bluuebunny/crossref_metadata_2025 huggingface dataset:
Accuracy and Measurement Error of the Medial Clear Space of the Ankle
Authors: Ghorbanhoseini Mohammad , Kwon John Y. , Metitiri Ochuko , Zurakowski David , Nazarian Ara
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Measurement of the medial clear space (MCS) is commonly used to assess deltoid ligament competency and mortise stability when managing ankle fractures. Lacking knowledge of the true anatomic width measured, previous studies have been unable to measure accuracy of measurement. The purpose of this study is to determine MCS measurement error and accuracy and any influencing factors.

Methods:

Using three normal trans-tibial ankle cadaver specimens, deltoid and syndesmotic ligaments were transected and the mortise widened and affixed at a width of 6 mm (specimen #1) and 4 mm (specimen #2). The mortise was left intact in specimen #3. Radiographs were obtained of each cadaver at varying degrees of rotation. Radiographs were randomized and providers measured the MCS using a standardized technique.

Results:

Lack of accuracy as well as lack of precision in measurement of the medial clear space compared to a known anatomic value was present for all three specimens tested. There was no significant differences in mean delta with regard to level of training for specimens #1 and #2; however, with specimen #3 staff physicians showed increased measurement accuracy as compared to trainees.

Conclusion:

Accuracy and precision of MCS measurements are poor. Provider experience does not appear to influence accuracy and precision of measurements for the displaced mortise. This high degree of measurement error and lack of precision should be considered when deciding treatment options based on MCS measurements.
Calcaneal Fracture Fixation Using a New Interlocking Nail Reduces Complications Compared to Standard Locking Plates
Authors: Herlyn Anica , Mittlmeier Thomas
Published: September 2017

Category:

Hindfoot, Trauma

Introduction/Purpose:

Surgical treatment of displaced intraarticular calcaneal fractures using a standard lateral extended approach for plate fixation is frequently complicated by wound healing complications and infections. This prospective matched- pairs analysis evaluates the new minimally-invasive calcaneal interlocking nailing technique in terms of reduction capacities, complication rates and functional outcome compared to standard locking plate fixation.

Methods:

40 feet (20 feet/group; mean patient age 53 years, range 27-78) with displaced intraarticular calcaneal fractures were either treated with a calcaneal locking nail (LN) or locking plate (LP) and observed clinically and radiologically after 1.6 years. Follow-up included CT-based radiological assessment of reduction and functional evaluation according to the AOFAS Ankle- Hindfoot- Score and Foot Function Index (FFI).

Results:

Time for surgery did not differ between both groups (LN 93 min vs. LP 96 min). Inpatient treatment time was significantly reduced in the LN group (7.6 days vs. LP 11 days). Postoperative and follow-up radiographic imaging revealed adequate restoration of the calcaneal body in both groups. The remaining defect of the posterior facet was significantly smaller in the LN group (0.7 mm vs. LP 1.6 mm). The mean AOFAS Score was slightly better for the LN group with 71.6 points vs. 66.1 points (LP). In analogy, the FFI revealed better results for the LN group (27.3 points) than the LP group (30.8 points). No intraoperative complications but two postoperative infections with wound healing complications were observed in the LP group.

Conclusion:

The new calcaneal interlocking nail shows promising results in terms of reduction capacities and safety. Postoperative infection complications were reduced whilst superior function was found applying the minimum-invasive interlocking nailing technique compared with standard locking plate fixation via a lateral extended approach.
Retrospective Comparative Analysis of Hallux Interphalangeal Joint Fusion Fixation Constructs
Authors: Hyer Christopher , Wakefield Elizabeth , Olson Jessica
Published: September 2017

Category:

Midfoot/Forefoot

Introduction/Purpose:

Arthrodesis is a common treatment for painful, deformed hallux interphalangeal joints (IPJ). To date, the ideal fusion construct for this treatment is unclear; however, intramedullary screw fixation has been proven a viable construct. The goal of this retrospective comparative analysis was to compare use of a single 4.0-mm intramedullary screw versus two 3.0- mm headless intramedullary screws in fusion rate, average time to fusion, and the rate of other clinical outcomes (e.g. infection, nonunion, delayed union, rate of hardware removal).

Methods:

Thirty-nine patients underwent hallux IPJ fusion at our institution from 2008 – 2014 that met all inclusion criteria (18 years or older and had hallux IPJ pathology requiring arthrodesis) and no exclusion criteria (concomitant procedures that would affect postoperative weightbearing course, other forms of fixation, and osteomyelitis). Of the 39 patients, 17.9% (n=7) received one intramedullary 4.0-mm screw and 82.1% (n=32) received two 3.0-mm headless intramedullary screws. Complete clinical chart and radiologic exams were reviewed for each patient to determine clinical and radiographic fusions.

Results:

Overall, 76.9% (n=30) of patients achieved complete radiographic hallux IPJ fusion, 10.3% (n=4) partial fusion and 12.8% nonunion. No statistically significant differences (p<0.05) were observed for complete fusion rate (single: 71.4%; two screws: 78.1%); median time to fusion (single: 36.7 (range: 11.0 – 83.9) weeks; two screws: 13.1 (range: 4.7 – 90.9) weeks); and the rate of other clinical outcomes (hardware removal: 1 (14.3%) from single screw, 6 (18.8%) from two screws; revision hallux IPJ arthrodesis: 1 (14.3%) from single screw, 3 (9.4%) from two screws; and infection: 2 (28.6%) from single screw, 4 (12.5%) from two screws).

