bluuebunny/crossref_metadata_2025 huggingface dataset:
Pediatric Osteochondral Lesions of the Talus: A Systematic Review and Treatment Algorithm
Authors: Liu Hanson , Varghese Jacob , Sritharan Praveen , Gaber Karim , Kishta Waleed
Published: December 2023

Category:

Hindfoot; Ankle

Introduction/Purpose:

Osteochondral lesions of the talus (OLT) peak in incidence during childhood, yet there exists a paucity of research on treatment among skeletally immature populations due to their high potential for spontaneous recovery without interventions. Unfortunately for patients who do require treatment, existing guidelines are based on adult studies, which likely differ in prognoses and outcomes due to varying capacity for regeneration. This paper compares outcomes across conservative and various surgical interventions for pediatric OLTs, with the synthesized evidence forming the basis of a treatment algorithm.

Methods:

An electronic literature search was conducted across PubMed, EMBASE, and MEDLINE databases for primary studies published prior to January 2022. Pediatric status in OLTs was defined as age < 18 at diagnosis, since many studies did not assess skeletal maturity. The main outcomes were clinical and radiological success rates, defined as achievement of good or fair outcomes according to measures used by individual studies. Articles were categorized by treatment method, and outcome rates were obtained via simple pooling.

Results:

35 studies involving 714 lesions were included. Studies were categorized into five overarching treatment methods – (1) conservative treatment, (2) bone marrow stimulation, (3) retrograde drilling, (4) fixation, and (5) osteochondral transplantation. These interventions had pooled clinical success rates of (1) 45%, (2) 85%, (2) 90%, (4) 82%, and (5) 74%, respectively. The pooled radiological success rates were (1) 58%, (2) 85%, (3) 55%, (4) 89%, and (5) 81%. Escalation from conservative to surgical treatment occurred at a rate of 62% among studies in which this was reported. Articles were heterogeneous in measurement tools and pre- treatment characteristics; average baseline lesion size was (1) 129.8, (2) 131.0, (3) 87.8, (4) 137.8, and (5) 237.5mm^2 across the five treatment methods, and initial Berndt-Harty staging was likewise disparate.

Conclusion:

Conservative treatments yielded lower clinical and radiological success rates than surgical interventions, but warrant an initial trial in stable lesions due to their cost-effective and non-invasive nature. Surgery should be indicated for unstable lesions, or failed conservative treatment. Drilling and bone marrow stimulation are effective in lower grade lesions, while fixation should be considered for loosened fragments, and transplantation for large, non-salvageable lesions. Future research utilizing more robust methodology and reporting outcomes according to baseline lesion characteristics will consolidate these guidelines.
Postoperative Rehabilitation Protocols May Affect Rates of Achilles Tendon Re-Rupture after Acute Surgical Repair: A Systematic Review
Authors: Ubillus Hugo A. , Mosquea Thelma R. Jimenez , Walls Raymond J.
Published: December 2023

Category:

Ankle; Hindfoot

Introduction/Purpose:

Acute achilles tendon ruptures (AATR) are the most common tendon rupture in the lower limb with an incidence of up to 37 patients per 100,000 patient population annually. Several different guidelines exist on time to full weight bearing after AATR repair. Advantages of surgical management of AATR repairs are to maximize function of the tendon and reduce post-operative complications such as re-ruptures. A systematic review of the literature was performed which evaluated post-operative rehabilitation protocols, their complications and if an optimal post-operative treatment algorithm can be determined.

Methods:

In October 2022, MEDLINE, EMBASE and Cochrane Library databases were systematically reviewed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The level of evidence (LOE) and quality of evidence (QOE) were evaluated, and statistics on clinical outcomes, post-operative management and complications were calculated.

Results:

Eleven studies with 437 patients were included. Two studies were LOE I, three were LOE II, three were LOE III and three studies were LOE IV. Mean post-operative follow-up was 33.4 ± 31.2 months. Weighted mean post-operative return to full-weight bearing (FWB) was 4.8 ± 6.4 weeks. Post-operative return to neutral ankle position was achieved at an average of 4.6 ± 3.9 weeks. The overall complication rate was 3.0% (16 of 420 patients) with surgical wound infection (1.9%) and re-rupture (1.2%) the most common. Seven studies described an early rehabilitation protocol that commenced within 4 weeks from surgery. Subgroup analysis showed that early full weight-bearing (≤4 weeks) was associated with a higher re-rupture rate: 1.5% versus 0.7%.

Conclusion:

This systematic review demonstrated marked heterogenicity in reported rehabilitation protocols after AATR repair. While the risk of re-ruptures after surgical repair are low, we found that rehabilitation protocols that incorporate early weight- bearing within 4 weeks have a markedly increased risk of re-rupture. While there is increasing use of early rehabilitation after surgical repair of achilles tendon ruptures, further study is required to determine the optimal protocol to optimise outcome while decreasing the risk of failure.
Primary Arthrodesis vs Open Reduction Internal Fixation for Lisfranc Fracture-Dislocations: A Cost Analysis
Authors: Ochuba Arinze Jason , Murdock Christopher J. , Xu Amy L. , Snow Morgan , Schmerler Jessica , Leland Christopher R. , McDaniel Claire , Aiyer Amiethab A.
Published: December 2023

Category:

Midfoot/Forefoot; Trauma

Introduction/Purpose:

Lisfranc fracture-dislocation is an uncommon but serious injury that currently lacks universal consensus on optimal operative treatment. Two common fixation methods are open reduction and internal fixation (ORIF) and primary arthrodesis (PA). The objective of this study is to analyze the cost difference between ORIF and PA of Lisfranc injuries, along with the contribution of medical services to overall costs.

