bluuebunny/crossref_metadata_2025 huggingface dataset:
Entry Point Safe Zone for Anteroposterior Screws in Posterior Malleolus Fracture Fixation: A Cadaver Study
Authors: McKissack Haley , Yu Jonathan , He Jun Kit , Montgomery Tyler , Moraes Leonardo , Dahlgren Nicholas , Shah Ashish
Published: October 2019

Category:

Ankle, Basic Sciences/Biologics, Trauma

Introduction/Purpose:

Percutaneous anterior-posterior (AP) screw is an option for posterior malleolus fracture fixation when the fracture fragment can be reduced indirectly by the means of ligamentotaxis. However, anterior anatomic structures could be injured during screw placement. We assessed this risk in cadavers.

Methods:

Eleven below-knee cadavers were employed for the placement of AP screws in an attempt of fixing assumed Haraguchi Type-I posterior malleolar fractures. Three entry point, medial, middle, and lateral, were selected as medial to the tendon of tibialis anterior (TAT), lateral to the TAT, and lateral to the extensor digitorum longus (EDL). On each cadaver, three AP screws were placed under the guidance of fluoroscopy. After dissection, measurements were made (mm) from each screw to nearby structures. Mean, minimum, maximum distances, and 95% confidence intervals were calculated. Instances of damage to the structures were recorded.

Results:

Mean, minimum, and maximum distances from the medial screw to the saphenous vein, TA, EHL, anterior tibial artery (ATA), and deep peroneal nerve (DPN), were 18.1 (12-25) mm, 2.0 (0-5) mm, 13.6 (9-20) mm, 16.6 (9-25) mm, and 20.1 (12-27) mm. From the middle screw to the ATA, DPN, TA, EHL, and EDL, were 1.2 (0-3) mm, 4.9 (3-9) mm, 3.8 (1-7) mm, 0.4 (0-2) mm, and 13.6 (10-18) mm. From the lateral screw to the superficial peroneal nerve (SPN), EDL, DPN, and ATA, were 10.8 (0-16) mm, 1.2 (0-4) mm, 15.9 (11-25) mm, 19 (15-27) mm. The SPN was found partially cut by the lateral screw on 1 specimen. The middle screws were adjacent to the ATA and DPN without damaging to them.

Conclusion:

Lateral and middle percutaneous AP screw placement put certain anatomic structures at-risk of injury. Medial screw placement did not result in appreciable damage to adjacent structures. Entry point of AP screws should be selected with respect to posterior malleolar fracture and anatomic structures. Meticulous dissection should be performed when placing anteroposterior screws.
Masquelet Technique for Hindfoot Fusion of Gustilo IIIA Open Ankle Dislocation with Complete Talar Extrusion and Loss
Authors: Miskiel Sandra A. , Caruso Steven A. , Pagliaro Andre J.
Published: October 2019

Category:

Hindfoot, Trauma, Ankle

Introduction/Purpose:

Complete talar extrusion is a rare injury resulting from high-energy trauma, with dissociation of the talus from surrounding bony and soft-tissue structures. Complications after complete talar extrusion include infection, osteonecrosis, posttraumatic osteoarthritis, and leg-length discrepancy. There is a lack of consensus on the optimal treatment algorithm for complete talar extrusion, due in part to high complication rates associated with injury and treatment. Thus, we report a staged treatment method utilizing the Masquelet Technique with temporary cement spacer, followed by bone grafting with use of femoral shaft autograft and bulk cancellous allograft.

Methods:

44-year-old male status post high-speed motorcycle collision presented with left ankle Gustilo IIIC open fracture dislocation with complete talar extrusion and loss, concomitant ipsilateral tibial plateau fracture and metatarsal shaft fractures. Twelve weeks post-injury, after multiple staged debridements, external fixation and extensive wound vac treatments, removal of the left leg multi-planar external fixator was performed with left distal tibial, fibular, navicular and calcaneal articular and subchondral bone debridement in preparation for Masquelet procedure and pantalar fusion. Open reduction and realignment of left ankle and foot with intramedullary fixation with hindfoot fusion nail was performed, with placement of antibiotic cement spacer for development of secondary reactive periosteal membrane. After nine weeks, intramedullary bone reaming aspiration tool was utilized for removal of left femur intramedullary bone marrow for autograft. Hindfoot pantalar fusion was performed using ipsilateral femoral shaft autograft and bulk cancellous allograft in place of antibiotic spacer.

Results:

Patient went on successfully to fusion and had one transfixation screw removed during the course of his recovery. Patient was also treated using a long leg ankle foot orthosis brace as a stress shielding device during heavy labor. Patient returned back to work and heavy labor as a landscaper and has had no residual pain. At 24 months postoperative, patient achieved an AOFAS ankle-hindfoot score of 83/100 (good).