Conclusion:

This is the first study to date comparing outcomes between a single and double intramedullary screws for hallux IPJ arthrodesis. Our finding suggests both fixation constructs are comparable in clinical outcome. Surprisingly, hallux IPJ fusion radiographic rates are lower than similar joint fusions; however, revision rates are low suggesting that clinical fusion rates are still acceptable. Future studies could increase power through larger sample size and could explore barriers to better fusion rates.
The Impact of Ankle Arthritis Treatment on Quality Adjusted Life Years
Authors: Hynes Kelly , Wing Kevin , Younger Alastair , Veljkovic Andrea , Penner Murray , Sutherland Jason
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Patients living with end stage ankle arthritis suffer significant disability. They are two standard deviations below population scores for all symptom and function SF-36 sub-scales. In addition, they tend to be younger and still active in the workforce. The economic impact of disability attributable to end0stage ankle arthritis has not been quantified. In the era of cost- effectiveness, policy makers want to see tangible evidence to justify the cost of treatment. One common metric has been quality adjusted life years (QALYs). The purpose of this study is to determine the gain in QALYs attributable to surgical treatment of end- stage arthritis.

Methods:

This study is based on an existing longitudinal cohort of end stage ankle arthritis patients. The study cohort included 180 subjects (45% female, 55% male) with an average age of 61 years, treated with either ankle arthrodesis or arthroplasty. Patients responses to the SF-36 questionnaire were transformed to SF-6D using SF-6D preference based algorithm licensed software (University of Sheffield, UK) to calculate the health utility value at time of surgical consent and at one year postoperatively. The difference in health utility value was assumed to be the gain in health attributable to end-stage ankle arthritis surgery. Using three theoretical valuations per QALY; $20000, $50000, and $100000, based on previously published cost per QUALY for other orthopedic conditions, we calculated the valuation per QALY for treating ankle arthritis at one year post surgery.

Results:

The mean pre-surgical health utility value was 0.603, and post-surgically it was 0.690, an average gain in health in one year of 0.087 QALY. This is greater than what is considered the minimally important difference threshold. We then calculated the economic gain at QALY valuations of $20000, $50000, and $100000; at $20000/QALY the cost per QALY is $1740. At $50000 the gain is $4350 cost per QALY, and at $100000 it is $8700 per QALY.

Conclusion:

From this study cohort, surgically treating end-stage ankle arthritis has a meaningful health benefit for a range of cost per QALYs. Moreover, spending on surgical treatment of end-stage ankle arthritis is cost-effective. These results from this cohort provide valuable empirical insights into treating end-stage ankle arthritis - these findings are meaningful for policy makers faced with resource allocation demands.
Sensory Mapping in Patients Following Excision of a Morton’s Neuroma
Authors: Jan Maryam , Ramaskandhan Jayasree Ramas , Torres Paulo
Published: September 2017

Category:

Lesser Toes, Morton’s neuroma

Introduction/Purpose:

Background: Morton’s neuromata are a common cause of forefoot pain. Surgical excision of the neuroma is expected to result in loss of sensation, however in the author’s experience post-operative sensation can be incongruent with the expected cutaneous innervation of the excised nerve. There is a lack of literature regarding this observed discrepancy. The purpose of this study was to carry out sensory mapping in post excision patients.

Methods:

Methods: Data was collated from the consecutive case series of a single surgeon from 2013-2015 resulting in a total of 19 respondents (23 excisions). All patients were a minimum of 7 months post-excision (average=23 months). Each toe was divided into 13 anatomical segments (total 65). Sensation was assessed using a 10 g monofilament and results were recorded on a sensory map.

Results:

19 excisions were done from the 3 rd intermetatarsal space (group A) and 4 from the 2nd intermetatarsal space (group B). The range of patients from group A affected by complete sensory loss within any individual segment varied from 5.3%-47.4%. In the lesser toes (2, 3, 4 and 5), at least 10% of patients described decreased or absent sensation in =7/13 segments in each of all the lesser toes. Over 36.9% of patients reported decreased or absent sensation involving =7/13 segments in each the 3 rd and 4th toes. The percentage of patients who reported unaltered sensation ranged from 21.1%-100% across all 65 segments. Group B followed a similar pattern but had a much smaller cohort of patients.

Conclusion:

The results of the sensory mapping indicate an unexpected pattern of loss and preservation of sensation when considering the perceived knowledge of the cutaneous innervation of the forefoot. Further research is required to evaluate this intriguing pattern of innervation. A greater understanding would be useful in better informing our patients during the consent process.
Is osteoporosis a risk factor for ankle fracture?
Authors: Jeon Ji Young
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

It is well known that fracture of the ankle is different from the typical osteoporotic fracture. Nevertheless, there remains controversy over osteoporotic feature of the ankle. Therefore, we investigated the possibility of the existence of a relationship between axial bone mineral density (BMD) in patients with ankle fracture with that of the normal population under control of other confounding factors such as body mass index (BMI).

Methods:

This study retrospectively reviewed medical records of patients who were treated in our institution from 2005 to 2015. A comparative analysis was carried out between 115 patients with ankle fracture and 72 patients admitted with other orthopedic reasons (control group). Sex, age, energy level of trauma, and BMI were analyzed as variables affecting axial BMD.