Methods:

This was a retrospective cost analysis of the MarketScan database from 2010-2020. Patients undergoing primary ORIF (CPT code 28615) versus PA (28730 and 28740) for Lisfranc fracture-dislocation were identified. The primary independent variable was ORIF versus PA of Lisfranc injury. Costs accrued due to operative management was the primary objective, and was analyzed according to net payment, total payment, coinsurance, copayment, deductible, and coordination of benefits per savings (COB/savings) amounts. Outpatient surgery setting (hospital versus ambulatory surgical center (ASC)) and requirement for secondary arthrodesis within the primary ORIF group were secondary independent variables. The utilization of and costs contributed by medical services were secondary outcomes. These included outpatient clinic visits, foot radiographs, lower extremity magnetic resonance imaging (MRI), lower extremity computed tomography (CT), physical therapy (PT), and opioid prescriptions. Student’s t-test, chi-squared test, and Poisson multivariable regression were used for statistical analysis, with significance set as P < 0.05.

Results:

From 2010 to 2020, 7,268 patients underwent operative management of Lisfranc injuries, with 5,689 (78.3%) ORIF and 1,579 (21.7%) PA. Of those undergoing initial ORIF, 22 (0.39%) were converted to secondary arthrodesis at a mean ± standard deviation of 10.2 ± 12.1 months after the index surgery. PA was independently associated with increased net payment, total payment, and coinsurance. When compared to primary ORIF, patients undergoing PA utilized more clinic and PT visits and imaging sessions. However, primary ORIF with secondary arthrodesis was associated with more clinic visits, imaging, and generated higher costs from these medical services compared to PA alone. Within hospital and ASCs, PA was associated with increased net and total payments. However, out-of-pocket (OOP) costs were found to be higher in ASCs.

Conclusion:

Treatment of Lisfranc fracture-dislocation with PA is associated with higher initial costs compared to ORIF with subsequent secondary arthrodesis. Conversely, secondary arthrodesis demonstrated significantly higher costs and resource utilization compared to primary procedures. Specific cost drivers for PA and secondary arthrodesis were clinic visits and perioperative imaging.
PROMIS Scores for Chronic Plantar Fasciitis Before and After Gastrocnemius Recession
Authors: Scheinberg Mila , Sanchez Thomas , Shah Ashish
Published: December 2023

Category:

Ankle; Hindfoot

Introduction/Purpose:

There has been an established relationship between increased loading on the Achilles tendon and tension on the plantar fascia. This supports the idea that either tight gastrocnemius and soleus muscles or contractures of the Achilles tendon are risk factors for plantar fasciitis. Gastrocnemius recession has gained popularity as a viable surgical intervention for cases of chronic plantar fasciitis due to isolated gastrocnemius contracture. To our knowledge, this is the first study to investigate PROMIS scores in patients with plantar fasciitis before and after gastrocnemius recession.

Methods:

The Electronic Medical Record was queried for medical record numbers associated with Current Procedural Terminology code 27687 (gastrocnemius recession). Our study included all patients with a preoperative diagnosis of chronic plantar fasciitis with treatment via isolated gastrocnemius recession with one-year minimum follow-up. 40 patients were included in our study. Patient variables were collected via chart review. Preoperative and postoperative PROMIS scores were collected in the clinic.

Results:

Preoperative and postoperative PROMIS scores improved for physical function and pain interference from 39.27 and 62.78 to 44.54 and 56.5 (p=0.0005, p=0.0001) respectively, PROIMS Depression scores were not significantly different (p=0.6727). VAS scores significantly decreased from 7.05 to 1.71 (p < 0.0001). Patients with preoperative peripheral neuropathy had significantly lower improvement in PROMIS physical function scores (p=0.0029). Tobacco use led to significantly lower improvement in in PROMIS depression (p=0.0202).

Conclusion:

Gastrocnemius recession is an effective option for patients with refractory pain in plantar fasciitis. Our PROMIS and VAS data confirm this procedure's utility and highlight its ability to significantly decrease pain and improve physical function in patients with chronic plantar fasciitis. We believe we have added to the literature by incorporating the, inherently superior, PROMIS scores. Based on the results of this study, the authors recommend gastrocnemius recession for patients who fail conservative management for plantar fasciitis.
Prospective Evaluation of Rate of Fusion with Augment Injectable Bone Graft
Authors: Shaheen Philip J. , Priester Jacob , Giza Eric , Kreulen Christopher D.
Published: December 2023

Category:

Hindfoot; Basic Sciences/Biologics

Introduction/Purpose:

Augment® Bone Graft is a mixture of rhPDGF-BB, beta-TCP and bovine collagen which has received FDA approval for use as a substitute for autografts during hindfoot and/or ankle arthrodesis. Although a recent meta analysis demonstrated that the rhPDGF-BB and beta-TCP mixture has comparable CT fusion rates and radiographic union rates to those of autografts, these studies excluded patients with prior joint site arthrodesis. In our study, we specifically use Augment® Injectable Bone Graft (AIBG) which has only very recently received labeling change approval. The goals of our study are to assess fusions rates in patients who receive AIBG during hindfoot and/or ankle arthrodesis, and then subsequently compare fusion rates between primary vs. revision hindfoot and/or ankle arthrodesis as primary outcomes.