Conclusion:

To our knowledge, this is the first case of complete talar extrusion treated with a Masquelet procedure with ipsilateral femoral shaft autograft and bulk cancellous allograft. While chronic pain is reported in as many as 75% of patients post- complete talar extrusion, and infection rates as high as 88%, our patient reports no residual pain and did not experience a postoperative infection. This technique represents a reasonable approach and warrants consideration for the treatment of this rare, complex injury.
Anti-Gravity Simulated Weight Reduction: A Pilot Study to Assess the Impact Upon Pain for Foot and Ankle Arthritis
Authors: Morley William , Dawe Edward , Boyd Robert , Creasey James , Grice John , Marsland Daniel , Taylor Heath
Published: October 2019

Category:

Ankle, Ankle Arthritis, Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

Osteoarthritis in the foot and ankle affects approximately 30,000 patients annually in the UK. Evidence has shown that excess weight exacerbates foot pain, with significant increases in joint forces. However, despite the current UK trend for Clinical Commissioning Groups to ration surgery for obese patients, studies have not yet determined the effect of weight loss in obese patients with foot and ankle arthritis.

Methods:

Following ethical approval, a prospective study of 19 obese patients (mean BMI 39.2, range 31.2 – 50.3) with foot and ankle arthritis was undertaken with funding from BOFAS. Under physiotherapist supervision, patients walked for one minute on an anti-gravity treadmill, which allowed simulated weight reduction. Following baseline assessment, reduced BMI was simulated, starting at 20, rising in increments of 5, until each patient’s usual BMI was reached. Pain was assessed using a Visual Analogue Scale (VAS). Repeated measures ANOVA was used to assess for significant changes in pain, comparing baseline with each simulated BMI category (significance set at p<0.05).

Results:

Simulated weight loss to BMI 25 caused a significant reduction in pain (p<0.05, power 0.91). Mean VAS pain scores improved by 46% (22.8 points, p=0.002) and 32% (15.9 points, p=0.04) for BMI categories 20 and 25 respectively, compared with baseline. Pain scores were not significantly different comparing between BMI categories of 25 and 20.

Conclusion:

Simulated weight loss to normal BMI significantly decreased pain in obese patients with foot and ankle arthritis. The use of the anti-gravity treadmill to demonstrate the feeling of normal BMI has also provided motivation to several patients to lose weight. The current study could be used to power future studies to investigate the effects of weight loss in foot and ankle patients.
Treatment of Avulsion Fractures of the Base of the Fifth Metatarsal with Walking Boot and Hard-Soled Shoes: A Comparative Study
Authors: Nishikawa Danilo Ryuko Cândido , Duarte Fernando Aires , Saito Guilherme Honda , Monteiro Augusto César , de Cesar Netto Cesar , Prado Marcelo Pires
Published: October 2019

Category:

Midfoot/Forefoot, Trauma

Introduction/Purpose:

Acute avulsion fractures of the base of the fifth metatarsal are common and usually treated non- surgically with satisfactory outcomes. Forms of conservative treatments are described such as elasticated bandaging, immobilization in a cast, walking boot and hard-soled-shoes. The aim of this study was to compare the clinical and functional outcomes, time to return to the previous activities, time and rate of fracture healing of the patients with avulsion fracture of the base of the fifth metatarsal treated in a hard-soled-shoes (HSS) or in a walking boot (WB). Our null hypothesis is that a less rigid immobilization without restriction of the ankle yields the same final results.

Methods:

A retrospective and comparative study of 72 patients with acute avulsion fractures of the base of the fifth metatarsal treated with the WB or the HSS, from March 2014 to November 2018. The average age of the patients was 41,25 (range, 11-88) and there were 56 female and 16, male. 39 were treated with the WB and 33, with the HSS. Patients with comorbities that could interfere in the rate and time of bony healing (diabetes and inflammatory joint disease), associated ankle ligament lesions and loss of follow-up were excluded. Patients were followed regularly until they were clinically asymptomatic and able to return to their previous activities (work, daily activities, sports). We retrospectively reviewed medical records containing the visual analogue scale (VAS) for pain and the american orthopaedic foot and ankle society (AOFAS) score of each visit as well as radiographic exams to evaluate time and rate of fracture healing.

Results:

Patients of both groups had similar VAS and AOFAS scores in 8 (p=0,34 and p=0,83) and 12 (p=0,25 and p=0,79) weeks. Age and gender distribution in the two groups were equal (p=0,23 and p=0,34, respectively). Time taken to return to the previous activities were not significant different between both groups, with the HSS group taking 8,33 weeks and the WB taking 9,73 weeks (p=0,10). The mean time for bone consolidation was significant higher in the HSS group, taking 8,64 weeks while in the WB took 7,18 weeks (p<0,001). Only 1 case of non-union was observed in the WB group and none in the HSS group.

Conclusion:

Our study concluded that avulsion fractures of the base of the fifth metatarsal can be treated equally with the HSS or the WB. Both types of immobilization showed to be equivalent in terms of clinical and function evaluation, return to the previous activities without difference in the rate of the fracture consolidation.
Age Is a Risk Factor for Contralateral Tendon Rupture in Patients with Acute Achilles Tendon Rupture
Authors: Park Young Hwan , Kim Jae Young , Choi Gi Won , Kim Hak Jun
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Rupture of the contralateral Achilles tendon following Achilles tendon rupture can lead to devastating outcomes. However, despite the clinical importance, the risk factors and incidence of contralateral Achilles tendon rupture have not been well-studied. This study aimed to determine the incidence of contralateral tendon rupture after Achilles tendon rupture and to identify associated patient characteristics.