Results:

Patients in ankle fracture group were significantly younger as compared to control group (p=0.041). BMI of ankle fracture group was higher. The other variables showed no differences between the two groups. The energy level of trauma in ankle fracture group was related to only BMI (p=0.01). Only lumbar BMD was correlated with BMI in ankle fracture group (p=0.003).

Conclusion:

Axial BMD of ankle fracture patients showed no difference from that of normal population. The occurrence of ankle fracture is affected by only BMI rather than axial BMD. Moreover, it appears that axial BMD is not always correlated with BMI in non-osteoporotic population.
Association of a Modified Frailty Index with Postoperative Outcomes after Ankle Fractures in Patients Aged 50 Years and Older
Authors: Kadakia Rishin , Bariteau Jason , Vu Catphuong , Pao Andrew , Tenenbaum Shay
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Frailty, a multifaceted syndrome resulting from a decrease in physiologic reserves, has been previously shown to play a significant role in elderly morbidity and mortality. The literature on frailty within orthopaedic surgery is limited currently. No study to date has assessed frailty as a predictor of postoperative outcomes in elderly patients with ankle fractures. We hypothesized that increasing frailty would be associated with increased 30-day reoperation rates and increased postoperative complications.

Methods:

The National Surgical Quality Improvement Project (NSQIP) was queried using the appropriate CPT codes to identify inpatients from 2005-2014 who were aged 50 years and older that sustained an ankle fracture and underwent operative fixation. Frailty was assessed using a modified frailty index (MFI), abbreviated with 11 variables from the Canadian Study of Health and Aging Frailty Index. The primary outcome was 30-day reoperation rate and secondary outcomes were postoperative surgical and medical complications, readmission rates, and length of stay. Bivariate and multivariate analysis was used to determine association between outcomes and MFI.

Results:

6,749 patients were identified, and the mean age of these patients was 64.4 years. Patients with increased MFI scores had significantly higher rates of postoperative complications. In addition, increased MFI scores was also associated with increased 30 day readmissions and reoperations. Multivariate analysis also demonstrated that MFI was a stronger predictor of 30 day reoperation rates (odds ratio of 17.7, P < 0.001) than age, wound class, and ASA class.

Conclusion:

Frailty has the potential to be an important predictive variable of postoperative outcomes in patients aged 50 years and older who sustain ankle fractures. The modified frailty index can be a valuable preoperative risk assessment tool for the orthopaedic surgeon. Further study is necessary to examine the effect of the MFI in a larger prospective setting.
The Effect of Ankle Arthrodesis on the Biomechanical Function of the Foot
Authors: Kozanek Michal , Brodsky James , Kane Justin
Published: September 2017

Category:

Ankle, Ankle Arthritis, Basic Sciences/Biologics, Hindfoot

Introduction/Purpose:

Several studies on the effect on gait of total ankle arthroplasty (TAA) have demonstrated significant functional improvement post-operatively, compared to the patients’ preoperative function. While there are many post-operative studies showing abnormalities of gait in patients who have had ankle arthrodesis, there are very limited published data in ankle fusion which compare post-operative gait to the patients’ own preoperative function. Moreover, there are no published correlation of those gait changes with patient reported outcomes.

Methods:

Twenty-six consecutive ankle arthrodesis patients were prospectively studied, with pre- and post-operative three- dimensional gait analysis. Kinematic data were collected at 100 Hz with a twelve-camera digital Vicon motion capture system, and two OR6-5 AMTI force plates. Patients walked barefoot at a self-selected speed over a 10-meter walkway. A minimum 20 gait cycles were used for averaging and statistical analysis for temporal-spatial and kinematic parameters and a minimum of five force plate readings for kinetic parameters. Gait parameters were collected for both operated and unaffected limbs (i.e. control). Demographic data were compiled. Prospectively collected patient-reported outcomes included SF-36, VAS, AOFAS scores, which were repeated annually postoperatively.

Results:

Mean age was 56 (19 – 80) years, BMI 29.7 (18.6 - 45.6), and follow-up 21.9 (12 - 69) months. There were multiple objective parameters of gait which showed statistically significant functional improvements compared to preoperative performance. Temporal-spatial: Improvements were detected in walking speed, step length and cadence; single and double limb support time. Kinematic parameters: Increase in maximum plantarflexion, decrease in maximum dorsiflexion, but total sagittal range of motion was not diminished, and slightly increased (mean 1.8 degrees). The preservation of total sagittal motion after arthrodesis suggested either precise postoperative compensation by the hindfoot, or that most of the preoperative motion was already occurring in the surrounding hindfoot joints. Kinetic parameters: Improvement in ankle moment and hip power were detected. Patient reported outcomes (table)

Conclusion:

Ankle arthrodesis improves gait in end-stage arthritis, as demonstrated by statistically significant improvements in multiple, objective parameters. Moreover, the increase in sagittal plane motion of the hindfoot, presumed in the literature to be compensatory to the arthrodesis, was shown to be present pre-operatively, as well, suggesting it is also an effect of tibiotalar stiffness due to end-stage arthritis. Improvements in gait corresponded to clinical improvements as well, as demonstrated by improvements in patient reported outcomes in this population. Biomechanical improvements corresponded to clinical outcomes.
Functional Results of Open Reduction and Internal Fixation with Primary Arthrodesis for Injuries to the Tarsometatarsal Joint Complex
Authors: Lannon Sean , Clare Michael
Published: September 2017

Category:

Midfoot/Forefoot, Trauma

Introduction/Purpose:

Controversy remains as to the optimal treatment of injuries to the tarsometatarsal (Lisfranc) joint complex. Recent studies have described open reduction internal fixation (ORIF) with primary arthrodesis as a viable treatment option but there is limited orthopaedic literature as to the functional results of primary arthrodesis for these injuries. The senior author began treating these injuries with primary arthrodesis in 2005. We present the functional results of a consecutive series of patients with injuries to the TMT joint complex treated by ORIF with primary arthrodesis.

