bluuebunny/crossref_metadata_2025 huggingface dataset:
Morphological Analysis of Intraarticular Fragments in AO/OTA 44 Category Posterior Malleolar Fractures
Authors: Taki Masanori , Hio Naohiro
Published: December 2023

Category:

Ankle; Trauma

Introduction/Purpose:

Intraarticular fragments (IAFs) associated with posterior malleolar fractures are a major obstacle in the treatment of ankle fractures. However, their frequency, location, and morphology, as well as their relationship with the classification of ankle posterior malleolar fractures, are poorly understood and unresolved. The Purpose of this study is to clarify the frequency and morphology of IAFs in posterior malleolar ankle fractures.

Methods:

This study was conducted at a single institution and included 104 consecutive patients with trimalleolar ankle fractures treated between 2015 and 2022. The inclusion criteria were 1) acute fracture within 2 weeks after injury and 2) cases with computed tomography (CT) images at the time of injury. The exclusion criteria were 1) previous ipsilateral ankle fracture, 2) pathological fracture, and 3) younger age with open physis. CT images at the time of injury were reviewed and each posterior malleolar fracture was classified using the Mason classification. Frequency of occurrence, size (long diameter × short diameter), and angle (the angle between the long diameter and fracture surface of the posterior malleolar fracture) of the IAF. The location of the IAF was described from CT axial images The dislocated distance of the IAF from the articular surface was measured on the sagittal CT view.

Results:

The patient’s mean age was 54.6 years. 46 cases were Type 1, 32 cases were Type 2A, 9 cases were Type 2B, and 17 cases were Type 3 according to the Mason’s classification. In Mason Type 2 and 3 cases, the IAF was present in 32 (78.0%) and 12 (70.6%) cases, respectively. The IAF was more frequently observed laterally in type 2 (22 cases) and medially in type 3 (7 cases). The long × short diameter of the IAF averaged 11.2 × 4.9 mm and 9.0 × 3.7 mm for Types 2 and 3, respectively. The angle of IAF was 10.5 ± 13.4° and 8.5 ± 7.8°, the distance of displacement was 3.0 ± 2.6 mm and 2.4 ± 1.2 mm, respectively.

Conclusion:

This study revealed a high incidence of IAFs in posterior malleolar ankle fractures. The IAF has a long medial to lateral shape, as well as the direction of the posterior malleolus fracture, occurs more often laterally in Mason Type 2 and medially in type 3. These findings suggest a pathophysiology in which the axial force causes secondary intraarticular impingement after the main fracture of the posterior malleolus. resulting in the development of an IAF. Handling IAFs is one of the keys in the treatment of posterior malleolar fractures and the surgical approach should be also selected based on the IAF.
3D Printed Titanium Wedges for Distraction Arthrodesis of the Subtalar Joint
Authors: Kreulen Christopher D. , Giza Eric
Published: December 2023

Category:

Hindfoot

Introduction/Purpose:

Distraction arthrodesis of the subtalar joint is performed to restore height and correct deformity in the case of subtalar joint arthrosis, malalignment of the rear foot, calcaneal fracture, or other pathologies. Historically, autograft or allograft bone blocks were used to restore natural alignment and improve hindfoot function. Although successful use has been reported, complications associated with donor site morbidity and size limitation for autograft, as well as additional complications including nonunion, graft collapse, and loss of alignment are common. Recently, innovative advancements have enabled the use of 3D printed porous titanium implants for use, improving the union rates and reduced risk of subsidence and graft collapse.

Methods:

6 patients with subtalar collapse and anterior ankle impingement were indicated for distraction subtalar arthrodesis. Surgery was performed with a lateral approach for the distraction arthrodesis using an off the shelf 3D printed subtalar wedge and a nitinol pseudoelastic fusion rod for stabilization and fixation. Patients were followed 6 months post op for fusion and alignment. Fusion was confirmed at 3 months with CT scans and alignment was monitored with weightbearing ankle X-rays.

Results:

3D wedge incorporation and sustained correction of height and alignment was maintained over time at the subtalar joint. There were no nonunions, 2 patients reports skin healing issues due to tension on the skin with wound closure. These healed with local wound care. Improvement in preoperative to postoperative tibiotalar sagittal plane alignment was observed in all patients.

Conclusion:

The use of a 3D printed titanium wedge for distraction Arthrodesis of the subtalar joint is a safe procedure and useful procedure in short-term follow-up. This procedure does provide improvement in the patients alignment and fusion occurs with in 3 months of surgery.
Analyzing the Quality and Educational Value of Achilles Tendinopathy-Related Videos on TikTok
Authors: Tabarestani Troy Q. , Anastasio Albert T. , Duruewuru Anthony , Taylor Joshua , Bethell Mikhail Alexander , Adams Samuel
Published: December 2023

Category:

Ankle; Other

Introduction/Purpose:

Social media platforms, like TikTok, have become popular options for the consumption and distribution of healthcare information. Due to the lack of scientific oversight, the consistency of healthcare-related videos has become a focus of the current literature. However, orthopaedic surgery has lagged behind other specialties in acknowledging the widespread utilization of TikTok videos for medical information. This study aims to assess the quality and educational benefits of Achilles tendinopathy-related TikTok videos.