Methods:

Medical records for 226 consecutive patients with Achilles tendon rupture were retrospectively reviewed. The occurrence of contralateral Achilles tendon rupture and patient characteristics were determined through review of medical records and telephone surveys.

Results:

The cumulative incidences of contralateral Achilles tendon rupture at one, three, five, and seven years after Achilles tendon rupture were 0.4%, 1.8%, 3.4%, and 5.1%, respectively. The only statistically significant risk factor was age between 30 and 39 years at the time of initial Achilles tendon rupture (hazard ratio = 4.9).

Conclusion:

Patients who sustain Achilles tendon rupture in their 30 s have significantly increased risk for contralateral tendon rupture.
An MRI Analysis of the Site of Acute Achilles Tendon Rupture: Is the Most Common Site 2–6 Cm from the Calcaneal Insertion?
Authors: Park Young Hwan , Chang An Seong , Choi Gi Won , Kim Hak Jun
Published: October 2019

Category:

Sports, Ankle

Introduction/Purpose:

No previous study has performed a quantitative analysis of the site of acute Achilles tendon rupture. The purpose of this study was to investigate the site of acute Achilles tendon rupture via magnetic resonance imaging (MRI).

Methods:

The medical records and MRIs of 201 patients with acute Achilles tendon rupture were retrospectively reviewed. The rupture site was measured as the distance from the calcaneal insertion of the Achilles tendon to the proximal end of the distal stump. The relationship between the site of the rupture and patient demographics was analyzed, and the intra- and interobserver reliability scores of the measurements were assessed using intraclass correlation coefficients.

Results:

The rupture site had a mean size of 6.1 cm with a standard deviation of 1.6. The median was 6.3 cm, and the range of the 10th–90th percentile was 5.0–8.1 cm. There was no significant difference in rupture site according to patient demographics. All of the intra- and interobserver reliability scores of the measurements of the rupture site were excellent.

Conclusion:

Most acute Achilles tendon ruptures that were visible on MRI occurred 5–8 cm above the calcaneal insertion, which is greater than the previously reported 2–6 cm location.
Understanding “Recovery” Following Ankle Reconstruction: A Qualitative Study
Authors: Pinsker Ellie , Gignac Monique A.M. , Sale Joanna E.M. , Daniels Timothy R. , Beaton Dorcas E.
Published: October 2019

Category:

Ankle, Ankle Arthritis, Outcomes research

Introduction/Purpose:

Patients’ perception of a good outcome (‘feeling recovered’) is not fully understood. A clear understanding of the benefits and harm of a surgery is necessary for clinical decision-making. Qualitative work exploring the nature of patient recovery would improve our ability to understand and measure these outcomes. The purpose of the study is to examine patients’ perceptions of post-surgical outcome following ankle reconstruction for treatment of end-stage ankle arthritis.

Methods:

Twenty-five English-speaking individuals were asked to participate following a routine clinic visit. They were recruited from an existing cohort of persons who had undergone total ankle replacement or ankle fusion at least one year prior. A qualitative researcher conducted semi-structured, face-to-face interviews with participants in a private hospital room.

Results:

Twenty-five adults (12 women, 13 men) ages 25–82 years were interviewed for 1-2 hours. Participants varied in their socioeconomic status and education levels. Patients did not view their recovery simply as physiological change. Most participants reported ongoing challenges or difficulties, yet considered themselves better. Participants described a broader concept of recovery with multiple contributing factors, including appraisal of the importance of ongoing issues and coping efforts. When participants experienced ongoing difficulty with valued activities, they gained a sense of recovery using coping efforts. Many ‘readjusted’ behaviorally to continue with their valued goals and activity preferences. Others cognitively redefined their goals or preferences to accommodate their ongoing issues. Participants who could not cope with their difficulties or disliked their coping effort perceived their recovery negatively.

Conclusion:

Perception of recovery and experience of outcome rarely involved resolution of all symptoms and functional limitations. The manner in which patients described their recovery was typically more nuanced than a simple change in magnitude of symptoms or functional limitations. This research expands our understanding of the experience of ankle reconstruction and draws attention to different meanings of recovery that has implications for outcome evaluation and measurement. Improved measures for evaluating the recovery outcome states will enable clinicians to identify facilitators and barriers to recovery.
MALDI-TOF Analysis of K-wire Biofilms: A Pilot Study
Authors: Rex James , Durante Elizabeth , Barcel Anthony , Gross Christopher
Published: October 2019

Category:

Basic Sciences/Biologics

Introduction/Purpose:

In orthopedic foot and ankle surgery, temporary fixation utilizing percutaneous Kirschner wires (K- wires) is required for a variety of procedures. Reported infection rates at the pin site are highly variable, and may be as high as 20%. Currently, there is a paucity of literature regarding the microbiology of K-wires used in foot and ankle surgery, as most wires are typically disposed of once removed. The purpose of this pilot study was to determine the specific pathogens which take advantage of K-wires, in order to further elucidate the etiology of pin tract infection, as well as inform antibiotic prophylaxis decisions with wire fixation.

Methods:

In this study K-wires were removed from patients in a sterile environment, and divided into external and internal segments. Each segment was cultured separately, and the dominant pathogen was isolated in a subculture. Matrix Assisted Laser Desorption/Ionization-Time of Flight (MALDI-TOF) was employed for analysis, allowing for speciation of the dominant pathogen growing on the wire. Results from internal and external samples were then compared.

