bluuebunny/crossref_metadata_2025 huggingface dataset:
The Impact of Pre-Operative Mental Health and Depression on Outcomes after Total Ankle Arthroplasty
Authors: Cunningham Daniel J. , Steele John , Adams Samuel B.
Published: November 2020

Category:

Ankle

Introduction/Purpose:

Poor pre-operative mental health and depression have been shown to negatively impact patient- reported outcomes (PROMs) after a broad array of orthopaedic procedures involving the spine, hip, knee, shoulder, and hand. However, the relationship of mental health and patient-reported outcomes in foot and ankle surgery is less clear. The purpose of this study is to characterize the impact of pre-operative mental health and depression on patient-reported outcomes after total ankle arthroplasty. The study hypothesis is that depression and decreased SF36 MCS will be significantly associated with diminished improvement in PROMs after total ankle arthroplasty.

Methods:

All patients undergoing primary TAA between January 2007 and December 2016 who were enrolled into a prospective, observational study and who had at least 1 to 2-year minimum study follow-up were included. Patients were separated into 4 groups based on the presence or absence of SF36 MCS<35 and diagnosis of depression. Pre-operative to post- operative change scores in the SF36 physical and mental component summary scores (PCS and MCS), Short Musculoskeletal Function Assessment (SMFA) function and bother components, and visual analog scale (VAS) pain were calculated in 1 to 2-year follow-up. Multivariable, main effects linear regression models were constructed to evaluate the impact of SF36 and depression status on pre-operative to 1 to 2-year follow-up change scores with adjustment for age, sex, race, body mass index, current smoking, American Society of Anesthesiologist’s score, smoking, and Charlson-Deyo comorbidity score.

Results:

As in Table 1, adjusted analyses demonstrated that patients with MCS<35 and depression had significantly lower improvements in all change scores including SF36 MCS (-5.1 points) and PCS (-7.6 points), SMFA bother (6 points) and function scores (5.7 points), and VAS pain (7.5 points) compared with patients that had SF36>=35 and no depression. Patients with MCS<35 and no depression had significantly greater improvement in SF36 MCS (5.3 points) compared with patients that had MCS>=35 and no depression. Patients with MCS>=35 and depression had significantly lower improvement in SF36 MCS (-3.2 points) compared with patients that had MCS>=35 and no depression. Adjusted analyses of minimum 5-year outcomes demonstrated significantly increased improvement in MCS and SMFA function for patients with pre-operative MCS<35 and no depression.

Conclusion:

Presence of depression and decreased SF36 MCS are risk factors for diminished improvement in PROMs. Patients with depression and decreased MCS should be counseled about their risk of diminished improvement in outcomes compared to peers. As PROM’s become part of physician evaluations, it is becoming increasingly important to identify factors for diminished improvement outside of the physician’s control. [Table: see text]
Periprosthetic Fracture of the Talus following Total Ankle Replacement: A Case Series
Authors: Day Jonathan , Kim Jaeyoung , Ellis Scott J. , Deland Jonathan T. , O’Malley Martin J. , Demetracopoulos Constantine A.
Published: November 2020

Category:

Ankle; Ankle Arthritis; Trauma

Introduction/Purpose:

Although total ankle replacement (TAR) for the treatment of end-stage ankle arthritis has been shown to have excellent radiographic and clinical outcomes, there is a risk for complications such as periprosthetic fractures. While periprosthetic fractures of the tibia are well described in the literature, little is known about such fractures involving the talus. The purpose of this case series is to describe the radiographic findings and surgical management of talar fractures sustained after placement of total ankle prostheses.

Methods:

We retrospectively reviewed 489 patients who underwent total ankle replacement from June 2015 to March 2019, and identified five cases (2 males, 3 females, average age 45.7 years) in which patients sustained a periprosthetic fracture of the talus. All patients presented symptomatically with ankle pain during postoperative follow-up, and fractures of the talus were confirmed on computed tomography (CT) imaging. One patient had psoriatic arthritis and four patients had primary osteoarthritis of the ankle. CTs were reviewed to confirm location and pattern of the fracture, as well as related pathology such as osteolysis and subsidence. Hospital charts and operative reports were reviewed to record patient demographics and postoperative management including reoperations.

