TAA have been mixed and inferior to both THA and TKA. There is a relative paucity of large series with long-term follow-up. The Salto mobile bearing prosthesis is now the most common prosthesis for TAA in New Zealand. We analysed a large series from a single surgeon with the purpose of reporting mid- to long-term survivorship, and performing radiographic analysis for radiolucencies and cytic changes.

Methods:

The New Zealand joint registry (NZJR) was used to obtain all Salto mobile bearing ankle replacements performed by the senior author between November 2005 and June 2012. The NZJR is a nationwide register of all joint arthroplasties performed in New Zealand and data on TAA has been collected since January 2000. Individual notes on each patient were reviewed to verify revision rate and reasons for revision. Post-op radiographs were analysed for alignment, radiolucencies, cystic changes and subsidence.

Results:

Of the 165 Salto mobile bearing ankle replacements in 150 patients, 62% were performed in males and 38% in females. Mean age at TAA was 65 years. Follow-up ranged from 5 to 121 months. Indications for primary included primary osteoarthritis (85%), inflammatory arthritis (9%), and post-traumatic arthritis (6%). 8% of patients (12 ankles) deceased during the follow-up although none had undergone revision. Over the course of the study, 8 ankles were revised giving a revision rate of 4.8% with mean time till revision of 69 months. Reasons for revision included aseptic loosening (3 ankles), talar collapse/avascular necrosis (2 ankles), broken polyethylene spacer without exchange of either component (2 ankles) and infection (1 ankle). At the time of study completion, 145 ankle replacements were still implanted in 130 patients which represents 94.7% survivorship in those patients still living. Post-operative radiographs demonstrated mean tibial alignment 90.7°, talar alignment 90.1°, tibial slope 82.6°, and talocalcaneal angle 11.2°. 49.1% demonstrated radiolucencies and 27.6% demonstrated cystic changes at long term. 7.2% showed subsidence over time.

Conclusion:

Our data represents one of the longest follow-up studies of the Salto mobile bearing TAA in the world. Our results show acceptable mid- to long-term survivorship. There is a notable percentage with radiolucencies and cystic changes but this does not seem to correlate with early failure. Component migration is uncommon. Further long-term follow-up of this cohort is necessary to determine the significance of the radiolucencies and cystic changes.
Measurement of Nitinol Recovery Distance Using Pseudoelastic Intramedullary Nail in Tibiotalocalcaneal Arthrodesis
Authors: Parekh Selene G. , Gross Christopher E. , Easley Mark E. , Adams Samuel B. , Kildow Beau J.
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Tibiotalocalcaneal(TTC) arthrodesis is a salvage procedure for patients with complex disease of the ankle and subtalar joints. Despite the clinical efficacy and mechanical advantage of intramedullary nails, complications, such as nonunion, are not uncommon. It may be possible to sustain compression in the face of bone resorption and implant loosening over the course of healing using a novel pseudoelastic intramedullary nail.

Methods:

We identified 15 patients (age+54.7+/-20.0 years) who had undergone a tibiotalocalcaneal arthrodesis using a pseudoelastic intramedullary nai. Serial radiographs were used to determine the amount and rate of Nitinol element migration over time.

Results:

Three months after surgery, there was at least 2.38mm of Nitinol element migration proximally with mean of 5.58mm(range: 2.38 to 8.11mm). Average follow up time was 195 days (range: 89 to 490 days).

Conclusion:

The Nitinol element recovers distance when stretched intra-operatively and maintains moderate compression in response to bone resorption. Further studies are needed to assess if this increased compression lends itself to higher fusion rates than traditional IMN’s.
Primary Open vs. Arthroscopic Ankle Arthrodesis
Authors: Barg Alexej , Lyman Mikayla , Morris S. Craig , Saltzman Charles L.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthrodesis is the gold-standard treatment option for patients with end-stage ankle osteoarthritis resulting in measurable improvements in postoperative pain relief. Arthroscopic ankle arthrodesis has gained increasing popularity, however there remains a lack of comparative data with open ankle arthrodesis. The objectives of this retrospective study were to compare (1) demographics, (2) surgical technique, (3) postoperative fusion rates, and (4) postoperative complication rates in patients with primary open vs. arthroscopic tibiotalar arthrodesis.