Results:

At this time a total of 10 samples have been analyzed: internal and external segments from 5 individual wires. Biofilm growth was exhibited on 60% of both the external (3/5) and internal samples (3/5). In one sample, growth occurred in the internal segment only, while the external segment was found to be sterile. Of the 5 wires tested, only one was found to be sterile (20%). All cultures were identified as Staph. Epidermidis by MALDI-TOF analysis.

Conclusion:

More attention should be given to microbial growth on these wires, especially in patients predisposed to infection. It is concerning that S. Epidermidis, with its propensity to form biofilms, was the dominant pathogen on our samples, especially internally. We are currently collecting further samples in order to determine which other pathogens may be taking advantage of K-wires, such that more informed decisions about antibiotic prophylaxis can be made, and to elucidate further the etiology of pin tract infections, etiology of pin tract infections.
EFAS Score – Multilingual Development and Validation of a Patient-Reported Outcome Measure (PROM) by the Score Committee of the European Foot and Ankle Society (EFAS)
Authors: Richter Martinus , Agren Per-Henrik , Besse Jean-Luc , Cöster Maria , Kofoed Hakon , Maffulli Nicola , Rosenbaum Dieter , Steultjens Martijn , Alvarez Fernando , Boszczyk Andrzej , Buedts Kristian , Guelfi Marco , Liszka Henryk , Louwerens Jan-Willem , Repo Jussi P. , Samaila Elena , Stephens Michael , Witteveen Angelique G. H.
Published: October 2019

Category:

Basic Sciences/Biologics

Introduction/Purpose:

A scientifically sound validated foot and ankle specific outcome measure for different European languages is still missing. Indeed, language-specific cross cultural validation in other languages than English is largely absent. Some outcome measures were validated for specific pathologies such as hallux valgus, ankle arthritis or flatfoot. The European Foot and Ankle Society (EFAS) established in 2013 a Score Committee to develop, validate, and publish a new score, the “EFAS Score”, which is not specific for single pathologies for different European languages. The principal aim of this project was to develop and validate the EFAS Score simultaneously for different European languages.

Methods:

The EFAS Score was developed and validated in three stages: 1) item (question) identification, 2) item reduction and scale exploration, 3) confirmatory analyses and responsiveness. The following score specifications were chosen: scale/subscale (Likert 0-4), questionnaire based, outcome measure, patient related outcome measurement. For stage 3, data were collected pre- operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using analyses from classical test theory and item response theory.

Results:

Stage 1 resulted in 31 general and 7 sports related questions. In Stage 2, a 6-item general EFAS Score was constructed using English, German, French and Swedish language data. In Stage 3, internal consistency of the scale was confirmed in seven languages: the original four languages, plus Dutch, Italian and Polish (Cronbach’s Alpha >0.86 in all language versions). Responsiveness was good, with moderate to large effect sizes in all languages, and significant positive association between the EFAS Score and patient-reported improvement. No sound EFAS Sports Score could be constructed.

Conclusion:

The multi-language EFAS Score has been successfully validated for orthopaedic foot and ankle surgery populations incorporating a wide variety of foot and ankle pathologies, including language-specific validation in seven languages so far (English, German, French, Swedish, Dutch, Italian, Polish). Validation for other languages (Danish, Finnish, Norwegian, Portuguese, Spanish, Turkish) is in progress. All validated score versions are freely available at www.efas.co .
Medial Femoral Condyle Periosteal Free Flap: A Novel Technique for the Treatment of Avascular Necrosis of the Talus
Authors: Saad Adam , Jimenez Megan L. , Rogero Ryan , Saad Sherif , Winters Brian S.
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

Avascular necrosis (AVN) of the talus is commonly caused by trauma and often requires surgical management. It is recommended that healthy patients, in pre-collapse stages, undergo joint preservation procedures. Good results have been published in patients in pre-collapse stages who undergo vascularized bone grafting. Although many graft options exist, more recently the medial femoral condyle (MFC) free vascularized graft has been introduced. This graft typically utilizes vascularized corticoperiosteal bone but can be modified to the use of solely periosteum, which theoretically decreases morbidity and operative time. There is limited research on the periosteal-only MFC flap to treat AVN of the talus. We present a case series and surgical technique utilizing a periosteal vascularized pedicle graft to teat AVN of the talus.

Methods:

A surgical technique is presented, in addition to a retrospective review of AVN of the talus of 6 lower extremities. Treatment included talus core decompression along with an ipsilateral medial femoral condyle free vascularized periosteal graft. All patients included were in the pre-collapse stage. Short-term clinical outcome measures of Foot & Ankle Ability Measure- Activities of Daily Living (FAAM-ADL) subscale, Short Form-12 (SF-12), and Visual Analog Scale (VAS) for pain were recorded for all patients post-operatively. Paired T-tests were used to compare pre- and post-operative functional scores. Post-operative MRIs were reviewed by a musculoskeletal radiologist.