Methods:

Sixty-eight consecutive patients underwent ORIF with primary arthrodesis from 2006 to 2015. Seventeen patients were unable to be evaluated or contacted and were therefore lost to follow up, leaving 51 patients available for follow-up evaluation. Clinical follow up and/or telephone interviews was conducted. AOFAS Midfoot scores and Foot and Ankle Ability Measure (FAAM) were collected as a measure of functional outcome at final follow up.

Results:

Sixty-seven of 68 patients (98.5%) went on to radiographic union following the index procedure. Among patients with a low energy mechanism (32 patients), AOFAS and FAAM were 88.7 and 94.0; among those with a high- energy mechanism (19 patients), AOFAS and FAAM were 86.9 and 89. Outcome scores were higher in the low energy group: AOFAS by 2.1(p=0.667); and FAAM by 5.0 (p=0.021). Injury to the lateral midfoot necessitating fixation was less likely in the low energy group compared to the high-energy group (7.5% versus 37.0%; p=0.0032). Eighteen of the 51 patients participated in professional, collegiate or recreational sports preoperatively. All 18 were able to return to their previous sport, with a mean FAAM sports sub scale score of 93.

Conclusion:

ORIF with primary arthrodesis remains a viable treatment for injuries to the tarsometatarsal (Lisfranc) joint complex, with functional results in the good to excellent range at midterm follow up. Patients with low energy mechanisms demonstrated higher functional scores compared to patients with high energy mechanisms, but outcomes remained good to excellent in both groups. Of those who participated in athletics prior to injury, all were able to return to their previous sport.
Radiographic Measurements Associated with the Natural Progression of the Hallux Valgus Deformity during at Least Two Years of Follow-up
Authors: Lee Kyoung Min , Lee Seung Yeol , Ahmed Sonya , Cho Byung Chae , Park Moon Seok , Sung Ki Hyuk , Koo Seungbum , Kim Sung Jin , Choi Hyun
Published: September 2017

Category:

Bunion

Introduction/Purpose:

There have been few longitudinal studies regarding hallux valgus deformity. This retrospective study aimed to investigate the radiographic measurements associated with the progression of hallux valgus deformity during at least two years of follow-up.

Methods:

Seventy adult patients (mean age, 58.0 years; standard deviation [SD], 12.3 years; 13 males and 57 females) with hallux valgus who were followed-up for at least two years and underwent weight-bearing foot radiography were included. Radiographic measurements included the hallux valgus angle (HVA), hallux interphalangeal angle, intermetatarsal angle (IMA), metatarsus adductus angle, distal metatarsal articular angle (DMAA), tibial sesamoid position, anteroposterior (AP) talo-first metatarsal angle, and lateral talo-first metatarsal angle. Progression of hallux valgus deformity was defined as an increase of 5 degrees or more in the HVA during follow-up. Patients were divided into progressive and non-progressive groups. Binary logistic regression analysis was performed to identify factors that significantly affect the progression of hallux valgus deformity. The correlation between change in HVA and changes in other radiographic indices during follow-up was analyzed.

Results:

Eighteen out of 70 patients showed progression of 5 degrees or more in the HVA during the mean follow-up of 47.0 months (SD, 19.8 months). The DMAA (p=0.027) and AP talo-first metatarsal angle (p=0.034) at initial presentation were found to be significant factors affecting the progression of hallux valgus deformity. Change in the HVA during follow-up was significantly correlated with changes in the IMA (r=0.423; p=0.001) and DMAA (r=0.541; p<0.001).

Conclusion:

Special attention needs to be given to patients with pes planovalgus and increased DMAA during follow-up. Change in HVA was significantly correlated with changes in IMA and DMAA. Therefore, progression of hallux valgus deformity is considered to be closely related to the progressive instability of the first tarsometatarsal joint.
Comparison of Clinical Outcomes in Patients with Generalized Ligamentous Laxity and without Generalized Laxity in the Arthroscopic Modified Broström Operation for Chronic Lateral Ankle Instability
Authors: Lee YoungKoo , Yoo Jungwoo , Yun Keon Hee , Park Ji Yong
Published: September 2017

Category:

Sports

Introduction/Purpose:

The arthroscopic modified Broström operation (MBO) has been developed and frequently used to treat chronic lateral ankle instability (CLAI). Clinical outcome of arthroscopic MBO was reported as good or excellent. But there were no report about comparison of clinical outcomes between patients with generalized ligamentous laxity (laxity) and without generalized ligamentous laxity (no laxity). The purpose of this study is to compare the clinical outcomes of the group with generalized ligamentous laxity and without generalized ligamentous laxity in chronic lateral ankle instability.