Methods:

Between March 2002 and November 2014, 385 primary ankle arthrodeses were performed at our institution. There were 212 male and 173 female patients with a mean age of 56 ± 14.7 years (18.0-88.8). The mean weight, height, and body mass index (BMI) were 89.4 ± 19.7 kg (46-168), 172.9 ± 11.1 cm (147-208), and 29.9 ± 5.8 kg/m2 (18.9-54.9), respectively. There were 322, and 63 patients with primary open and arthroscopic arthrodesis, respectively. Both patient groups were compared with regard to demographics including gender, weight, height, BMI, ASA classification, smoking, alcohol use, and comorbidities. The surgical technique was analyzed in both groups including approach, main fixation type, and allograft/autograft use. Finally, fusion rates and time to complete union were analyzed. Complication rates including wound complications, deep vein thrombosis/pulmonary embolism, and any secondary procedures were described in both groups. The mean time to final follow-up was 37.9 ± 27.0 months (12.0-150.4).

Results:

Demographics and comorbidities were comparable in both groups. All but one arthroscopy were performed using anterior portals. All arthroscopic ankle arthrodeses were performed using screw fixation, while fixation types varied in open arthrodesis (P < 0.001). Autograft use was higher in open arthrodesis at 84.2% vs. 6.3% (P < 0.001), while allograft was favored for arthroscopic arthrodesis at 66.7% vs. 20.2% (P = 0.101).Osseous union was with 92.2% and 90.5% in patients with open and arthroscopic arthrodesis, respectively (P = 0.529). However, the time to complete osseous fusion was significantly shorter in patients with arthroscopic ankle fusion, at 4.3 vs. 5.1 months (P = 0.034). Wound and thrombembolic complications occurred significantly more often in patients with open ankle arthrodesis.

Conclusion:

Osseous union rates were comparable in both patient groups,however union time was significantly shorter in the arthroscopic group. Wound healing problems and thrombembolic complications were more common in patients who underwent open ankle arthrodesis.
The Arterial Anatomy of the Deltoid Ligament
Authors: Haynes Jacob A. , Gosselin Michelle , McCormick Jeremy J. , Johnson Jeffrey E. , Klein Sandra E.
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Injuries to the deltoid ligament complex on the medial aspect of the ankle account for 10-15% of ankle sprains. Chronic deltoid insufficiency can lead to medial or multidirectional ankle instability, necessitating operative stabilization. Many studies have examined the anatomy of the deltoid ligament complex, with a focus on characterizing the various bands that comprise its structure. To our knowledge the vascular supply to the deltoid ligament has not been previously studied. This information may have implications in the progression of deltoid injuries to chronic insufficiency, and is an important consideration when performing operative reconstruction of the deltoid ligament. The purpose of our study was to describe the vascular supply to the deltoid ligament utilizing a method of chemical debridement with cadaveric specimens.

Methods:

Twenty-seven matched pairs of adult cadaver legs, fifty-four legs total, were studied. Specimens with any signs of prior trauma or surgical treatment were excluded. The legs were amputated below the knee and injected with India Ink, followed by Ward Blue Latex, in the anterior tibial, posterior tibial and peroneal arteries. Specimens were chemically debrided utilizing 6.0% sodium hypochlorite, leaving vascular casts, ligaments and bones. The vascular supply to the deltoid ligament was evaluated, photographed, and recorded.

Results:

The vascular supply to the deltoid ligament complex was clearly visualized in 50 of the specimens. The deltoid ligament in all 50 specimens was supplied by arterial branches from the dorsalis pedis, specifically the medial tarsal arteries. Thirty-two of the specimens (64.0%) had an additional contribution from the anterior tibial artery, while the medial tarsal arteries were the only anterior vascular supply in the remaining eighteen specimens (36.0%). Thirty-nine specimens (78.0%) had additional arterial supply to the deltoid ligament from the posterior tibial artery. In thirteen (30.0%) of these specimens, the posterior tibial artery provided the dominant arterial supply, as determined by vessel diameter.