Methods:

We prospectively enrolled patients aged 18-85 who underwent subtalar, calcaneocuboid, talonavicular, and/or ankle arthrodesis from one of two academic surgeons including both primary and revisions fusions. The patients received AIBG and were excluded if any other graft material was used. Demographic data and patient reported outcomes were collected preoperatively and at follow-up visits including Visual Analog Pain Scale (VAS), Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM) Sports Subscale, and Veterans Rand 12 (VR-12) physical and mental subscores. Patients were followed at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. The primary outcome measure was fusion rate via CT scan at 4 months with secondary outcomes consisting of the patient reported outcome data and rate of revisions.

Results:

62 patients met inclusion criteria, 50 patients had a 4-month postoperative CT scan to assess for fusion with 78% of the CT scans (39 out of 50) demonstrating fusion at that time. There were only 3 revision fusion patients, with 1 of the 3 failing to fuse. 54 of the patients were followed through their 6 month visits, 44 patients through 1 year, and 24 patients were seen for their 2-year follow-up visit. All patient reported outcomes demonstrated improvement from preoperatively to final follow-up with VAS scores improving from 5.52 to 3.21, FFI improving from 57.87 to 35.64, FAAM-sports improving from 18.65 to 29.30, VR-12 Physical improving from 28.67 to 35.18, and VR-12 Mental improving from 44.27 to 47.74.

Conclusion:

This prospective study demonstrates that Augment® Injectable Bone Graft is an acceptable alternative to allograft for either primary or revision hindfoot arthrodesis procedures with 78% of patients achieving fusion on a 4-month postoperative CT scan and with steady noted improvement in multiple validated patient-reported outcome measures.
Prospective Randomized Controlled Trial Between Fibula Intramedullary Nail Fixation vs Open Reduction and Internal Fixation for the Surgical Management of Unstable Ankle Fractures
Authors: Lee Sung Hyun , Jo Yang Hun
Published: December 2023

Category:

Ankle; Trauma

Introduction/Purpose:

The fundamental concept of open reduction and internal fixation (ORIF) of unstable ankle fractures was anatomical reduction and firm fixation that allow early mobilization and rehabilitation. On the other hand, ORIF of ankle fractures is associated with complications including wound dehiscence, necrosis and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using fibula nail was emerged as additional surgical option for unstable ankle fractures especially in elderly and medical high-risk patients. We hypothesized that fibula nailing for unstable ankle fractures would have similar functional outcomes to standard ORIF. The purpose of this study is to perform a prospective randomized study to compare clinical outcomes, bone union, and postoperative complications between ORIF and CRIF using fibula nail.

Methods:

A total of 59 patients (32 men, 27 women) with the mean age of 50.2 years were prospectively randomized to undergo standard ORIF or fibular nailing for unstable ankle fractures: those who underwent ORIF (31 patients 14 men, 17 women) and those who underwent CRIF using fibula nail (29 patients; 18 men and 11women). Exclusion criteria of fracture characteristics were open fracture and highly comminuted fibula fractures. Functional scoring including VAS, AOFAS and FAOS were evaluated at minimum postoperative 2 years follow up. In addition, union period, reduction status of fracture and ankle mortise at postoperative CT scan, complications including wound problem and posttraumatic arthritis were evaluated.

Results:

The VAS, AOFAS, and all FAOS subscales were not significantly different between two group at 2 years postoperatively (all, p>0.05). Significantly fewer infections and wound complication occurred in the fibula nail group. (p < 0.05; ORIF group (12.9%), fibula nail group (0%)). Postoperative at fracture site of fibula was high in fibula nail group (p < 0.05; ORIF group (0%), fibula nail group (13.7%)), but there were no significant differences in the status of mortise and the rate of posttraumatic arthritis (all, p>0.05).

Conclusion:

We concluded that the fibula nail allows acceptable reduction and secure fixation of unstable ankle fracture, with low soft tissue complication rate than ORIF. Considering the property closed reduction, the fibula nail would be an excellent treatment option for patients with unstable ankle fractures when indications is well selected
Radiographic Anatomy of the Lateral Ankle Ligament Complex: A Cadaveric Study
Authors: Tansey Patrick J. , Robbins Jordan , Stahel Shepherd A. , Morris Randal , Jupiter Daniel , Chen Jie , Panchbhavi Vinod
Published: December 2023

Category:

Ankle; Sports

Introduction/Purpose:

Lateral ankle sprains are common orthopedic injuries that may progress on as chronic lateral ankle instability (CLAI). Great care must be taken to restore precise anatomic relationships of the lateral ankle ligament complex (LALC) in the surgical management of CLAI. This study aimed to quantify the radiographic relationships between the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and prominent osseous landmarks visible under fluoroscopy to assist in perioperative practices for minimally invasive surgery (MIS) for CLAI.

Methods:

Ten fresh frozen ankle specimens were dissected to expose the LALC and prepared by threading a radiopaque filament through the ligamentous footprints of the ATFL and CFL. Lateral ankle fluoroscopic images were obtained and digitally analyzed to define dimensional characteristics of the ATFL and CFL. Directional measurements of the ligamentous footprints relative to the lateral process of the talus and the apex of the posterior facet of the calcaneus were also calculated.