Methods:

TikTok was queried using the hashtags "#achillestendonexercises”, “achillestendonitisexercises", "achillestendinosisexercises" and "achillestendinopathyexercises". 100 videos (25 for each term) were included after applying the exclusion criteria. The number of views, likes, shares, comments, and favorites was recorded. The content was graded using DISCERN (a well-validated informational analysis tool) and ATEES (a self-designed tool for exercise evaluation).

Results:

The total number of views of the 100 videos was 1,647,148, with a median of 7,562.5 (IQR = 2,281- 19,575). The videos collectively received 73,765 likes, 1,125 comments, 14,491 favorites and 6,897 shares with a median of 283 (IQR= 73. 8-957.8), 7 (IQR= 1.8-16.0), 61.5 (IQR= 8.8-184.3), and 18.5 (IQR= 2.0-49.8), respectively. General users uploaded slightly less (48%) when compared to healthcare professionals (52%). Healthcare professionals had more videos graded as “very poor” (43.4%) in comparison to the general users (36.2%). General users had more videos graded as “poor” (63.8%) in comparison to healthcare professionals (54.7%). However, there were no significant differences between the groups on either of the video grading scales.

Conclusion:

Although TikTok is a powerful tool for information distribution, the educational value of the videos related to Achilles tendinopathy exercises was poor. With only 1% of videos receiving a grade of ‘fair,’ and no videos reaching a score of ‘good’ or ‘excellent’, healthcare professionals should be aware of the high viewership of low-quality content easily accessible on TikTok.
Assessing the Appropriateness of Repeat MRI Scan Requests Within a Foot and Ankle Department
Authors: Ardakani Amir Hossain Gahanbani , Haldar Anil , Patel Shelain , Welck Matthew J. , Cullen Nicholas , Malhotra Karan
Published: December 2023

Category:

Other

Introduction/Purpose:

With diagnostic resources often in great demand, it is important to ensure clinicians request investigations appropriately. Unnecessary radiological investigations are costly and delay patient care. This study aimed to assess the incidence and appropriateness of repeat MRI scans being requested in a single foot and ankle unit, to identify areas which can be improved.

Methods:

This was a retrospective analysis of 1322 scans between October-2019 to October-2022. We included all patients who had a diagnostic MRI scan requested after being assessed in our foot-and-ankle clinics. Assessments were made on the proportion of repeat scans, the seniority of requester, the indications put forward for the repeat scan, the modality of patient assessment (telephone vs face-to-face appointment), and the impact on patient management. A scan was considered a repeat, if the same anatomical location was scanned within a 3-year period. Scans were deemed appropriate if they were: part of a clinical trial, for tumour/infection/stress-fracture monitoring, for new trauma, pre-operative planning, following agreement in MDT discussions, or following significant changes in clinical symptoms. We expected that scans should ideally only be requested where the result is expected to influence management and that a scan should not be repeated without evidence of change in clinical symptoms (unless for monitoring).

Results:

Over the 3-year period, 6.5% of MRI scans performed were considered repeat scans. The average time between initial and repeat scans was 13.1±8.6months (range 1-33 months). 88% of patients had only one repeat scan. The majority(58%) of repeat scans were requested by non-senior clinicians. In total, 47/85(55%) scans were deemed appropriate. 75% of the patients in this cohort had been assessed face-to-face. Twenty of these scans were repeated for significant change in clinical symptoms and 50% meaningfully influenced management plans. Conversely, 38/85(45%) repeat scans did not have strong clinical indications. The majority(80%) of these were requested by non- senior clinicians and 50% were requested after a telephone review. From the scans requested by the non-senior clinicians, none(0%) had a meaningfully influence on patients’ management plans.

Conclusion:

This study highlights that although repeat MRI scans were not common, they seldom influenced patient management unless there was a meaningful change in patient symptoms. MRI scans were more likely to influence management when initiated by senior clinicians and following a face-to-face assessment. In order to streamline patient care and reduce unnecessary investigations we propose a protocol to guide the requesting of repeat scans. This protocol includes identifying significant symptomatic change, in-person review, and senior clinician or multi-disciplinary input when a repeat scan is being considered.
Assessment of Clinical Outcomes After Mini-Open Reduction of Depressed Calcaneal Fractures Using the Push-Out Molding Technique
Authors: Bae Su-Young , Park Jae Yong , Park Jung Hun
Published: December 2023

Category:

Trauma; Hindfoot

Introduction/Purpose:

As minimal invasive techniques for depressed calcaneal fracture treatment have become more common, great progress has been achieved with various surgical methods. While these techniques are still currently utilized, new methods have been developed. This study aimed to report the radiologic and clinical outcomes of depressed calcaneal fracture treatment with the “push-out molding” technique and to propose its clinical utility.

Methods:

From March 2009 to October 2020, a retrospective study was conducted with 52 patients, who received the “push-out molding” technique to treat depressed intra-articular calcaneal fractures (Sanders type II, III, IV). Exclusion criteria were as follows: patients with bilateral calcaneal fractures, open fractures, and a follow-up period < 12 months. Radiologic parameters were assessed at following periods: preoperative, postoperative, 3-month follow-up, and last follow-up. Limitation of range of motion (ROM), subjective satisfaction, and complications were assessed at the last follow-up period. Repeated measures ANOVA was used to analyze values at preoperative, postoperative, 3-month, and last follow-up periods.