Methods:

From January 2013 to November 2015, Arthroscopic MBO was performed in 99 patients for CLAI. We retrospectively analyzed 99 consecutive patients were included in terms of inclusion criteria. All patients had giving way, persistent pain and an inability to resume one’s preinjury activity level for more than 6 months. Patients were divided into 2 groups: laxity group (24 ankles) and no laxity group (75 ankles). Evaluation was performed preoperatively and at a final follow-up a minimum of 12 months postoperatively using the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot ankle score, pain Visual Analogue Scale (VAS)(0~100), and talar tilt angle.

Results:

In terms of radiological outcomes, the preoperatively talar tilt angle was greater in patients in laxity group than in no laxity group (p < .001). The last follow-up talar tilt angle was the same between in patients in laxity group and in no laxity group (p=0.413). But preoperative-last follow up difference was found between two groups (p=0.03). The variation from preoperative to last follow up talar tilt angle showed significant greater value in laxity group (-6.9 ± 5.2) than in no laxity group (-4.2 ± 4.2)(p=0.03). In terms of clinical outcome, last follow up AOFAS and VAS in all groups were improved than preoperative scores (27.5 ± 23.7, 24.1 ± 18.4, respectively). But preoperative-last follow up differences were not found between two groups (P=0.52).

Conclusion:

In terms of radiologic outcomes, there was difference outcome variation between two groups, in terms of clinical outcomes, there were no difference outcome variations between two groups. All groups achieved successful clinical and radiological last follow up outcomes even though there was difference outcome variation in talar tilt. Arthroscopic MBO should be considered as a reasonable method in patients who have chronic lateral ankle instability regardless of generalized ligamentous laxity.
The Road to Recovery for Bunion Surgery
Authors: MacDonald Ashlee , Houck Jeff , Baumhauer Judith
Published: September 2017

Category:

Bunion, Midfoot/Forefoot

Introduction/Purpose:

Patient reported outcomes (PROs) can provide information on individual patient’s progress throughout a treatment course and additionally, with common surgeries, powerful numbers can be generated to provide data analytic curves to provide a recovery road map for patients and surgeons. Those who deviate negatively from the predicted path may have a complication and early intervention can be initiated. Those who deviate positively have the potential to need less physical therapy, early return to sports or work. Hallux valgus (HV) is a common condition of the foot with 4.4 million patients seeking care yearly and surgery is equally common. The purpose of this study was to determine if PROMIS PROs can be used to construct data analytic curves for HV surgery.

Methods:

PROMIS scores were prospectively obtained from patients evaluated in a specialty foot and ankle clinic between February 2015 and November 2016. Using ICD-9/10 and CPT codes, a total of 65 patients with hallux valgus who underwent a bunionectomy by a single surgeon were identified. Those with less than two-month follow-up, multiple procedures during the follow-up period, as well as incomplete PROMIS assessment scores at any time point were excluded, resulting in 34 patients. Using a previously described method, bunionectomy-specific pre-operative cut-off values to achieve and fail to achieve minimally clinically important differences (MCID) in PF with 95% specificity and 95% sensitivity were determined. We then stratified patients based on their pre-operative PF T-scores as above or below the MCID cut-off. PF was evaluated using two-way ANOVA at 4 follow-up time periods and pre-operative cut-offs (above or below MCID cut-off) as factors to establish data analytic curves based on pre- operative scores.

Results:

Bunionectomy-specific PF cut-off for 95% specificity of exceeding MCID was 39.6 and 50.2 for 95% sensitivity for failing to achieve MCID. Patients were stratified based on PF T-scores above (n = 13) or below (n = 21) the MCID cut-off of 50.2. Data analytic curves were generated for above the PF cut off and below PF cut off. (Figure 1) Pairwise comparison demonstrated that those starting with a T-score above the bunionectomy specific cut-off had significantly better PF pre-operatively (p < 0.01) and again at 6-12 week follow-up (p = 0.02). There were no differences at 1 week or 3-4 week follow-up time points.

Conclusion:

This data confirms pre-operative PROMIS PF scores are significant post-operative predictors. While patients with pre-operative scores below the bunionectomy-specific cut-off met MCID changes in PF, their T-scores were significantly lower at 6-12wk follow-up than patients with high pre-operative T-scores. Although longer term follow-up is desirable, this short term follow up suggests a significant clinical impact of using PROMIS scores for pre-surgical decisions as well as provides a road map for recovery for patients and surgeons.
Percutaneous proximal oblique osteotomy fixed (ludloff) to the surgical treatment of severe hallux valgus
Authors: Marijuschkin Igor
Published: September 2017

Category:

Bunion

Introduction/Purpose:

to present the clinical and radiographic results of surgical correction of severe hallux valgus using percutaneous proximal oblique osteotomy (Ludloff) fixed with screw.

Methods:

we evaluated prospectively 15 feet in 14 patients with severe hallux valgus considering the hallux valgus angle (HVA) greater than 30 degrees and the intermetatarsal angle (IMA) greater than 17 degrees. The average follow-up was 18 months (12 to 36). Were submitted to percutaneous proximal oblique osteotomy, put a K wire proximal to dislocate the first metatarsal head and fixed the osteotomy with a screw (picture). After we associated this technique with percutaneous Akin procedure, exostectomy and distal soft tissue release. Patients were evaluated by the AOFAS score, followed by radiographic evaluation and by the degree of subjective satisfaction of Johnson.