Results:

Dimensional measurements of the ATFL included a mean length of 9.3 mm, fibular footprint of 9.4 mm, and talar footprint of 9.1 mm. Dimensional measurements of the CFL included a mean length of 19.4 mm, fibular footprint of 8.2 mm, and calcaneal footprint of 7.3 mm. From the lateral process of the talus, the fibular attachment of the ATFL was found 13.3 mm superior and 4.4 mm posterior, while the talar attachment was found 11.5 mm superior and 4.8 mm anterior. From the apex of the posterior facet of the calcaneus, the fibular attachment of the CFL was found 0.2 mm inferior and 6.8 mm anterior, while the calcaneal attachment was found 14.3 mm inferior and 5.9 mm posterior.

Conclusion:

The ATFL and CFL were radiographically analyzed in a unique manner and localized in reference to two prominent osseous landmarks. These findings may assist in perioperative practices for keyhole incision placement and arthroscopic guidance.
Sagittal Orientation and Variabilities of the Anatomical Insertional Footprint of the Achilles Tendon: A Cadaveric Study
Authors: Maher Moustafa A. , Zhu Mingjie , Baldini Todd , Hunt Kenneth , Myerson Mark , Li Shuyuan
Published: December 2023

Category:

Hindfoot; Sports

Introduction/Purpose:

New surgical techniques for Achilles tendon insertional pathology are evolving rapidly. Whether via open surgery, minimally invasive, or endoscopic approaches, more information about the Achilles' insertional footprint is needed to help surgeons with decision making. This study investigated the footprints of the Achilles insertion in sagittal orientation to delineate the anatomical landmarks, safe zones for bone resection3-down surgeries in treating insertional Achilles tendinopathies.

Methods:

Twenty fresh frozen cadavers were selected excluding insertional Achilles tendon pathology on lateral view x-rays. The calcanei were dissected maintaining the Achilles tendon insertion intact. Dimensions of the posterior tuberosity were recorded and marked to plan for three sagittal cuts (medial, middle, and lateral) (Fig 1 A). Using an oscillating saw (Fig 1 B.), the posterior tuberosity was cut into four pieces (Fig 1 C,E). A trapezoid shape (Fig 1 D) was reconstructed demonstrating relative location of the footprints of the Achilles insertion compared to the boundaries of the tuberosity on each piece (A, most superior point in the posterior tuberosity; B, most superior point in the Achilles insertion; C, most inferior point in the Achilles insertion; D, most inferior point in the posterior tuberosity). Data regarding footprints of the Achilles tendon insertion in the sagittal orientation was analyzed and compared within each trapezoid region and among different regions.

Results:

AB (calcaneal tuberosity tip to the upper limit of the Achilles insertion) was shortest at the medial cut (9.35mm) and longest at the lateral cut (12.15mm). However, the tendon thickness at the insertion (the distance from the proximal to the distal limits) represented by BC was shortest at the lateral cut (13.19mm) and longest at the middle cut (14.04mm). AD, the distance from the highest to the lowest point of the calcaneal tuberosity, was the longest at the middle cut (41.20mm). AB:BC ratio was highest at the lateral cut and lowest at the medial cut, indicating the safe amount of bone to be resected at the Achilles insertion. Tendon thickness relative to the whole calcaneal tuberosity (BC:CD) was highest at the medial wall (Table1).

Conclusion:

The sagittal orientation and variability of the Achilles tendon insertion is an under-studied topic in the literature. It needs to be addressed given recent trends towards minimally invasive procedures in treating insertional Achilles pathology. This study precisely delineated the footprint in each region of the insertion by creating a trapezoid pattern to compare the coordinates across these areas. This could lead to future three-dimensional reconstruction of the Achilles insertional footprint and patient- specific instrumentation software directed towards optimizing the management of Insertional Achilles pathology.
Should We Fix Them? A Comparison of Outcomes at Mid-Term Follow-Up of Operatively and Non- Operatively Treated Weber B Ankle Fractures
Authors: Ge Laurence , Talusan Paul G , Holmes James , Walton David
Published: December 2023

Category:

Trauma; Ankle

Introduction/Purpose:

Our group previously presented a novel protocol for non-operative management of Weber B ankle fractures with medial clear space (MCS) < 7mm on gravity stress (GS) radiographs and within 2mm of ipsilateral superior clear space and contralateral GS MCS. The goal of this study is to recruit an operative cohort for comparison of clinical, radiographic, and patient reported outcomes.

Methods:

We recruited a cohort of patients who may have been considered for the non-operative protocol but underwent surgery instead. Outcome measures were obtained including Kellgren-Lawrence scale for evaluation of arthritis, American Orthopedic Foot & Ankle Society (AOFAS) Hindfoot, Olerud Molander Ankle (OMA), Lower Extremity Functional Scale (LEFS), and PROMIS (physical function, depression, pain interference) scores. This data was then compared to the non-operative cohort.

Results:

There were 20 patients in the operative cohort and 29 in the original non-operative cohort. Mean follow-up was 6.9 and 6.7 years, respectively. Average outcome scores were as follows for the operative and non-operative groups, respectively: LEFS, 68.1 and 75.2 (p=0.009); OMA, 89.0 and 94.1 (p=0.05); AOFAS, 91.7 and 98.5 (p=0.0003); PROMIS Physical Function, 50.4 and 58.2 (p=0.01); PROMIS Depression, 45.4 and 42.8 (p=0.29); PROMIS Pain Interference, 49.7 and 42.2 (p=0.004). All patients in both groups achieved union of their fracture. There was no difference in Kellgren-Lawrence arthritis scores though interobserver reliability for scoring was poor. In the surgical cohort there were 3 (15%) cases of implant removal, 1 (%) SPN neurapraxia, and 1 (%) delayed wound healing.