Results:

Significant differences in the talo-calcaneal angle (p < 0.001), Böhler’s angle (p= < 0.001), Gissane’s angle (p = 0.023), distance from the lower cortical border of calcaneus to the anterior (p= < 0.001) and posterior (p= < 0.001) points of posterior articular surface, calcaneal length (p = 0.019), and talo-calcaneal height (p= < 0.001). Postoperatively, the posterior articular surface was well maintained, while 21.2% retained a ROM limitation by 20° or higher. Subjective satisfaction was as follows: excellent (42.3%), good (48.1%), fair (9.6%), and poor (0%).

Conclusion:

The “push-out molding” is a simple technique with the advantage of not requiring much force to treat depressed calcaneal fractures. It can be used as a beneficial surgical technique with minimal damage to the soft tissue, owing to the reduction from the depressed interior part and less severe ROM limitation.
Assessment of the Learning Curve of Minimally Invasive Surgery for Hallux Valgus: A Systematic Review
Authors: Walley Kempland , Baumann Anthony , Anastasio Albert T. , Gong Davin , Talusan Paul G
Published: December 2023

Category:

Bunion; Other

Introduction/Purpose:

Hallux valgus (HV) is a common orthopedic foot and ankle condition involving deformity with subsequent pain and dysfunction of the first ray. Surgical interventions, such as open and minimally invasive surgery (MIS), are frequently utilized if conservative management is insufficient. In recent years, MIS has been increasingly used and has been regarded as one of the most innovative surgical interventions for HV. However, insufficient and/or delayed mastery of MIS for HV has the potential to affect patient outcomes and complication rates. The purpose of this study is to examine the learning curve associated with MIS for the treatment of HV.

Methods:

A systematic review was performed using PubMed, ScienceDirect, Web of Science, CINAHL and MEDLINE databases from database inception to February 16th, 2023. Inclusion criteria was articles with level of evidence I-III, any outcomes associated with learning curve, MIS, full-text articles in English, and diagnosis of HV in adult patients. Exclusion criteria was articles not containing data on learning curves, non-English full-text, and level IV studies.

Results:

A total of 165 articles were found with 6 articles meeting final article selection. For all six articles, 368 total patients (422 total feet) were included in the study with an average age of 55.69 years (range 15 - 84). Three studies reported the number of surgeries needed to reach the plateau phase of the learning curve of MIS for HV, with a frequency weighted mean of 35.5 surgeries (range 27 – 40). In the selected articles, significant results were found for increased OR time and fluoroscopy shots in the learning phase. There was no significant increase in complications in the learning phase. There was no significant decrease in patient outcomes, or the quality of correction performed during the learning phase for MIS for HV.

Conclusion:

An average of 35.5 surgeries (range 27 – 40) are needed to reach the plateau phase for MIS for HV. The learning phase of the learning curve of MIS for HV has a significant increase in OR time and fluoroscopy usage. However, the learning phase of the learning curve of MIS for HIV is not associated with decreased outcomes, decreased corrections, or higher complication rates. More research with higher quality studies is needed to determine the impact of the learning curve of MIS for HV on patient outcomes.
Association between Socioeconomic Status and Increased Postoperative Emergency Department Utilization following Ankle Fracture Surgery
Authors: Ogawa Takahisa , Kwon John , DiGiovanni Christopher W. , Guss Daniel
Published: December 2023

Category:

Trauma; Ankle

Introduction/Purpose:

There is a paucity of literature regarding the effect of socioeconomic disparity on patient access to health care following surgery for acute musculoskeletal injuries. We hypothesized that lower socioeconomic status (SES) is independently associated with increased utilization of the emergency department (ED) for care, and less reliable outpatient follow up after ankle fracture surgery.

Methods:

A retrospective analysis was performed of 1,571 patients who underwent ankle fracture surgery between 2010 and 2020 at three large academic medical centers and one community hospital. Using 2010 United States Census data linked to place of residence, a summary measure of SES was created for each zip code. SES was divided into three percentile groups: 0-25%, 26-75% and 76-100%, wherein the 0- 25% group represented the lowest SES score. Independent patient and injury factors associated with ED visits and outpatient in-office follow up within 90 days of ankle fracture surgery were examined using multivariable Poisson regression models.

Results:

Patients in the lowest quintile of SES had a higher incidence of ED visits within 90 days after surgery (adjusted incidence ratio [aIR], 1.54, p< 0.001). Patients in the highest quintile of SES had a higher frequency of outpatient follow up within 90 days after surgery (aIR, 1.23, p< 0.001) compared to those in the middle SES quintile. Independent factors associated with increased ED visits following ankle fracture surgery were lower SES, lateral malleolus fracture, heightened comorbidities, increased BMI, Spanish-speaking patients, and patients with drug and/or alcohol dependence.