Results:

The causes of AVN included trauma (2/6, 33%), sepsis (2/6, 33%), and idiopathic (2/6, 33%). Post-operative FAAM-ADL (P=0.004) and VAS (P=0.003) scores showed statistically significant improvement from pre-operative values at an average of 16.0 months (range, 6-28 months) after surgery. Additionally, all patients (100%) reported being “very satisfied” with their surgical outcome. There was 1 minor complication, with one patient reporting minimal paresthesias following surgery. Post-operative MRIs, taken at a mean of 12.7 months, demonstrated both resolution of marrow edema and soft tissue inflammation surrounding the areas of AVN and a lack of AVN progression in 100% of lower extremities, when compared to pre-operative MRIs.

Conclusion:

Medial femoral condyle free vascularized periosteal graft is a complex procedure which requires a team comprised of a foot & ankle surgeon and a plastic/hand surgeon familiar with microvascular surgery. This study shows promising initial results for the treatment of an extremely challenging diagnosis: AVN of the talus. Long-term, prospective studies are needed to confirm the findings presented in the current study.
Isolated Fibular Stress Fractures: Demographic and Radiographic Factors
Authors: Sarpong Nana O. , Levitsky Matthew , Held Michael , Greisberg Justin K. , Vosseller J. Turner
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Fibular stress fractures are rare injuries that are incompletely understood in terms of pathogenesis and predisposing factors. While stress fractures all involve relative stress concentration in a finite area leading to local mechanical failure, the risk factors for this injury have not been assessed. Their relative rarity has made understanding of these risk factors difficult. In a retrospective case series, we sought to define demographic and radiographic risk factors for isolated fibular stress fractures.

Methods:

We retrospectively reviewed the records of 13 patients with isolated fibular stress fractures at our institution between January 2010 and November 2018. We collected and analyzed baseline demographic data and radiographic parameters including prior history of fracture, location of stress fracture, bone quality, and heel alignment.

Results:

The cohort consisted of 6 men and 7 women with a mean age of 41.8 years at the time of diagnosis of the fibular stress fracture. The average BMI in the cohort was 28.5 kg/m2. The location of the stress fracture was in the distal third of the fibula in 69.2% (9/13), proximal third in 23.1% (3/13), and middle third in 7.7% (1/13). There was no evidence of osteopenia on radiographic analysis in any patients, by assessment of the senior author and attending radiologist at our institution. Isolated stress fractures in the distal third of the fibula were observed more commonly in women. Distal fibula stress fractures were associated with physiologic hindfoot valgus, while proximal fractures were seen with a varus hindfoot.

Conclusion:

In this retrospective case series of a rare injury, isolated stress fractures in the distal third of the fibula were the most common fibular stress fracture. Proximal fibular stress fractures were associated with a varus hindfoot. All fractures in this case series healed with immobilization in a walking boot with or without a short period of nonweightbearing.
Surgical Treatments of Talar Osteochondral Lesion: A Long-term Follow-up of Return to Sport and Patient-Reported Outcome Measures
Authors: Schwartz Andrew , Niu Shuo , Mirza Faris , Thomas Ashley , Labib Sameh
Published: October 2019

Category:

Ankle, Arthroscopy, Sports, Trauma

Introduction/Purpose:

Talar osteochondral lesion (TOCL) is a common problem in the young athletic population, mostly related to trauma. TOCL surgical treatment algorithm remains controversial, though results are improving as we gain experience. The results of TOCL surgical treatment on function and return to sport are promising, but quantified return to sport metrics remain largely unknown.

Methods:

A total of 156 consecutive patients following TOCL chondroplasty (10/1/2000-5/31/2018) by a single practice were retrospectively reviewed and included in this study. There were 54.5% female with a mean age 38.2 years, and mean follow-up 40.2 months following the index surgery. Patients were divided into four groups according to the type of chondroplasty performed: Antegrade arthroscopic drilling and/or microfracture (antegrade, 83 patients), retrograde arthroscopic drilling (retrograde, 35 patients), osteochondral autograft transfer (OATS, 26 patients), and allograft cartilage implantation (allograft, 12 patients). VAS scores for pain and function at the final clinic visit were collected. Patient-reported outcome measures including the short form-12 (SF-12), The Foot and Ankle Disability Index Sports Module (FADI-sports), Tegner score, Marx scale, Naal’s Sports inventory are also actively being collected.

Results:

Nearly 75% of patients are satisfied with surgical intervention of TOCLs. Allograft transplant was the least satisfying (71.4%), while OATS was the most satisfying (90%). Each surgical intervention yielded significantly decreased pain and increased function postoperatively (all p<0.001). Currently, 57 patients (36%) provided patient-reported outcome measures, with an average follow up of 79.8 months (Table 1). All surgical interventions trended toward decreased Tegner score, though only antegrade drilling showed a significant decrease (p<0.001). Based on Naal’s sports inventory, 85.7% of surgically treated patients reported participating in sport activities, on average 3 times/week and 50.6 minutes/session.