Conclusion:

In carefully selected patients with isolated Weber B fractures and MCS < 7mm on gravity stress radiographs that is within 2mm of ipsilateral superior clear space and contralateral GS MCS, non-operative management may be considered as it can lead to equivalent or superior outcomes with none of the risks typically associated with surgical intervention.
Significant Early Loss of Correction in Modified Lapidus Compared to Original Lapidus for Hallux Valgus
Authors: Acker Antoine , Zainudin Tunko Naziha Tunku , Schauer Elisabeth , Peurière Laura , Reymond Nils , Drittenbass Lisca , Dubois-Ferrière Victor , Assal Mathieu
Published: December 2023

Category:

Bunion; Other

Introduction/Purpose:

The Lapidus procedure (first tarsometatarsal joint (TMT1) fusion) is an established treatment for correcting hallux valgus with 1st ray hypermobility. The original Lapidus (OL) technique involves fusing the TMT1 joint and first metatarsal base to the second, while the modified Lapidus (ML) technique involves fusing only the TMT1 joint. The purpose of this study was to investigate whether the ML procedure results in an early loss of correction.

Methods:

This retrospective study analyzed the outcomes of 45 feet in 40 patients with hallux valgus who underwent either the ML (21 feet) or OL (24 feet) procedure between 2014 and 2022 at a single center. All fixations were performed with 3.5 cortical screws, except for 9 cases that were fixed with a plantar locking plate. Differences in the immediate postoperative (6 weeks) and postoperative (6 months) intermetatarsal angle (IMA) and hallux valgus angle (HVA) were analyzed using Mann-Whitney tests, and complications were reported.

Results:

The mean preoperative IMA and HVA for the OL were 15.8° ± 3.5° and 36.4° ± 9.5°, respectively, and 14.5° ± 2.3° and 33.0° ± 7.0° for the ML. The immediate postoperative IMA and HVA were similar for both procedures (7.2° ± 2.0° and 7.7° ± 4.3° for OL, 7.3° ± 2.1° and 8.5° ± 5.5° for ML). Although from 6 weeks to 6 months postoperatively, the loss of correction of the HVA did not differ between both procedures (4.2° for OL, 5,6° for ML), the IMA loss of correction was significantly higher in the ML (1.1° ± 1.4° vs 0.5° ± 1.1°) (p < 0.05). One case of delayed union was reported in the OL group, but it did not require revision.

Conclusion:

The study results suggest that the ML procedure does not provide the same stability as the OL procedure in the early postoperative period, as there was a significantly greater early loss of correction of the IMA at 6 months postoperatively in the ML group compared to the OL group. Although there were no differences in the loss of correction of the HVA angle (HVA), an observed loss of 5 degrees remains a concern. Further studies are necessary to better understand the indications of the modified and original procedures.
Structural Validation of the Manchester-Oxford Foot Questionnaire (MOxFQ) for use in Foot and Ankle Surgery
Authors: Borsky Kim , Goodall Richard , Harrison Conrad , Welck Matthew J. , Malhotra Karan , Rodrigues Jeremy
Published: December 2023

Category:

Other

Introduction/Purpose:

The Manchester-Oxford Foot Questionnaire (MOxFQ) is a condition specific patient reported outcome measure (PROM) for foot and ankle surgery. It consists of 16 items across three subscales measuring distinct, but related traits: walking/standing ability, pain, and social interaction. Although it is the most used foot and ankle PROM in the UK, initial MOxFQ validation involved analysis of only 100 individuals undergoing hallux valgus surgery. This project aimed to establish whether an individual’s response to the MOxFQ varies with anatomical region of disease (measurement invariance), and to explore structural validity of the factor structure (subscale items) of the MOxFQ.

Methods:

This was a single-centre, prospective cohort study involving 6640 patients (mean age 52, range 10-90 years) presenting with a wide range of foot and ankle pathologies between 2013 and 2021. Firstly, to assess whether the MOxFQ responses vary by anatomical region of foot and ankle disease, we performed multi-group confirmatory factor analysis. Secondly, to assess the structural validity of the subscale items, exploratory and confirmatory factor analyses were performed.

Results:

Measurement invariance by pathology was confirmed suggesting the same model can be used across all foot and ankle anatomical regions. Exploratory factor analysis demonstrated a 2-3 factor model, and suggested that item 13 (inability to carry out my work/everyday activities) and item 14 (inability to undertake social/recreational activities) loaded more positively onto the walking/standing subscale than their original social interaction subscale.