Conclusion:

Patients of lower socioeconomic status, those with substance use disorders, and those who must overcome language barriers to seek care demonstrate higher emergency resource utilization and are less likely to follow up in clinic after ankle fracture surgery. A better understanding of patient and injury factors associated with such increased ED visits may provide guidance as to which patient subpopulations may require more attention after ankle fracture surgery.
Biomechanical Comparison of Open vs Percutaneous Techniques for Primary Mid-Substance Achilles Tendon Repair: A Systematic Review and Meta-Analysis
Authors: Lawson Jonathan , Sequeira Sean , Imbergamo Casey , Guyton Gregory P. , Hembree Walter C. , Gould Heath P.
Published: December 2023

Category:

Hindfoot; Basic Sciences/Biologics

Introduction/Purpose:

Primary repair of mid-substance Achilles tendon rupture may be performed using an open or a percutaneous technique. Previous meta-analyses of clinical data comparing the two techniques have demonstrated mostly equivalent functional outcomes and re-rupture rates. Individual cadaveric studies have also compared the biomechanical properties of the two approaches. However, the results of these studies have been heterogeneous, and there is currently no consensus as to whether one technique may be biomechanically superior. The purpose of this meta-analysis was to evaluate the biomechanical properties of open versus percutaneous Achilles tendon repair.

Methods:

A systematic review of original research articles was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. To qualify for study inclusion, articles were required to be published in English, utilized a cadaveric laboratory design, and had to directly compare the biomechanical properties of open Achilles repair using a Krackow or Kessler technique versus percutaneous repair using either the PARS (Arthrex) or Achillon (Integra) tendon repair systems. Evaluated outcomes included displacement (mm), load to failure (N), and stiffness (N/m).

Results:

Nine studies met inclusion criteria, including 190 cadaveric specimens (open: 83, PARS: 56; Achillon: 51) that underwent primary mid-substance Achilles tendon repair. Pooled analysis demonstrated no statistically significant difference in displacement (p = 0.418; Figure 1), load to failure (p = 0.923; Figure 2), or stiffness (p = 0.195; Figure 3) between the open and percutaneous techniques. Among the percutaneous approaches, there was no difference in displacement (p = 0.109; Figure 4) between the PARS and Achillon tendon repair systems.

Conclusion:

The results of this study suggest that both open and percutaneous techniques are biomechanically viable approaches for primary mid-substance Achilles tendon repair. These biomechanical findings must be interpreted in the context of clinical outcomes data as well as the differing complication profiles of the two techniques to best inform the surgical decision-making process for primary mid-substance Achilles tendon repair.
Can the Contralateral Ankle be used for Preoperative Planning in Total Ankle Arthroplasty in the Posttraumatic Patient? A Prospective Study
Authors: Barbero Agustin , Efrima Ben , Maccario Camilla , Indino Cristian , Ovadia Joshua , Usuelli Federico Giuseppe
Published: December 2023

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

Total ankle arthroplasty (TAA) for posttraumatic osteoarthritis (OA) is becoming an increasingly popular treatment option. Clinical results and prosthesis longevity correlate directly with the hind foot and components' postoperative alignment. Therefore, a preoperative plan (PROP) that can accurately predict postoperative alignment of TAA could be valuable. Most PROPs use the diseased ankle as a reference despite the arthritic deformation. PROPs of the contralateral, unaffected limb have been tested in other fields, but not in TAA. In most cases of posttraumatic OA, the contralateral ankle is relatively preserved and therefore could serve as a valuable tool for preoperative planning. This prospective study aims to assess the accuracy of preoperative planning using a WBCT of the contralateral healthy ankle for TAA in the treatment of posttraumatic OA.

Methods:

A total of 44 patients were included. For each case, a preoperative WBCT scan of the contralateral foot was acquired. Individual PROPs consisted of virtual realignment and osteotomies prior to each surgery. After surgery, postoperative WBCT scan of the affected foot was performed. Six angles were used to assess the accuracy of the coronal and sagittal alignment of the prosthesis.

Results:

Forty-four ankles across 44 patients were operated on. Three angles had a statistically significant difference between the pre and postoperative measurements: (1) α angle was -3±4 degrees (p-value < 0.0001), (2) TTS 2.884±4 degrees (p-value < 0.00001), (3) TTR -7±14 mm (p-value < 0.001). Only 49% and 34% of the coronal and sagittal angles could be found within 3 degrees from the PROPs.

Conclusion:

In conclusion, the contralateral ankle cannot be used accurately as a preoperative planning tool for TAA. It should be used only in cases where the diseased ankle cannot be a referenced in the setting of deformation.
Chevron vs Oblique Medial Displacement Calcaneal Osteotomy - Which Is More Stable? Results From a Finite Element Analysis Study
Authors: Subasi Omer , Sharma Siddhartha , Karaismailoglu Bedri , Ashkani-Esfahani Soheil , Bejarano-Pineda Lorena
Published: December 2023

Category:

Hindfoot; Ankle

Introduction/Purpose:

The medial displacement calcaneal osteotomy is used to correct hindfoot valgus in adult-acquired flatfoot disease(AAFD). This is done by means of an oblique cut, which is then translated medially. The chevron variant of the MDCO has gained popularity in recent times. This osteotomy involves a V-cut, with the apex of the V placed anteriorly. This is thought to be inherently more stable than the conventional MDCO owing to its geometrical design and higher contact area, especially with higher magnitudes of translation of the osteotomized fragment. However, it is technically more demanding, and many surgeons may not be familiar with the technique. Moreover, there is no literature comparing the stability of the chevron and oblique MDCO. Hence, we conducted this study to address this knowledge gap.