Conclusion:

Traditionally, TOCLs presented a difficult problem that is marred by unsatisfactory surgical outcomes in typically active patients. As our surgical understanding has evolved, we’ve continued to improve on outcomes. Our patients demonstrated a 74.5% satisfaction rate, a statistically significant improvement in pain and function, and a high rate of return to sport with little difference between surgical interventions at a long-term follow-up.
Lateral Flexor Digitorum Longus Transfer for Peroneal Tendinopathy
Authors: Sherman Thomas I. , Koury Kimberly , Orapin Jakrapong , Schon Lew C.
Published: October 2019

Category:

Sports

Introduction/Purpose:

Flexor digitorum longus (FDL) transfer to the lateral foot for concomitant irreparable rupture of the peroneal tendons has been reported in few clinical series. The purpose of this study is to provide midterm outcomes including subjective outcome scores, clinical examination data, and objective power after single-stage FDL tendon transfer.

Methods:

Twenty-five consecutive patients over a 7 year period (2008-2015) underwent FDL to fifth metatarsal transfer for irreparable peroneal tendon tears. Fifteen patients with a mean follow-up of 53.7 months completed the pain visual analog score (VAS), Foot Function Index (FFI), Short Musculoskeletal Functional Assessment (SMFA), and Foot and Ankle Ability Measure (FAAM) scores and participated in range of motion, peak force, and peak power testing.

Results:

All 15 patients were satisfied with their surgery and reported a reduction in their pain level with the average decrease in VAS of 5.59 +/- 2.5 (range: 1 - 9). The mean FAAM was 86.4 +/- 9.7 (range: 52.4 - 100). The mean FFI was 12.8 +/- 9.2 (range: 0 - 21.4). The mean SMFA Function index was 12.4 +/- 8 and the mean SMFA Bothersome Index was 11.5 +/- 11. Patients had on average 58% less eversion and 28% less inversion compared to the nonoperative side. Both isometric peak torque and isotonic peak velocity were decreased by 38.4% and 28.8%, respectively. On average, power in the operative limb was diminished by 56% compared to the nonoperative limb.

Conclusion:

FDL transfer to the lateral foot for significant, non-reconstructable peroneal tendinopathy is an effective, and durable treatment option.
Arthroscopic Debridement and Micronized Adipose Tissue Injection for End-Stage Ankle Arthritis
Authors: Shimozono Yoshiharu , Kennedy John G.
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Joint arthritis is one of the leading musculoskeletal disorders in the adult population. The surgical treatment for end-stage ankle arthritis generally includes arthrodesis, distraction arthroplasty and total replacement. Recently, new therapeutic approaches, including the use of biologics, have been developed. Among the many sources, the adipose tissue is considered a greater chondrogenic potential and thus a lot of attention is being placed on it in the treatment of arthritis. Although several studies reported good clinical outcomes of adipose-based therapies for knee arthritis, there is a paucity of studies reporting the effects of adipose-based therapies for ankle arthritis. The purpose of this study is to evaluate the effect of intra- articular injection of autologous micronized adipose tissue in patients with end-stage ankle arthritis.

Methods:

A retrospective cohort study investigating consecutive patients treated with arthroscopic debridement and micronized adipose tissue injection for end-stage ankle arthritis was performed. Micronized adipose tissue was obtained from abdomen using a minimal manipulation technique in a closed system (Lipogems) without the addition of enzymes or any other additives. Clinical outcomes were evaluated using the Foot and Ankle Outcome Scores (FAOS), Short-Form 12 (SF-12), and visual analog scale (VAS) scores preoperatively and at final follow-up.

Results:

Total of 12 patients were included. The mean age was 57.5 years and mean follow-up time was 13.1 months. Mean symptoms, pain, daily activities and quality of life scores in FAOS significantly improved from 44.5, 41.3, 58.9, and 20.6 preoperatively to 76.2, 70.1, 80.9, and 60.7 postoperatively, respectively at final follow-up (p<0.001). The mean SF-12 and VAS score significantly improved (33.8 to 63.4, 7.2 to 2.9, respectively, p<0.001). One patient did not receive any benefits. In 4 patients, although they had symptomatic relief in early stage, FAOS and VAS scores deteriorated to baseline by 6 months after procedure. Total 4 patients were not satisfied with the procedures. No adverse events or relevant complications were reported.

Conclusion:

The current study demonstrates that arthroscopic debridement and micronized adipose tissue injection is a safe and beneficial procedure in the treatment of end-stage ankle arthritis. However, in 4 of 12 patients in this small cohort, the deterioration of clinical outcomes to the baseline was observed by 6 months after procedures. All of these patients had mechanical malalignment of hindfoot, suggesting that mechanical alignment may be one of the prognostic factors of this procedure. Further studies investigating longer-term effects in larger cohort should be warranted to confirm the benefit of micronized adipose tissue injection for end-stage ankle arthritis.
Arthroscopic Repair of Lateral Ankle Ligament for Chronic Lateral Ankle Instability: A Systematic Review and Meta-Analysis
Authors: Shimozono Yoshiharu , Brown Alexandra J , Hurley Eoghan T , Kennedy John G
Published: October 2019

Category:

Ankle, Arthroscopy, Sports

Introduction/Purpose:

Open modified Broström-Gould procedure is generally accepted as the gold-standard treatment for chronic lateral ankle instability. Recently an arthroscopic lateral ankle ligament repair technique has become increasingly popular in an effort to reduce post-operative pain and facilitate early recovery. The purpose of the current systematic review was to evaluate the current evidence on arthroscopic lateral ankle ligament repair techniques and to compare the clinical outcomes of arthroscopic and open techniques for chronic lateral ankle instability with meta-analysis.