Results:

we present as a result 15 feet operated on 14 patients being 93% female with an average age of 66.9 years (29 a 78), HVA of 39.7° (30 to 51), IMA of 18.6° (17 to 22) and 43 points of AOFAS, while postoperative the HVA was 18° (8 to 28), IMA 13.8° (7 to 17) and average AOFAS 86.6 points. We have complications in 33% of cases, we had 1 recurrence of deformity in less than 1 year, 1 transference metatarsalgia, 2 withdrawals of synthesis and 1 complaint of dorsal callosity due to probable elevation of 1 metatarsal. No major complications were noted. We present a patient unhappy with the result (recurrence case).

Conclusion:

the surgical technique described proved effective in the treatment of severe valgus halux with improvement of the AOFAS score, high level of patient satisfaction and good radiographic corrections.
Sagittal Alignment in Fixed Bearing Total Ankle Replacements
Authors: Nielsen Natalie , Sanders Austin , Nguyen Joseph , Demetracopoulos Constantine
Published: September 2017

Category:

Ankle Arthritis

Introduction/Purpose:

Placement of the talar component in total ankle replacement (TAR) is technically challenging and malposition can occur. Implant alignment can affect both contact stresses at the articulation of the prosthesis, as well as forces at the bone implant interface, and survivorship of the implant. In mobile bearing implants, postoperative pain relief and functional outcome correlates with sagittal position of the talar component. The purpose of this study is to evaluate the sagittal alignment of the talar component between two fixed bearing total ankle replacements and determine the effect of alignment on patient outcomes.

Methods:

We performed a retrospective review of total ankle replacements at a single institution over a seven-year period. Seventy-one patients who underwent a fixed bearing TAR (Salto Talaris, Integra LifeSciences, and INBONE, Wright Medical) with two year minimum followup were included. Preoperative and one year postoperative radiographs were assessed to determine sagittal alignment of the talar component. The preoperative sagittal alignment was measured as the tibial-axis-to-talus ratio (T-T ratio) and the postoperative sagittal alignment was measured as the A-P offset ratio. Postoperative sagittal alignment was categorized as neutral (A-P offset ratio <0.1, N=39) or anterior (A-P offset ratio >0.1, N=32). Functional outcomes were assessed at 2 years utilizing SF12 scores and the FAOS outcome score, which has been previously validated for ankle arthritis. Differences in sagittal alignment between the two implant types and differences in postoperative outcome scores were assessed using T-tests. Interobserver reliability was assessed using intraclass correlation coefficient.

Results:

Interobserver reliability for the preoperative sagittal alignment using the T-T ratio had very good agreement, while the postoperative A-P offset measurement had only fair/moderate agreement. Preoperatively, there was no difference in the T-T ratio amongst patients receiving a Salto Talaris or INBONE implant. Postoperatively, patients with a Salto Talaris implant have a greater AP offset ratio than patients with an INBONE implant (p <0.01). There was no difference in FAOS or SF12 MCS/PCS scores between postoperative neutral and anterior sagittal alignment groups.

Conclusion:

Preoperative sagittal alignment can be reliably assessed using the T-T offset ratio. The A-P offset ratio is somewhat less reliable as a measure of postoperative sagittal alignment in fixed bearing implants. Patients with INBONE implants had more neutral sagittal alignment postoperatively. Differences in alignment between the two implants may relate to anterior-posterior coverage of the tibial component and the fixed bearing nature of the prostheses. Patient reported outcome scores did not differ between neutral and anterior sagittal alignment groups.
Is Magnetic Resonance Imaging (MRI) Reliable in the Diagnosis of Ankle Instability
Authors: Nurm Triin , Torres Paulo , Ramaskandhan Jayasree Ramas
Published: September 2017

Category:

Ankle, Sports, Trauma

Introduction/Purpose:

MRI is the preferred modality for the diagnosis of ankle joint pathology. The aim of this study was to specifically analyse the reliability of MRI reported lateral ligament findings in relation to examination under anaesthesia and stress X-rays in patients with symptomatic ankle instability.

Methods:

A single centre, single surgeon consecutive series of patients who had undergone examination under anaesthesia and stress X-rays preceded by an MRI scan for symptomatic ankle pathology were included in this retrospective clinical study. All MRI scans were reported by a musculoskeletal radiologist. MRI reports and procedure findings were extracted and analysed.

Results:

Between April 2012 and December 2016, 49 patients who fulfilled the above criteria were included. There were 25 male and 24 female patients, the average age was 43.1. The average time interval between MRI scan and examination under anaesthesia was 9.7 months (2-49 months). There is a significant association between MRI reported lateral ligament findings and status of ankle stability detected on examination under anaesthesia and stress views, p=0.003 (Chi-square analysis for association). In 34 patients who had abnormal lateral ligament findings on MRI, 20 patients (58.8%) had stable findings and 14 (41.2%) had unstable findings on stress views. There was, however, a 100% concordance between MRI reported normal lateral ligament findings and stability on examination under anaesthesia and stress views (N=15).