Conclusion:

Deltoid injuries can become chronic, leading to recurrent ankle instability. Our study shows that the deltoid ligament complex receives a consistent arterial supply from the dorsalis pedis and anterior tibial arteries, and that this anterior vasculature is the dominant supply in the majority of specimens. A large portion of our specimens also had additional arterial supply from the posterior tibial artery. Knowledge of the arterial anatomy of the deltoid ligament complex is valuable when planning operative treatment of medial ankle, and may also provide information for future studies examining the progression of medial ankle sprains to chronic deltoid insufficiency.
The Effects Of Protease-Activated Receptors 1 And 4 In Human Platelet Activation And Inflammation
Authors: Zhang Jianying , Rocha Jorge L. , Hicks Justin H. , McLane Melissa , Wang James H-C. , Hogan MaCalus V.
Published: October 2016

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Tendon injuries occur frequently and cost billions of health care dollars annually. Recently, there has been an increase in the use of platelet-rich plasma (PRP) to treat tendon injuries. However, the efficacy of PRP treatment is controversial due to inconsistent results from human clinical trials. It is thought that variations in PRP preparation contribute to these inconsistencies. Specifically, platelets in PRP contain pro-angiogenic (e.g. VEGF) or anti-angiogenic (e.g. endostatin) factors, which may differentially affect the healing of tendon injuries. It is known that these factors are selectively released after platelet activation by specific receptors. Therefore, in this study we investigated the effect of protease-activated receptors 1 and 4 (PAR1 and PAR4) in platelet activation and inflammation.

Methods:

Platelet preparation – Human blood was obtained from 12 healthy donors and 9 ml of blood was mixed with 1 ml of 3.8% sodium citrate and centrifuged at 500g for 10 min. Then, the supernatant (PRP) without the buffy coat was centrifuged at 1000g for 10 min and the resulting pellet was washed in Tyrodes-HEPES buffer and centrifuged for 10 min at 1000g. Finally, platelets in the pellet was suspended in Tyrodes-HEPES buffer and used in experiments. Platelet activation – About 100 μl of platelet from above was activated with 5 μl 1 mM PAR1-activating peptide (PAR1-AP) or PAR4-activating peptide (PAR4-AP) at 25°C for 10 min. Then, the mixture was centrifuged at 1000g for 10 min, and the levels of VEGF, endostatin, IL-1RA and HMGB-1in the supernatant was determined by ELISA. Platelets without activators were used as controls.

Results:

PAR1 induced angiogenic effects in human platelets. PAR1 activated platelets released 3 times more VEGF than when activated with PAR4 (Fig. 1A). However, PAR4 activated platelets released 7 times more endostatin than the PAR1 activated platelets (Fig. 1B). Further, PAR1 induced anti-inflammatory effects in human platelets; it did not change IL-1R-A (Fig. 2A) but decreased HMGB-1 levels (Fig. 2B). In contrast, PAR4 stimulated inflammatory effects in human platelets by lowering IL-1-RA and increasing HMGB-1 levels.

Conclusion:

Our findings indicate that PAR1 induces angiogenetic and anti-inflammatory effects in human platelets, while PAR4 has anti-angiogenetic and inflammatory effects. Of significance is HMGB-1, which is constitutively expressed in the nuclei of most mammalian cells. Under cellular stress, HMGB1 is released into the extracellular matrix and activates the immune response thus acting as a danger-signal. Both PAR1 and PAR4 selectively regulated the release of VEGF and endostatin, and IL-1RA and HMGB-1 from human platelets. Therefore, the role of PAR1 and PAR4 on human platelet activation and inflammation should be considered prior to the use of PRP to treat tendon injuries.
The Use of Cryo-Preserved Umbilical Cord Plus Amniotic Membrane Tissues in the Resection of Tarsal Coalition
Authors: Covell D. Jeffrey , Cohen Bruce , Ellington J. Kent , Jones Carroll P. , Davis W. Hodges , Anderson Robert B.
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

Tarsal coalition can be a common underlying cause of painful flatfoot deformity in adolescent and adult patient populations. When conservative options fail, surgical resection becomes the mainstay of treatment. Adequate resection leaves a void, often filled with bone wax, fat graft or adjacent muscle or tendon. Interposition grafting is designed to provide a physical barrier between the ends of the excised segment and deter recurrence or bony overgrowth. No definitive graft choice has been shown to be superior to another. The goal of this study was to evaluate the use commercially available umbilical cord plus amniotic membrane tissues as an interposition graft with functional and radiological outcomes at one year follow-up.