Methods:

Computed Tomography (CT) scan of the foot of a patient diagnosed with Johnson stage 2 AAFD was segmented and converted into a 3D computational model. Subsequently, oblique and chevron (160o V-angle) calcaneal osteotomies were performed virtually. For each variant, the osteotomized fragment was translated medially by 8-, 10- and 12-mm and then fixed virtually with two 6.5 mm screws. The six models were imported into a Finite Element Software (ANSYS v19) and subjected to 500 N axial loading through the tibia to simulate a single-leg stance. The von Mises stresses at the osteotomy interfaces and the screws, and the total displacement of the posterior fragment was recorded for each model.

Results:

The compiled simulation results are presented in Table 1. For both osteotomies, the overall stresses at the osteotomy contact site and the screws increased incrementally with increasing medial translation. Similarly, sagittal plane displacement of the anterior fragment was noted to follow a similar trend. Across all translation levels, the stresses were recorded to be lower for chevron MDCO when compared to the oblique variants. Relative fragment displacement was also noted to be lower for the chevron MDCO.

Conclusion:

The chevron osteotomy results in lower contact stresses and osteotomy fragment displacement and may prove to be a more stable alternative to the oblique MDCO. However, these results need to be replicated in a larger cohort of patients, as well as in cadaveric studies to determine if surgeons can permit early weight-bearing with the chevron MDCO.
Corrective Distal Tibio-Fibular Osteotomy for Medial Ankle Osteoarthritis: Consecutive 67 Cases, Prognostic Factors and 3B Cases Outcomes Evaluation
Authors: Im Je-Min , Lim Jung-Won , Jung Hong-Geun
Published: December 2023

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

Supramalleolar osteotomy is a considerable technique for medial compartment ankle arthritis as a joint preservation and has been shown to be effective in several studies The indication for supramalleolar osteotomy is generally presented as early and mid-stage arthritis (Takakura stage 2 or 3A), and there is much arguments about the application of stage 3B. This study analyzes the results of suprmalleolar osteotomy performed in patients with Takakura stage 3B arthritis and seeks to identify factors that influence clinical outcomes.

Methods:

From August 2007 to May 2021, a total of 67 cases in which tibio-fibula osteotomy were performed for medial compartment arthritis of the ankle joint. We analyzed 67 cases and 19 cases of 3B stage before surgery which were possible for at least on year follow-up. Clinical assessments assessed VAS score, AOFAS score, and ROM, and radiological assessment assessed TAS angle, TLS angle, Talar tilt, and Contact surface percentage.

Results:

VAS pain scores improved from 6.6(3-9) to 2.3(0-6), AOFAS scores improved from 56.6(20-87) to 85.1(66-100), and ROM DF/PF improved from 15.3/30.6 to 16.7/34.6 degrees, which was not significantly different from the Takakura stage 2 or 3A group performed in this center at the same time. The preoperative and final follow-up TAS angle was 2.5 degrees overcorrection, from 84.7 to 97.2, and the TLS angle changed from 77.6 to 81.5. The talus tilt improved from 9.1 to 6.8 degrees, which was higher than in the Takakura stage 2 or 3A patient group. Except one case, All cases obtained bone union, with an average duration of 7.5 (3-12) months. And we found contact surface percentage help us anticipate possibility of correction and clinical outcomes.

Conclusion:

Compared to stage 2 or 3A, the results of supramalleolar osteotomy in Takakura stage 3B patients showed radiologically TAS overcorrection and higher talar tilt angles, but clinically there was no significant difference and showed good results. Therefore, it is believed that even in advanced medial compartment ankle arthritis at stage 3B, it may be a selectively good indication for supralleolar osteotomy.
Do Syndesmotic Injury Patterns Influence Functional and Radiological Outcomes in Complex Ankle Fractures? A Retrospective Cohort Study
Authors: Patel Sandeep , Dhillon Mandeep S. , Sharma Siddhartha , Nishani Manjunath
Published: December 2023

Category:

Ankle; Trauma

Introduction/Purpose:

Syndesmosis injury can be of a varying magnitude; little information exists about the influence of degree of initial syndesmotic injury/instability on functional outcomes in ankle fractures, nor is there any correlation of this with follow up radiological parameters.

Aims and Objectives:

To identify and define morphological patterns of syndesmotic injury in ankle fractures according to a zone based evaluation, and correlate initial degree of instability with mid-term functional and radiological outcomes using validated scores

Design:

Retrospective cohort study, to review a prospective question.

Methods:

40 complex ankle fractures out of 120 ankle fractures in our ankle registry met the inclusion criteria ie significant documented syndesmosis involvement needing stabilization, with all initial clinical and radiological records available. The patients were followed up between January 2020 to July 2021. Injury characteristics, fracture morphology of posterior malleolus, medial malleolus and fibula were noted and classified by validated classification systems based on x-rays and CT scan. The syndesmosis was analyzed on axial CT scan; it was divided into 3 zones, A,B,C from anterior to posterior, and degree of displacement and morphology was noted. Immediate post-operative radiographs were evaluated for fracture and syndesmosis reduction. The patients were evaluated at final follow up with both ankle specific scores (Olerud Molander score, Ankle-Hindfoot scale, Manchester-Oxford Foot questionnaire) and quality of life score (SF-12). Ankle Osteoarthritis grade was used to evaluate radiological outcomes.