Methods:

A systematic search of MEDLINE and EMBASE databases was performed during August 2017. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Variable reporting outcome data, clinical outcomes, and percentage of patients who returned to sport at previous level were also evaluated. Comparative studies were compared using RevMan version 5.3, and a p-value of < 0.05 was considered statistically significant.

Results:

Twelve studies for a total of 421 ankles were included; 92% of studies were LOE III or IV and the QOE in all studies was of poor or fair quality. There were three comparative studies of open and arthroscopic repair procedures, with two Level III studies and one Level I study. There was a significant difference in favor of arthroscopic repair at final follow-up for the Karlsson- Peterson score (MD; 2.59, 95%CI, -0.19 to 2.36, I2=0%, p=0.10) and the AOFAS score (MD; 1.50, 95%CI, 0.41 to 2.59, I2=0%, p=0.007) in the comparative studies. The overall complication rate was 13.4% in the included studies but in the comparative studies there was no statistically significant difference between open and arthroscopic repair (12.1% vs 11.4%, p=0.90).

Conclusion:

The current systematic review demonstrated that arthroscopic lateral ankle ligament repair may yield favorable clinical outcomes and may be superior to open procedure in the short-term, but there is no clinical evidence to support the advantages of the arthroscopic procedure over the open procedure in the mid- long-term follow-up. There was a relatively high complication rate associated with the arthroscopic procedures, with a 13.4% complication rate, although recent comparative studies demonstrated similar complication rates.
Mid-Term Outcomes of Bone Marrow Stimulation for Primary Osteochondral Lesions of the Talus: A Systematic Review
Authors: Shimozono Yoshiharu , Toale James , Mulvin Conor , Dahmen Jari , Kerkhoffs Gino MMJ , Kennedy John G
Published: October 2019

Category:

Ankle, Arthroscopy, Sports

Introduction/Purpose:

Arthroscopic bone marrow stimulation (BMS) is the most common reparative surgical intervention in the treatment of small osteochondral lesions of the talus (OLT). BMS has shown favorable short term clinical outcomes but several recent studies have shown less satisfactory results in the mid- to long-term due to fibrocartilagenous repair tissue deterioration over time following BMS. However, conflicting results with good mid- to long-term outcomes following BMS have been reported. There is still a lack of evidence on the success rates of BMS at mid-term and longer-term follow-up. The purpose of this systematic review was to evaluate the clinical evidence of mid- to long-term outcomes following BMS for the treatment of OLT.

Methods:

A systematic search of the MEDLINE, EMBASE and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Methodological quality of evidence was decifered using the Modified Coleman methodology score (MCMS). Studies reporting outcomes of BMS for primary ostechndral lesions at a minimum 4-year follow-up were included. Clinical outcomes, radiological outcomes, and reported data were evaluated.

Results:

Fifteen studies containing 853 patients (858 ankles) were included at a weighted-mean follow-up time of 71.9 (48-141) months. The mean age was 35.3 (24.7-41.9) and the mean lesion size was 110.5mm2 (87-140). Nine studies (60%) used the AOFAS ankle hindfoot score with a weighted-mean postoperative score of 89.9 (78.4-91.8). Six studies showed both pre and post-operative AOFAS scores and showed a weighted-mean improvement of 24.5 (16-38.5). Four studies utilised the VAS score. The weighted-mean postoperative VAS scores were 2.4 (1.8-2.6). Three studies (20%) measured post-opeartive MRI at mid-term using the MOCART score and showed 48% complete filling, 74% complete integration, 76% surface damage, and 78% inhomogeneous repair tissue. Complication rate was 3.2% and reoperation rate was 6% following BMS at mid-term.

Conclusion:

This systematic review found good clinical outcomes following BMS for primary OLT at mid-term follow-up based on the AOFAS score. The complication rates were relatively low and the data showed a reoperation rate of 6% at mid-term. However, the radiological and MRI outcomes did not show similarly positive results, which may lead to recurrence and reoperation at long-term. Data were variable and numerous aspects largely under-reported in the literature relevant to the systematic review. Further high quality studies, a validated outcome scoring system and further MRI reports are required to accurately assess the success of BMS at mid-term.
Risk Factors for Periprosthetic Joint Infection Following Total Ankle Replacement
Authors: Smyth Niall A. , Kennedy John G. , Schon Lew C. , Parvizi Javad , Aiyer Amiethab A.
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

A major complication of total ankle replacement (TAR) is a periprosthetic joint infection (PJI). The reported rate of this complication ranges between 2.4 – 8.9%. Identifying preoperative patient characteristics that correlate with an increased risk of PJI is of great interest to orthopaedic surgeons, as this may assist with appropriate patient selection. The purpose of this study is to systematically review the literature to identify risk factors that are associated with PJI following TAR.

Methods:

Utilizing the terms “(risk factor OR risk OR risks) AND (infection OR infected) AND (ankle replacement OR ankle arthroplasty)” we searched the PubMed/MEDLINE electronic databases. Using the PRISMA guidelines, studies were selected for inclusion if they assessed clinical risk factors for developing a PJI following TAR. In addition, the reference lists of included studies were also reviewed and compared to the collected studies to ensure that no pertinent papers were omitted. The quality of the included studies was then assessed using the American Academy of Orthopaedic Surgeons Clinical Practice Guideline and Systematic Review Methodology. Recommendations were made using the overall strength of evidence.