Conclusion:

MRI is accurate in diagnosing the status of ankle ligaments and in particular, in predicting true stability.
Treatment of 5th Metatarsal Shaft Fracture using MIPO (Minimally Invasive Plate Osteosynthesis) Technique
Authors: Park Yoo Jung , Hwang Yeokgu , Shim Dong-Woo , Lee Jin Woo , Han Seung Hwan
Published: September 2017

Category:

Lesser Toes, Trauma

Introduction/Purpose:

The standard treatment of 5th metatarsal shaft fracture is still not determined yet. Conservative treatment using cast immobilization can be applied for shaft fractures without displacement, but there are reports that open reduction is indicated for displacement more than 3 mm, rotational displacement, and angular displacement more than 30 degrees. In this study, we report the result of 5th metatarsal shaft fracture using MIPO technique, which can shorten recovery period by reducing soft tissue damage with minimal incision.

Methods:

This study consists of 25 patients who had undergone surgery for displaced 5th metatarsal shaft fracture from March 2013 to December 2015; 8 males and 17 females. Mean age at the time of surgery was 47.4(29~69) and mean follow period was 15.0(8~25) months. 11 cases were simple oblique fracture and 14 cases were comminuted fracture with fracture fragments. Mean fracture gap was 4.4(3.1~7.6)mm. MIPO technique with LCP Compact Hand Locking Condylar Plate 2.0(Depuy-Synthes, Zuchwil, Switzerland) was used for all cases. Partial weight bearing was allowed until 4th week post-op, then full weight bearing was allowed until 6th week post-op. Clinical and radiological follow-up was made at post-op week 2, 6, 12, 24. Clinical results were obtained using Visual Analogue Scale(VAS) and American Orthopedic Foot and Ankle Society(AOFAS) score.

Results:

VAS of 24 weeks post-op was decreased from 5.6 ± 0.8 (4~7) preoperatively to 1.2 ± 1.3 (0~4), and AOFAS score of 24 weeks post-op was increased from 42.0 ± 12.8 (24~54) preoperatively to 86.4 ± 7.7 (74~95), both showed significant difference. Anatomic reduction and complete bone union was noted in all cases. Mean union period obtained from follow-up radiograph was 6.0 week post-op. For 15 cases, plate removal was performed at 9.5(7~25) months post-op.

Conclusion:

Plate fixation can be the preferred option for 5th metatarsal shaft fracture, because 5th metatarsal shaft is surgically easily accessible and more stable fixation can be applied. Since it results complete bone union without any complications and enables early weight bearing, MIPO techinque for displaced 5th metatarsal shaft fracture can be considered as useful surgery technique.
The Predictive Value of MRI for Syndesmotic Instability of Ankle Fracture
Authors: Park Young Hwan , Kim Hak-Jun
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Although many ankle fractures are combined with syndesmosis injury, preoperative imaging studies rarely reveal instability of the syndesmosis. This study assessed the use of magnetic resonance imaging (MRI) for syndesmotic instability in patients who have an unstable ankle fracture.

Methods:

A total of 74 patients who were treated for Lauge-Hansen supination external rotation, Weber B type fracture or pronation external rotation, Weber C type fracture and who underwent MRI before surgery to evaluate syndesmosis injury were enrolled. The MRI findings of the syndesmotic ligament and the results of an intraoperative stress test were assessed.

Results:

Twenty-six patients had a positive result on the intraoperative stress test. Regarding the MRI findings of the syndesmotic ligaments, complete tear of the posterior inferior tibiofibular ligament (PITFL) was the most reliable predictor of syndesmotic instability (sensitivity, 0.62; specificity, 0.94; positive predictive value, 0.84). Interobserver agreements for the intraoperative stress test and MRI assessment were excellent, except for the MRI findings of the interosseous ligament (62% agreement; kappa, 0.3).

Conclusion:

On the basis of the study results, complete tear of the PITFL on MRI has additional diagnostic value for syndesmotic instability in ankle fracture.
Evaluation of anatomical structures after calcaneal Evans- or Hintermann osteotomy
Authors: Plaass Christian , Ettinger Sarah , Claassen Leif , Stukenborg-Colsman Christina , Yao Daiwei , Daniilidis Kiriakos
Published: September 2017

Category:

Hindfoot

Introduction/Purpose:

Both Evans- and Hintermann-osteotomies are commonly used for the treatment of flexible pes planovalgus deformity. The aim of this study was to examine, which anatomical structures are affected by the performed osteotomy.

Methods:

Two experienced foot and ankle surgeons performed an Evans- or Hintermann-osteotomy on each of 7 cadaver feet (Science Care, Arizona, USA). There were no defects on the preparations. All cadaver feet were prepared in the same way following predetermined preparation guidelines. All individual anatomical structures were prepared and, in particular, peroneal tendons, nervus suralis as well as articular surfaces evaluated.

Results:

The mean age of the donors was 80.8 years. Eight left and six right feet were prepared. After Hintermann osteotomy there was no damage of the peroneus longus tendon, after evans-osteotomy in one case (14.3%). The peroneus brevis tendon was once totally damaged after Hintermann osteotomy and once partially damaged after evans osteotomy. In one cadaver the suralis nerve was partially damaged after hintermann osteotomy, in no case after evans osteotomy. After Hintermann osteotomy the calcaneal anterior and medial articular surface were 100% and 85.7% intact, whereas after Evans osteotomy only 42.9% and 71.4% were not damaged. The posterior articular surface was affected in no cadaver.