Results:

Mean follow-up was 19 months. 22(55%) patients had syndesmotic widening on plain radiographs; however in pre- operative CT scan evaluation 40(100%) patients had syndesmotic injury based on the Zone evaluation of the syndesmosis. 22 patients had Zone A injury (widening, AITFL, Chaput, Wagstaff). 22 patients had widening of Zone B. Zone C was involved in 30 patients (PM fracture,PITFL involvement). At final follow up; the mean OMAS was 83.38±16.35, mean Ankle-Hindfoot scale= 88±9.98, mean Mox-FQ score=27.15±13.35 & mean SF-12 were (MCS=56.59±8.24, PCS=51.18±8.48). There was no significant difference in outcome scores based on fracture types, Posterior malleolus morphology, or based on zones of syndesmosis injury. Syndesmosis malreduction contributed to significantly poorer outcomes (SF-12, OMAS, MoxFQ)

Conclusion:

Despite a zonal classification of syndesmotic injury on CT and more clarity of injury patterns, we could not corelate the site and extent of syndesmotic injury with final functional and radiological outcomes. The one factor that has significant influence is initial accurate reduction of both the malleolar fractures and syndesmosis injury. In this the CT based axial classification may play a role.
Does Suture Type or Configuration Matter in Percutaneous Achilles Tendon Repairs?
Authors: Benner Nathan , Branam Grant , Chin Kenneth , Telfer Scott , Keller Hana
Published: December 2023

Category:

Trauma; Sports

Introduction/Purpose:

The human Achilles tendon is functionally important for dynamic activities and is a common site of injury, resulting in pain, weakness, and removal from sport. While treatment options vary and the opinions regarding optimal management are not uniform, percutaneous repair through commercially available guides is one option that has been used in the United States. The purpose of this study was to test the mechanical properties of four suture permutations.

Methods:

This biomechanical study included Porcine toe flexor tendons as an analogue for the human Achilles tendon. Simulated rupture was performed and tendons repaired using a percutaneous guide. Technique was uniform with pre-determined allotment into one of four groups based on suture configuration (single or double locked) and type (round or flat) with a total of 10 specimens in each group. Specimen then underwent static creep test, a dynamic load creep test, and finally load to failure test. An analysis of variance test was performed, followed by pairwise comparisons using independent t-tests to assess inter-group differences if significant effects were found, adjusted for multiple comparisons.

Results:

No significant differences were seen between conditions for the creep tests. The suture configuration used was determined to have a significant effect on the maximum load to failure of the constructs (p = 0.018) and maximum stress in the construct during the load to failure test (p = 0.019). Double Tape had a significantly greater load to failure than the Single Round (66N (0.021, [25, 107]) and Single Tape (72N (0.037, [18, 126]) conditions, and reached greater stresses before failure (0.1N/mm^2 (0.04, [0.03, 0.17] and 0.1N/mm^2 (0.04, [0.02, 0.18], respectively). No significant differences were found between the double tape and double round techniques, nor the Double Round and either of the Single techniques for any of the load to failure variables.

Conclusion:

Currently, there is no compelling data to support surgical over non-surgical management of Achilles tendon ruptures. However, by patient or surgeon preference, many patients undergo operative intervention, and percutaneous repair through a guide is a popular modality. The results of this study, using a porcine model to simulate a minimally invasive technique for Achilles tendon repairs, suggest that the use of a double locked tape suture configuration leads to a stronger overall construct. The clinical implications of these findings will be the subject of future work.
Effect of Tibial Cortex Transverse Transport in Patients with Recalcitrant Diabetic Foot Ulcers: A Prospective Multicenter Cohort Study
Authors: Hua Qikai , Zhao Jinming
Published: December 2023

Category:

Diabetes; Other

Introduction/Purpose:

Management of recalcitrant diabetic foot ulcer (DFU) remains difficult. Distraction osteogenesis mediates new bone formation and angiogenesis in the bone itself and the surrounding tissues. Recently it was reported that tibial cortex transverse transport (TTT) was associated with neovascularization and increased perfusion at the foot in patients with recalcitrant DFUs and facilitated healing and limb salvage. However, the findings were from several single-center studies with relatively small populations, which need to be confirmed in multicenter cohort studies with relatively large populations. Furthermore, the effect of this technique on patient's health-related quality of life is still unclear.

Methods:

We treated patients with recalcitrant (University of Texas wound grading system 2-C to 3-D and not responding to prior routine conservative and surgical treatments for at least 8 weeks) DFUs from seven centers using TTT (a 5 cm 1.5 cm corticotomy followed by 4 weeks of medial and lateral distraction) between July 2016 and June 2019. We analyzed ulcer healing, major amputation, recurrence, health-related quality of life (physical and mental component summary scores), and complications in the 2-year follow-up. Foot arterial and perfusion changes were evaluated using computed tomography angiography and perfusion imaging 12 weeks postoperatively.