Conclusion:

This large-cohort study supports the current widespread use of the MOxFQ across a broad range of foot and ankle pathologies. Items 13 and 14 might be better moved from the “social interaction” to the “walking/standing” subscale and this may have future implications for deriving/analysing subscale scores.
Subtalar Joint Fusion For STJ OA before vs after Total Ankle Replacement: Does it affect patient outcomes? – A 10 year follow up clinical study
Authors: Hakeem Samir , Nicolas Andrea Pujol , Porter Anna , Ramaskandhan Jayasree R. , Siddique Malik
Published: December 2023

Category:

Ankle; Hindfoot

Introduction/Purpose:

There is paucity of literature reporting outcomes in patients who undergo subtalar joint fusion surgery before vs. after having a Total Ankle Replacement (TAR). We aimed to study the PROMs in patients who underwent a staged approach of Subtalar arthrodesis (STJA) followed by TAR vs patients who underwent TAR followed by further STJA surgery.

Methods:

All patients who underwent a STJA surgery and TAR surgery (in either order) between 2006 and 2010 included in this study. patient reported outcomes including WOMAC (Western Ontario McMasters Osteoarthritis score), SF-36 general health score and patient satisfaction scores were compared between groups. They analysed pre-operatively and at 1, 2, 5 and 10 years post-operatively. Out of 210 TARs performed, 14 patients underwent a two staged procedure between 2006 and 2010 by a single surgeon. 5 patients had STJ fusion after TAR (Group A) and 9 patients had STJ fusion before TAR (Group B).

Results:

Mean age of Group A and B was 52.5 years and 62.1 years respectively. 1 patient in Group A and 3 patients in Group B were deceased. Both groups reported improvement in scores for WOMAC, SF -36 from pre-op to 1 year post operatively (p < 0.05) and the results plateaued to 5 years with slight decline in scores from 5 to 10 years. At 2 years, Group B reported lower scores for stiffness (9.6±11.7 vs. 64.3 ±27.4) p=0.002, At 5 years, Group A reported lower scores than group B for General health and mental health components of SF-36 scores (p=0.044); however, there was no differences between groups for WOMAC, SF-36 and patient satisfaction outcomes at 10 years post-operatively.

Conclusion:

There were similar outcomes reported by patients who underwent STJA either before or after TAR at average of 10 year follow up in this series
Suture Button Fixation for Lisfranc Injuries: A Systematic Review
Authors: Lachance Andrew , Jonas Margaret , Edelstein Alexander , Lee Wonyong
Published: December 2023

Category:

Midfoot/Forefoot; Trauma

Introduction/Purpose:

Lisfranc injuries remain a significant but often misdiagnosed orthopaedic injury. Alongside traditional methods of surgical fixation, including arthrodesis and ORIF with screws, suture button fixation is an emerging technique. While several studies have reviewed the outcomes of Lisfranc injuries utilizing plate, screw, and k-wire constructs for arthrodesis or ORIF, there has yet to be a review of the literature focusing on suture button fixation outcomes of Lisfranc injuries. The purpose of this systematic review is to consolidate studies utilizing suture button fixation for the treatment of Lisfranc injuries.

Methods:

A comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, Web of Science, and Cochrane databases for original, English-language studies observing outcomes of Lisfranc injury until August 19, 2022. This combination search strategy employed the following keywords: ((Lisfranc OR Midfoot OR Tarsometatarsal) AND (Injury OR Instability OR Fracture OR Dislocation)) AND (ORIF OR Fixation OR Reconstruction OR suture* OR button* OR Fiber*). The quality of all included studies in this review was evaluated by a modified Coleman score. Clinical outcomes including pre and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, pre and postoperative Visual Analogue Scale (VAS) for pain, and radiographic outcomes such as diastasis were extracted from the text and figures of each study. Return to sports/duty and time to return as well as postoperative complication diagnoses and complications were also extracted from each article.

Results:

Of the 10 studies included, there were 186 total patients with an age range of 13-72. In every study, all patients were able to return to sport or activity with a return time averaging from 10.8-55.1 weeks. Postoperative AOFAS scores ranged from 83.5- 97 while VAS ranged from 0.6-2.5. Complications were reported in six studies at a rate of 6.7 % including two cases of diastasis, two cases of paresthesia, one case of button irritation, and one of postoperative degenerative joint disease, with no reported revisions.

Conclusion:

This study summarizes the current evidence regarding suture button fixation of Lisfranc injuries including return to sport, postoperative diastasis, and patient-reported outcomes. In sum, these studies found that suture button fixation shows high levels of patient-reported outcomes, return to sport, and stable fixation in isolated Lisfranc injuries. This surgical technique is advantageous as it provides a more physiologic reduction across the Lisfranc joint and reduces the need for reoperation including the removal of hardware. Further evidence such as large sample size and high-quality RCT studies is needed to draw a definitive conclusion regarding the best treatment for Lisfranc injuries.
Talar Neck Rotation Angle in Adults with Clubfoot Deformity: Observed Values and Intra- and Inter- Observer Reliability using Weightbearing CT
Authors: Malhotra Karan , Colta Raul , Haldar Anil , Patel Shelain , Welck Matthew J. , Cullen Nicholas
Published: December 2023

Category:

Ankle; Basic Sciences/Biologics

Introduction/Purpose:

Adults presenting with symptomatic clubfoot represent a challenging cohort of patients. An appreciation of the location and degree of deformities is essential for management. Talar anatomy is often abnormal with varus within the talar neck, however, there are few reproducible methods which quantify talar neck deformity in adults. We describe a technique of assessing talar neck deformity, and report on observed values and intra- / inter-observer reliability.