Conclusion:

After both osteotomies anatomical structures can be damaged. Besides biomechanical advantages, with the Hintermann osteotomy the calcaneal anterior and medial articular surface can be protected in a higher percentage than with the Evans osteotomy. Further studies should be performed, if these findings correlate with the clinical outcome.
A Retrospective Review of Risk Factors and Conversion Rate of Transmetatarsal Amputations to Below or Above Knee Amputation
Authors: Sabatini Jefferson , Odum Susan , Ellington J. Kent , Jones Carroll P. , Davis W. Hodges
Published: September 2017

Category:

Diabetes

Introduction/Purpose:

Despite the presence of several studies examining the conversion from transmetatarsal amputation (TMA) to a more proximal amputation, few studies identified the possible predictors of failure. The objective of this study is to examine the rate of conversion of transmetatarsal amputation to below or above knee amputation, and to identify the risk factors for conversion.

Methods:

A retrospective cohort study was performed examining 71 transmetatarsal amputations performed by a single group of foot and ankle subspecialists within a single specialty group between October 1 2005 and August 25 2015. Demographic information and comorbidities were recorded, as were complications, readmission rate, and rate of conversion to a more proximal amputation.

Results:

Of the 71 patients who underwent transmetatarsal amputation during the study period, 74.7% progressed to a revision amputation or more proximal amputation at a mean of 9.7 months, but a median of only 3.2 months. 87.3% progressed to below knee amputation, 9.9% underwent revision transmetatarsal amputation, and 2.8% received an above knee amputation. Of the patients who progressed to more proximal amputation, 88.2% had diabetes mellitus, 72.4% had a pre-operative ulceration, and 81.7% had peripheral neuropathy. Only 52.7% had diagnosed peripheral vascular disease, 38.1% had a history of renal disease, and 35% were smokers.

Conclusion:

Transmetatarsal amputation has an extremely high short-term reamputation rate with the vast progressing to a below knee amputation. Comorbidities such as diabetes mellitus, neuropathy, and history of ulceration are often found in these patients, while renal and peripheral vascular disease as well as tobacco abuse are not necessarily present. This high rate of reamputation may bring into question the efficacy of performing transmetatarsal amputation as opposed to a more proximal amputation as a definitive procedure when lower extremity amputation is required.
Supine Surgical Achilles Tendon Repair
Authors: Sage Katherine , Guyton Gregory
Published: September 2017

Category:

Ankle, Hindfoot, Trauma

Introduction/Purpose:

Open Achilles tendon repair is typically performed in the prone position for easy visibility of the tendon, but serious complications may be associated with general anesthesia in this position. Open Achilles tendon repair with supine position has been described and potentially avoids these issues, but it is not known whether this position is safe. We reviewed the complication rate of supine open Achilles tendon repair in a retrospective series of patients, looking specifically at wound healing, infection, re-rupture, and sural nerve injury.

Methods:

CPT codes for Achilles tendon rupture were used to search the records of one surgeon for the years 2010-2014. The charts were then reviewed. Patients were included if they had an Achilles tendon rupture that was surgically treated with primary repair in the supine position within 15 days of injury. Patients were excluded if further reconstruction or tendon transfer was performed. A paramedian incision was utilized 1 cm medial to the Achilles sheath.

Results:

A total of 37 patients met the inclusion criteria. Of these 37 patients, 31 were men and 6 were women. The average age was 40.0 years (range, 20 to 66 years). Average length of follow-up was 159 days (range 25 to 1589 days). The average BMI was 28 (range 24-36). There were no major complications, including no infections or wound complications. No reruptures and no sural nerve injuries were observed.

Conclusion:

In 37 patients with early follow-up, supine open Achilles tendon repair had a complication rate equivalent to reported historical data for the prone procedure.
Outcomes of Lisfranc Injuries Treated with Joint Preserving Fixation
Authors: Scofield Harrison , Lam Kenrick , Panchbhavi Vinod , Stautberg Eugene , Weiss William , Bender Sean , Mahmoud Ali
Published: September 2017

Category:

Midfoot/Forefoot

Introduction/Purpose:

Open reduction and internal fixation with transarticular screws to stabilize Lisfranc injuries may increase the risk of arthritis or affect outcomes. Extra-articular or bridge plating to stabilize these injuries avoids this articular damage. This study analyzes the functional outcomes and complications in patients who underwent this type of joint preserving fixation for Lisfranc injuries.

Methods:

A retrospective review of all patients treated for a Lisfranc injury at a level 1 trauma center from July 2008 to October 2015 was conducted. Patients over 18 years of age who were not incarcerated and did not have any concomitant procedures in the lower extremities were included. Patient electronic medical records were reviewed. Outcomes were analyzed with AOFAS scores.

Results:

There were 16 patients included in the study with an average follow up time of 57 months (15 - 102 months). Average AOFAS score was 79 (SD 16) and time to return to regular activities was 35 weeks (SD 25 weeks). Seven patients (44%) had their hardware removed during the follow up period. There was 1 complication which comprised of a screw backing out and needing to be removed.

Conclusion:

In the present case series, joint preserving fixation for Lisfranc injuries offered similar AOFAS scores as those reported for ORIF with transarticular screws, but with a decreased rate of hardware removal and need for mid-foot fusion.