Results:

A total of 1175 patients were enrolled. Patients who died (85, 7.2%) or lost to follow-up (18, 1.7%) were excluded, leaving 1072 patients for evaluation. The mean ulcer size was 41.0 8.5 cm2 and 187 (16.6%) ulcers extended above the ankle. During the follow-up, 1019 (94.9%) patients healed in a mean time of 12.4 5.6 weeks, 53 (4.9%) had major amputations, and 33 (3.1%) experienced recurrences.Closed tibial fracture at the corticotomy site was found in 8 (0.7%) patients and was treated using external fixation and healed uneventfully.Compared to preoperatively, the patients had more small arteries and higher foot blood flow (8.1 2.2 versus 28.3 3.9 ml/100 g/min, p ¼ 0.003) and volume (1.5 0.3 versus 2.7 0.4 ml/100 g, p ¼ 0.037) 12 weeks postoperatively.

Conclusion:

TTT promotes healing, limb salvage, and health-related quality of life in patients with recalcitrant DFUs as demonstrated in this multicenter cohort study. The surgical procedure was simple and straightforward and the complications were few and minor. The effect of this technique was associated with neovascularization and improved perfusion at the foot mediated by the cortex distraction. The findings are required to confirm in randomized controlled trials.
Intra-Articular Calcaneus Osteoid Osteoma With an Ankle Varus and a Red-Brown Synovial Fluid in the Affected Joint, a Case Report
Authors: Ngo Dat Quoc , Cao Thi
Published: December 2023

Background:

Only one article described ankle varus as a typical symptom in the late stage of the intra-articular osteoid osteoma of the calcaneus. And the red-brown color of synovial fluid in the affected joint hasn’t been reported. This report shows a patient with intra-articular osteoid osteoma of the calcaneus who had the 2 above symptoms.

Case presentation:

A 39-year-old man had left ankle pain and the diagnosis was delayed for 20 months. At the late stage, the ankle was gradually varus. In our hospital, the withdrawal of the subtalar joint gave a red-brown synovial fluid. Together with the typical lesion on MRI, the diagnosis of intra-articular osteoid osteoma of the calcaneus was made. An open operation was performed for treatment. In the procedure, the red-brown synovial fluid was exuded. A specimen was harvested for biopsy confirming osteoid osteoma.

Conclusions:

It is still essential that intra-articular calcaneal osteoid osteoma should be considered in patients with prolonged pain and varus of the ankle. The red-brown synovial may be used as a finding for diagnosis.
Healthcare professionals’ perceived barriers in providing palliative care in primary care and nursing homes: a survey study
Authors: Kochems Katrin , de Graaf Everlien , Hesselmann Ginette M. , Ausems Marieke J. E. , Teunissen Saskia C. C. M.
Published: December 2023

Background:

Palliative care in primary care and nursing home settings is becoming increasingly important. A multidimensional palliative care approach, provided by a multiprofessional team, is essential to meeting patients’ and relatives’ values, wishes, and needs. Factors that hamper the provision of palliative care in this context have not yet been fully explored.

Objectives:

To identify the barriers to providing palliative care for patients at home or in nursing homes as perceived by healthcare professionals.

Design:

Cross-sectional survey study.

Methods:

A convenience sample of nurses, doctors, chaplains, and rehabilitation therapists working in primary care and at nursing homes in the Netherlands is used. The primary outcome is barriers, defined as statements with ⩾20% negative response. The survey contained 56 statements on palliative reasoning, communication, and multiprofessional collaboration. Data were analyzed using descriptive statistics.

Results:

In total, 249 healthcare professionals completed the survey (66% completion rate). The main barriers identified in the provision of palliative care were the use of measurement tools (43%), consultation of an expert (31%), estimation of life expectancy (29%), and documentation in the electronic health record (21% and 37%). In primary care, mainly organizational barriers were identified, whereas in nursing homes, most barriers were related to care content. Chaplains and rehabilitation therapists perceived the most barriers.

Conclusion:

In primary care and nursing homes, there are barriers to the provision of palliative care. The provision of palliative care depends on the identification of patients with palliative care needs and is influenced by individual healthcare professionals, possibilities for consultation, and the electronic health record. An unambiguous and systematic approach within the multiprofessional team is needed, which should be patient-driven and tailored to the setting.
Practitioners’ experiences with 2021 amendments to Canada’s medical assistance in dying law: a qualitative analysis
Authors: Close Eliana , Downie Jocelyn , White Ben P.
Published: December 2023

Background:

In 2016, Canada joined the growing number of jurisdictions to legalize medical assistance in dying (MAiD), when the Supreme Court of Canada’s decision in Carter v Canada took effect and the Canadian Parliament passed Bill C-14. Five years later, Bill C-7 introduced several significant amendments. These included removing the ‘reasonably foreseeable natural death’ requirement (an aspect that was widely debated) and introducing the final consent waiver. Since Bill C-7 is so new, very little research has investigated its operation in practice.

Objectives:

This study investigates the experiences of MAiD assessors and providers regarding the Bill C-7 amendments. It explores implications for understanding and improving regulatory reform and implementation.

Design:

Qualitative thematic analysis of semi-structured interviews.

Methods:

In all, 32 MAiD assessors and providers (25 physicians and 7 nurse practitioners) from British Columbia ( n = 10), Ontario ( n = 15) and Nova Scotia ( n = 7) were interviewed.

Results:

The analysis resulted in five themes: (1) removing barriers to MAiD access; (2) navigating regulatory and systems recalibration; (3) recognizing workload burdens; (4) determining individual ethical boundaries of practice and (5) grappling with ethical tensions arising from broader health system challenges.