Methods:

This was a single-centre, retrospective study including 96 feet from 56 adult patients with clubfeet (82 feet had clubfoot deformity, 14 were normal). Mean age was 34.3±16.9 years and 31 (55.3%) were male. Weight-bearing CT scans captured as part of routine clinical care were analysed. Image reformats were oriented parallel to the long axis of the talus in the sagittal plane. In the corresponding axial plane two lines were drawn (on separate slices): 1) a line perpendicular to the intermalleolar axis, 2) a line connecting the midpoints of the talar head and narrowest part of the talar neck. The talar neck rotation angle (TNR angle) was the angle formed between these lines. Intraclass correlation coefficients (ICC) were performed for intra- and inter-observer reliability.

Results:

Mean TNR angle in clubfeet was 27.6±12.2 degrees (95%CI = 25.0 to 30.2 degrees). Mean TNR angle in normal feet was 18.7±5.1 degrees (95%CI = 16.0 to 21.4 degrees) (p < 0.001). The ICC for clubfeet was 0.944 (95%CI = 0.913 to 0.964) for intra- observer agreement, and 0.896 (95%CI = 0.837 to 0.932) for inter-observer agreement.

Conclusion:

This measurement technique demonstrated excellent intra- and inter-observer agreement. It also demonstrated that compared to normal feet, clubfeet had about 9 degrees of increased varus angulation of the talar neck. This technique and data may be used for future research into clubfoot deformity and in planning treatment.
Talonavicular Dislocations: A Bad Actor Made Worse Without Sufficient Fixation
Authors: Campbell Megan L. , Siebert Matt , Sroka Oliver , Haller Justin , Marchand Lucas
Published: December 2023

Category:

Trauma; Midfoot/Forefoot

Introduction/Purpose:

The talonavicular joint (TNJ) is critical to midfoot architecture, and traumatic disruptions of this joint threaten the midfoot arch. We sought to better elucidate injuries to the TNJ and understand if transient methods of stabilization after TN dislocations (TNDs), such as closed/open reduction with or without percutaneous pinning resulted in different radiographic and clinical outcomes when compared to more permanent methods such as bridge plating or primary arthrodesis of the TNJ.

Methods:

We retrospectively identified skeletally mature patients from one tertiary level 1 trauma center treated for midfoot injuries between 2002-2022. Patients with isolated or concomitant TNDs were included. Demographics, treatment, radiographic outcomes, and patient reported outcomes (PROs) were recorded. Patients who underwent temporary fixation methods (closed/open reduction and trans-articular pinning with k-wire removal at 6-8 weeks) were compared to those with permanent fixation (bridge plating or primary arthrodesis). Primary outcome was reoperation, including fusions and amputations. Secondary outcomes were radiographic arch measurements (Meary’s angle [MA], calcaneal inclination angle [CIA]) and PROMIS measures of physical function, pain interference, and anxiety. Sixty-two patients and 66 feet were included (Table 1). Average follow up was 2 years.

Results:

TNDs manifested as both pure dislocations (18) and in conjunction with associated injuries: chopart dislocations (5), talar head/body fractures (23), navicular fractures (35), and subtalar dislocations (25). Twelve were a part of Hawkins IV talar neck fracture dislocations (18%). Forty-two patients were treated with temporary fixation (64%). Injuries treated with transient fixation had higher mean change in MA from immediately postop to final follow-up (-7.9° v -1.1°, p=0.006). They also exhibited significantly different MA and CIA values at final follow-up (7.8° v -1.4°; 17.3° v 21.3°, p< 0.03). Nearly two thirds required reoperation; 32% underwent fusion and 7% required amputation. Fixation method had no significant association with PROMIS scores, but those with temporary fixation methods trended toward lower final PF scores (34.9 v 41.1, p=0.11).

Conclusion:

TNDs are generally the result of high energy mechanisms, often occurring in combination with other significant mid/hindfoot injuries. Reduction and fixation method of these injuries should be carefully considered to avoid potential ramifications of loss of normal arch and midfoot sag.
The Effect of Focused Vibration on Tibialis Anterior Function in Normal Subjects
Authors: Lui Chun Wai , Loureiro Rui CV , Malhotra Karan
Published: December 2023

Category:

Basic Sciences/Biologics; Other

Introduction/Purpose:

Foot drop is a debilitating condition which may be caused by peripheral nerve pathology. Focused vibration therapy (FVT) is a novel treatment in this setting which aims to improve the response of muscle motor units to nervous stimuli, improving muscle function and rehabilitation potential. This study investigates the effect of FVT on tibialis anterior (TA) function in normal subjects to determine the optimal timing of application.

Methods:

Fifteen normal subjects with mean age 25.47±3.27 years and BMI of 21.93±1.54kg/m2 were recruited. Using surface electromyography (EMG), a rotary potentiometer, video analysis (KINOVEA software), and force gauges, the activity of TA, ankle range of movement (ROM), and force at maximal isometric voluntary contraction (MVC) in dorsiflexion were measured. Baseline TA strength was recorded, and participants then performed a series of dorsiflexion exercises to induce fatigue. Strength measurements were repeated after a 5-minute rest period (control). This process was repeated with FVT applied before exercise (FVBE) and after exercise (during the rest period, FVAE). FVT was delivered over the TA muscle belly at 75Hz / 0.4mm amplitude. Data was analysed using ANOVA.

Results:

There was no significant change in EMG readings or dorsiflexion ROM between baseline, control and FVBE/FVAE measurements. Compared to baseline, MVC increased by 10.87N (6.6%) after FVBE (p=0.034) and 13.87N (8.4%) after FVAE (p=0.034). Compared to control, MVC did not increase significantly with FVBE, but did increase by 7.70N (4.3%) following FVAE (p=0.049).