Methods:

Retrospective review was performed of patients who had resection of tarsal coalition at our institution. Patients who had interposition of umbilical cord plus amniotic membrane tissues (Amniox Medical, Atlanta GA) at the site of the resection were included in this review. Postoperative data collection included VAS scores, Foot Function index scores, and radiographic review. Radiographic review included postoperative CT scans in all patients. Assessment of hindfoot ROM was noted on physical examination at last follow up visit.

Results:

Fourteen patients (8 male and 6 female; median age 28.5 years at time of evaluation) were enrolled in the study. Of these patients, 7 were calcaneonavicular coalitions and 7 were talonavicular coalitions. Average follow up occurred at 18 months (range 9-32 months). Interposition of umbilical cord plus amniotic membrane tissues was performed at the site of the resection. Median improvement in pain visual analog score (VAS) was 89.75%, with no post-operative infection or wound complications. Post-operative CT scan review demonstrated evidence of osteoarthritis in two patients (one at talonavicular and one subtalar joint). Four of 14 patients (29%) were found to have recurrence at follow-up. The median post-operative Foot Function Index score was 46 (range 30-110) and 64% of patients had improvement in range of motion.

Conclusion:

Based on radiological and functional outcomes at an average 19 month follow up, the interposition of umbilical cord plus amniotic membrane tissues after tarsal coalition resection appears to be a viable option in treating these patients. No adverse reactions were found and recurrence rate was noted to be 29%.
Tibiotalocalcaneal Fusion with a Retrograde Triple Bending Nail - 2-Year-Followup Results
Authors: Richter Martinus , Zech Stefan , Meissner Stefan A.
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

Retrograde nails are one option for fixation in tibiotalocalcaneal fusion (TTCF). Most actual designs include straight or distally lateral bent nails that could have a short bone purchase in the calcaneus with potentially limited stability and resulting delayed union or nonunion. A nail with additional distal posterior bend for longer purchase in the calcaneus for increased stability was developed (A3, Small Bone Innovation, Morrisville, PA, USA). The aim of this study was to investigate the clinical application and short-term clinical followup.

Methods:

In a prospective consecutive non-controlled clinical followup study, all patients with TTCF using A3 from October 18th, 2011 to April 29th, 2013 were analyzed. The specific shape of the nail includes a distal double bend; one posterior (15°) and one lateral (10°). Posterolateral approach to the ankle and subtalar joint were utilized. The times and accuracy of the alignment and implant position (Visual analogue scale, 0-10) for implant placement, complications, radiological fusion, and Visual Analogue Scale Foot and Ankle (VAS FA) were recorded. Time for implant position comprised placement of the nail, 4 locking screws and compression with the compression screw. Calcaneal pitch and hindfoot angles were measured, pre-, postoperatively and at 24 months. Fusion (≥50% bony bridge at ankle and subtalar joints assessed on radiographs) was assessed at 6, 9, 12 weeks, 12, 24 months. VAS FA was recorded at 24 months.

Results:

66 cases/feet were included (age, 58.5 (22-80) years; VAS FA, 29.6 (0-69)). Indications were specified as follows (multiple indications possible): osteoarthritis, n=43 (65%); instability, n=12 (18%); deformity, n=36 (55%), failed total ankle replacement, n=4 (6%); failed previous fusion, n=9 (14%), diabetes mellitus, n=5 (8%). The time for implant preparation and positioning was 17.5 (5-31) minutes. The accuracy of alignment and implant position was 9.4 (7.5 - 10). Sixty (91%) patients completed follow-up: VAS FA 59.9 (t-test (comparison with preoperative scores), p=.01)), fusion rate 100%, high accuracy of correction and implant position. The deviation of the measured angles from the desired angles (hindfoot angle, 5° valgus; calcaneal pitch angle, 20°) were lower at follow-up than pre-operatively (each p < 0.001).