Results:

Eight studies met the inclusion criteria, totaling 12,704 patients who underwent a TAR. A limited strength of recommendation can be made that the following preoperative patient characteristics correlate with an increased risk of PJI following TAR: inflammatory arthritis, prior ankle surgery, age greater than 65 years, body mass index less than 19, peripheral vascular disease, chronic lung disease, hypothyroidism, and low preoperative AOFAS hindfoot scores. There is conflicting evidence in the literature regarding the effect of obesity, tobacco use, diabetes, and duration of surgery.

Conclusion:

Several risk factors were identified as having an association with PJI following TAR. These factors may alert surgeons that a higher rate of PJI is possible. However, because of the low level of evidence of reported studies, only a limited strength of recommendation can be ascribed to regard these as risk factors for PJI at this time.
The Effect of Immobilization Devices on Contact Pressures of the Ankle and Hindfoot
Authors: Smyth Niall A. , Abbasi Pooyan , Netto Cesar de Cesar , Michnick Stuart M. , Casscells Nicholas D. , Parks Brent G. , Schon Lew C.
Published: October 2019

Category:

Ankle, Hindfoot

Introduction/Purpose:

The tall Controlled Ankle Motion (CAM) boot and the short CAM boot are commonly used devices to immobilize the foot and ankle. These devices are preferably used instead of casts and splints as they are easily removed, allowing possible wound examination, personal hygiene, and therapeutic exercises. However, the effect of these devices on joint contact pressures is unknown. The aim of this study is to assess the effect of the tall CAM boot and short CAM boot on contact pressures of the ankle, subtalar, talonavicular, and calcaneocuboid joints. We hypothesize that both the tall CAM boot and short CAM boot will reduce contact pressures of the ankle and hindfoot joints, with the tall CAM boot having the greatest effect.

Methods:

Eight lower extremity cadaver specimens were mounted on a servohydraulic test frame. The specimens were loaded to 700 N at a cyclical frequency of 1 Hz with the posterior tibial, peroneus longus, peroneus brevis, flexor hallucis longus, flexor digitorum longus, and Achilles tendon physiologically tensioned. TekScan (TekScan, Boston, MA) pressure sensors were placed in the ankle, subtalar, talonavicular, and calcaneocuboid joints. In the sagittal plane, the specimens were loaded on a neutral surface, followed by 20o of dorsiflexion. Each specimen served as its own control, with contact pressures measured with no immobilization (control), followed by placement in a short CAM boot and tall CAM boot. In addition, contact pressures in the immobilized limbs were measured at muscle loads both equal to and half of the load applied to the control in order to account for decreased muscle activation during immobilization.

Results:

There was no difference in the average and peak contact pressures of the ankle, subtalar, talonavicular and calcaneocuboid joints when comparing the short CAM boot to no immobilization at equal tendon loads. The tall CAM boot significantly decreased average and peak contact pressures of the ankle, subtalar, and talonavicular joints when compared to no immobilization. The reduction in contact pressures was accentuated when the load applied to the tendons was decreased in accordance with diminished muscle activation during immobilization. Neither immobilization device decreased the contact pressures of the calcaneocuboid joint at equal tendon loads.

Conclusion:

Immobilization in a tall CAM boot decreases contact pressures of the ankle and hindfoot in both a neutral position and in dorsiflexion. A tall CAM boot should be used clinically if the goal of its use is to maximally reduce contact pressures of the ankle and hindfoot.
Adjacent Joint Arthrodesis Risk After First Metatarsophalangeal Joint Arthrodesis: A 10 Year FollowUp Study
Authors: Teoh Kar , Gonzi Gianluca
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Arthrodesis remains the gold standard for end stage symptomatic first metatarsophalangeal (MTP) joint osteoarthritis. Based on several ankle arthrodesis studies, it is well known that adjacent joints are put under more stress leading to secondary osteoarthritis. However, the direct association between first MTPJ arthrodesis and the progression of adjacent joint arthrosis remains unclear. The purpose of this study was to determine the progression of interphalangeal (IPJ) and 1st tarsometarsal joint (1st TMT) degeneration following first MTP joint arthrodesis.

Methods:

All patients treated with first MTP joint arthrodesis from 2003 to 2008 were identified from our regional centre. Data was obtained from our institution’s electronic clinical workstation which included demographic information, radiographs and clinical letters. A telephone survey with a predetermined written script was carried out in patients as we were not able to obtain ethics to perform repeat radiographs.

Results:

A total of 166 first MTPJ arthrodesis were included with at least 10 year follow-up. We excluded patients who have moved out of region. There was a 3:1 female to male ratio, with an average age at time of operation being 63 (27- 83). 25% of the patients reported adjacent joint pain (15% at IPJ, 10% at 1st TMTJ) at final follow up. 3 (1.8%) patients required arthrodesis of adjacent joints (1 at IPJ, 2 at 1st TMTJ).

Conclusion:

This study improves the understanding of biomechanical impact on the foot following 1st MTPJ fusion and is helpful in the consenting process.