Conclusion:

FVT improved the MVC of TA - this was most pronounced when FVT was applied during the recovery phase, after exercise. The lack of EMG / ROM improvement is expected in normal subjects. Our results suggest that FVT is more effective than passive rest and may enhance muscle strength recovery. Further work will investigate the optimal dose of FVT and response in patients with pathology.
The Keystone of Muller Weiss Disease: How Does the Compressed Navicular Cause the Cascade of Deformities in the Mid and Hind Foot?
Authors: Hu Haonan , Gu Wanjun , Zhu Mingjie , Sun Chengyi , Zhang Mingzhu , Myerson Mark , Li Shuyuan
Published: December 2023

Category:

Hindfoot; Midfoot/Forefoot

Introduction/Purpose:

It is believed that Müller Weiss Disease (MWD) starts with narrowing of the lateral and dorsal side of the navicular, followed by lateral rotation and slight dorsal lifting of the talar head and medial rotation of the navicular, a varus heel, and ultimately additional changes in the hindfoot and midfoot. This study used the technique of distance mapping to measure the space of the “peri-navicular” joints on an averaged 3D foot model for both normal controls and a group of MWD feet, to prove the key pathologic changes of MWD.

Methods:

Weight bearing Scans of 55 health feet without deformities, trauma and surgical history, and 69 feet with MWD were included in this study. The Bonelogic program (Disior, Paragon28) was used to automatically segment the bones and 3D information of each foot in the same group was pooled to create an average foot model for both the controls and the MWD feet. On the two foot models, distance mapping was applied and compared to compare the space of the perinavicular joints (the talonavicular joint, the three navicular cuneiform joints, and the calcaneocuboid joint). The morphology of the navicular bone and the talonavicular articulation in the two groups were also studied.

Results:

In the MWD foot model, there was significant narrowing of the lateral pole and the dorsal side of the navicular compared with the average normal foot model. The bone articular surfaces of the two foot models matched well, meaning that the deformity changes occurred predominantly to the shape of the navicular but not the contour of the joint surface. The joint space measured using distance mapping was significantly greater in the talonavicular joint, middle and lateral naviculocuneiform joints, and the calcaneocuboid joint in the MWD feet than in normal controls. There was no difference in the joint space of the medial naviculocuneiform joint between the two foot models.

Conclusion:

It is the change in the shape of navicular bone but not articular surface contour which causes the development of the cascade of deformities in MWD. The sequalae includes increased joint space on both sides of navicular tail, and in the calcaneocuboid joint, lateral subluxation of the talus head, relative medial subluxation of the navicular, a varus heel with more opening in the sinus tarsi, proximal shift of the calcaneal tuberosity, a flat medial arch with subsidence at the talonavicular joint, decreased adduction of the forefoot, medial translation of the cuboid at the calcaneocuboid articulation, and a shortened 1st metatarsal.
The Proximal 5th Metatarsal Fracture: A Spectrum of Misunderstood Fractures
Authors: Kingery Matthew T. , Kadiyala Manasa , Walls Raymond J. , Leucht Philipp , Rivero Steven , Ganta Abhishek , Konda Sanjit , Egol Kenneth A.
Published: December 2023

Category:

Midfoot/Forefoot; Trauma

Introduction/Purpose:

Several different types of 5th metatarsal fractures exist and are treated with various methods of immobilization, weight bearing restrictions, and occasionally operative procedures. The purpose of this study was to evaluate the differences in clinical and radiographic outcomes between pseudo-Jones fractures (Zones 1 and 2 of the 5th MT base), True Jones fractures (Zone 3), and 5th MT shaft fractures.

Methods:

This was a retrospective cohort study of patients presenting to a single large, urban, academic medical center with any 5th MT fracture between 2012 and 2022. Inclusion criteria for this analysis included patient follow up until there was evidence of radiographic healing, clinical healing, or duration greater than one year following injury. Radiographs obtained at the initial presentation were reviewed and fracture patterns were categorized as either Zone 1, Zone 2, Zone 3, or Shaft. Linear regression models were used to evaluate the effect of fracture type on the duration of healing when controlling for age, sex, BMI, smoking status, and history of diabetes. 1,279 patients with 5th metatarsal fracture met the inclusion criteria and were included in the analysis (mean age 49.2 +/- 17.9 years). Overall, 5.2% were treated in a splint or cast, 67.5% in a CAM boot, 20.3% in a hard sole shoe, and 7.0% without immobilization.

Results:

31.2% of patients were non-weight bearing, 8.1% partial weight bearing, and 60.7% weight bearing as tolerated. There was no difference in time to radiographic union (p=0.946) or time to clinical healing (p=0.520) between any of the fracture types. Similarly, there was no difference in the proportion of patients with incomplete radiographic healing at 6 months (p=0.310) and at 1 year after injury (p=0.552) based on the fracture type. Likewise, there was no difference in any clinical or radiographic healing parameter based on fracture type for patients treated operatively. Based on linear regression model, there was no difference in the time to clinical or radiographic healing when controlling for confounding factors.

Conclusion:

All commonly occurring 5th metatarsal fractures, including those of both the metatarsal base and the shaft, demonstrate similar times to clinical and radiographic healing.