Conclusion:

TTCA with the A3 implant system showed accurate correction and implant position. Two-year-follow-up in 60 patients showed good clinical outcome scores and 100% fusion rate.
Treatment of Severe Hallux Valgus Deformity in Rheumatoid Arthritis With 1st MTP Joint Fusion Combined With Proximal Chevron Metatarsal Osteotomy
Authors: Moon Yong-Seok , Kim Myung Jin , Ahn Jae Hoon
Published: October 2016

Category:

Bunion

Introduction/Purpose:

A severe hallux valgus deformity in rheumatoid patient is usually treated with the 1st MTP fusion, since the high success rate with low percentage of recurrence leads to higher patient satisfaction. However the large 1st inter- metatarsal angle, sometimes, is not decreased after the fusion, and the patient may suffer the persistent bunion pain. We tried to solve this problem by performing the 1st MTP fusion and the 1st proximal metatarsal osteotomy in one stage. We report our surgical technique with the outcome analysis of the patients.

Methods:

Six patients with the severe rheumatoid hallux valgus deformity were followed for more than 12 months after the combined 1st MTP fusion and 1st proximal metatarsal osteotomy. All were women. The mean age of patients was 51.3 years, and the mean follow up period was 2 years and 1 month. Inclusion criterion was a rheumatoid hallux valgus deformity of more than 18 degrees of the 1st intermetatarsal angle. The MTP fusion was fixed with threaded Steinmann pins and the proximal metatarsal osteotomy was fixed with Kirschner wires through the single curvilinear skin incision. Clinically American Orthopaedic Foot and Ankle Society (AOFAS) hallux MP-IP scale, and patient’s satisfaction after the surgery were analyzed. Radiographically the union of the fusion and the osteotomy was investigated.

Results:

Clinically the AOFAS scale improved from the preoperative 51.2 points to the postoperative 84.3 points. All patients were satisfied with the results. There were no wound problem or nonunion of fusion/osteotomy.

Conclusion:

The combined 1st MTP fusion and 1st proximal metatarsal osteotomy was an effective and safe procedure for the severe rheumatoid hallux valgus deformity with the large 1st inter-metatarsal angle.
Weight-Bearing 3D Foot Model Reconstruction From Standing Radiographs Using Deformable Surface Fitting Method
Authors: Seo Sang Gyo , Kim Jaeil , Ryu Chang Hyun , Kim Eo Jin , Lee Doojae , Lee Dong Yeon , Park Jinah
Published: October 2016

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Although weight-bearing CT of the foot and ankle definitely reflect the morphology of joint and foot deformity, it is hard to obtain the standing CT due to difficulty of availability. The purpose of this study is to introduce a semi- automatic method based on a deformable surface fitting for achieving the weight-bearing 3D model reconstruction from standing radiographs for foot and ankle.

Methods:

Our method is based on a Laplacian surface deformation framework using a template model of foot bones. As pre- processing step, we obtained template surface meshes having the average shapes of foot bones from standing CT images (Planmed Verity® CT scanner) in 10 normal volunteers. First, 3D standing CT was obtained by Planmed Verity® CT scanner and used as gold standard of reconstruction for one patient with flatfoot. Second, in the reconstruction step, the surface meshes are deformed following guided user inputs (talus 6, calcaneus 8 in lateral, talus 6, calcaneus 6 in anteroposterior standing radiograph) with geometric constraints to recover the target shapes of patients while preserving average bone shape and smoothness as much as possible. Finally, we compared reconstructed 3D model to original standing CT images.

Results:

In this study, the comparison results indicate that the obtained reconstruction is close to the actual standing foot and ankle geometry. We present the accuracy and robustness of our method via comparison between the reconstructed 3D models and the original bone surfaces

Conclusion:

Weight-bearing 3D foot model reconstruction from standing radiographs is concise and the effective method for analysis of foot joint alignment and deformity.