Conclusion:

This is one of the first studies to investigate physicians’ and nurse practitioners’ experiences of the impact of Bill C-7 after the legislation was passed. Bill C-7 addressed key problems under Bill C-14, including the two witnesses requirement and the 10-day waiting period. However, it also introduced new complexities as practitioners decided how to approach cases involving a non-reasonably foreseeable natural death (and contemplated the advent of MAiD for persons with a mental disorder as a sole underlying condition). This study highlights the importance of involving practitioners in advance of legislative changes. It also emphasizes how the regulation of MAiD involves a range of organizations, which requires strong leadership and coordination from the government.
A narrative review of illegal online pharmacies and contemporary issues with restricting FDA-approved medication access
Authors: Jillani Zarnab , Reinhard Lauren , Hertig John
Published: December 2023

The rapid growth of technology has transformed the way the public purchases many products, including medications. Online medication purchasing has become a convenient and confidential route for patients to access healthcare without leaving their homes. Online pharmacies have many benefits but also present an increased risk for patient harm caused by unintentionally purchasing from illegal online pharmacies. Illegal online pharmacies are those that operate online without the requisite valid licenses or supply drugs not approved by the Food and Drug Administration (FDA). As obtaining certain medications has become restricted, either due to policy or drug shortages, more patients are relying on services provided by Internet pharmacies. The overturning of Roe versus Wade has caused an emerging drug restriction that may coerce the public to turn to Internet pharmacies for purchasing medications. A narrative review was conducted to analyze both the past and present effects of medications sold by illegal online pharmacies to help recognize the implications of restricting access to FDA-approved medications. Several large science and health literature databases were searched to find relevant references. Resulting resources, which referenced the connection between restricting access to FDA-approved medications and the increase in illegal online sales, were included in this review. The information evaluated in this article will help inform healthcare providers and policymakers of the inadvertent effects of restricting access to FDA-approved medications.
How I treat myeloproliferative neoplasms in pregnancy
Authors: Robinson Susan , Ragheb Monica , Harrison Claire
Published: December 2023

Although myeloproliferative neoplasms (MPNs) are traditionally considered diseases of adults in their sixth or seventh decade, these conditions do occur in young patients; for example, for essential thrombocythemia, in particular, there is a second peak in women of reproductive age. Therefore, pregnancy is an uncommon but not rare occurrence and clinical challenge in some scenarios. Here, we discuss in detail our local approach to the management of pregnancy in patients with MPN while taking a case-based approach. We include relevant updates in the field and point to a future research strategy that should be internationally focused to obtain as much information in as short a time as possible.
A 14-year-old male patient with diagnosis of Prader–Willi syndrome in Ethiopia: a case report
Authors: Belay Kibret Enyew , Ayalew Beza Leulseged , Amogne Melaku Taye , Alemneh Theodros Aberra , Geletew Tedla Kebede
Published: December 2023

Background

Prader–Willi syndrome is a complex multisystem disorder due to the absent expression of paternally active genes in the Prader–Willi syndrome-critical region on chromosome 15 (15q11.2-q13). The main clinical features are hyperphagia (which frequently results in early-onset obesity), hypogonadism, developmental delays, typical behaviors (such as obsessive–compulsive tendencies, tantrums, perseveration, insistence on sameness, and rigidity), and distinctive facial features. In infants, the most prominent findings are hypotonia and feeding difficulties.

Case presentation

This paper highlights a case of a 14 year old male patient of an Ethiopian ethnicity with diagnosis of Prader–Willi syndrome, which is first report in Ethiopia. He presented with progressive excessive weight gain, insatiable appetite, clinical and laboratory features of hypogonadism, ophthalmological refractory error, and facial features of Prader–Willi syndrome, which was further confirmed by genetic analysis. He is currently on lifestyle intervention, testosterone replacement, and treatment for vitamin D deficiency.

Conclusion

Prader–Willi syndrome should be considered in a child who presents with progressive weight gain and other typical clinical features such as cognitive impairment, excessive insatiable eating, or hypothalamic hypogonadism. Early lifestyle intervention may help to reduce excessive weight gain. To our knowledge, this is the first case reported in Ethiopia.
Plausible reasons for the resurgence of Mpox (formerly Monkeypox): an overview
Authors: Zebardast Arghavan , Latifi Tayebeh , Shafiei-Jandaghi Nazanin-Zahra , Gholami Barzoki Mehdi , Shatizadeh Malekshahi Somayeh
Published: December 2023

Poxviruses are large and diversified viruses that cause an emerging zoonotic disease known as monkeypox (mpox). In the past, mpox predominated primarily in the rural rainforests of Central and West Africa. Recently, the exportation of mpoxv from Africa to other continents has been progressively reported. However, the lack of travel history to Africa in most of the currently reported cases in 2022 promotes the sign of changing epidemiology of this disease. Concerns over the geographic distribution and continued resurgence of mpox is growing. In this review, we addressed the geographic distribution, transmission, reasons for the resurgence of mpox, and vaccination. Although the precise cause of the resurgence in mpox cases is mostly unknown, several suggested factors are believed to be waning immunity, accumulation of unvaccinated people, ecological conditions, risk behaviors of men who have sex with men, and genetic evolution.