Results:

Overall the incidence of talar fractures was 1% (5/489) and all occurred in implants with a talar stem (4 INBONE II, 1 Salto Talaris). All fractures extended from the stem of the talar component into the subtalar joint, with one case of a non- displaced fracture. Osteolysis surrounding the talar stem was observed in all cases, with subsidence of the talar component observed in four out of five patients on CT. All five patients presented symptomatically and underwent reoperation (1 revision of talar component with ORIF, 3 subtalar fusions, 1 tibiotalar fusion).

Conclusion:

The findings in this case series suggest that periprosthetic fractures of the talus following total ankle replacement is a possible complication of stemmed implants and is associated with poor clinical outcomes requiring reoperation. Therefore, a periprosthetic fracture of the talus should be considered in a patient with unexplained pain and evidence of radiographic osteolysis around the stemmed component. [Table: see text]
Severe Ankle Varus Malalignment Management with a Fix-Bearing Total Ankle Replacement Implant
Authors: Silvestri Claudia A. Di , D’Ambrosi Riccardo , Maccario Camilla , Indino Cristian , Usuelli Federico Giuseppe
Published: November 2020

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

Despite Total ankle replacement (TAR) is currently considered a safe procedure and an optimal alternative to ankle fusion in end-stage ankle arthritis, still the precise indications and the limits of TAR are a highly controversial topic. Coronal malalignment correction with TAR is also a widely debated point. Purpose of this work was to confront two patient groups undergoing Total Ankle Replacement (a group of patients with a pre-operative ankle varus misalignment on coronal plane, versus a group of patients with neutral pre-operative ankle alignment) comparing clinical and radiographic results, complications and survival rate of the implant.

Methods:

171 patients, all affected by end-stage ankle arthritis and all treated with total ankle replacement with fix-bearing Trabecular Metal Total Ankle System (Zimmer-Biomet, Warsaw IN, USA), were divided in two groups. Group ‘A’ included 159 patients having a normal alignment or a slight valgus or valgus misalignment within 10°. Group ‘B’ included 12 patients with a pre- operative varus malalignment >10°. Each patient of the study was evaluated, clinically and radiologically, before and after surgery, and subsequently at 6 and 12 months follow-up, then once every year. Clinical evaluation comprised some score: visual analogue scale (VAS); American Foot and Ankle Society Score (AOFAS); and the Short Form (SF)-12 Quality of Life, in both of its ‘physical’ (PCS) and ‘mental’ (MCS) components. Radiological evaluated parameters were: tibio-talar surface angle (TTS), lateral distal tibial angle (LDTA-α), and anterior distal tibial angle (ADTA-β). Complications and implant survival rate were evaluated for both groups.

Results:

At a mean follow up of 2,75 years (range 2.09-5.66 years), improvement was found in all clinical and radiological evaluated parameters of two groups, without statistically significant differences between two groups at last follow-up. In group A most frequent reported complication was the presence of a fibular symptomatic hardware. Major complication were a deep arthroplasty infection and a 3 months post-operative ankle fracture-dislocation/periprostethic fracture. In group B there were 2 delayed wound healing, and one case of loosening of correction. No significant difference in complication and revision rate comparison between two groups was founded.

Conclusion:

Mid-term results reported in the present show that in patients with varus greater than 10 ° it is possible to obtain a post-operative alignment similar to pre-operative neutral ankles and that the complication rate is not greater. Despite this, is Authors opinion that major and complex misalignment should be approached by skilled surgeons, with an adequate learning curve experience, with a wide range of cases and in highly specialized centers.
Are Locked Plates Necessary to Maintain Reduction in the Treatment of Geriatric Ankle Fractures?
Authors: Dib Aseel G. , Crocker Caitlin Curtis , Prather John C. , Johnson Michael D.
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

Treatment of geriatric fractures are unique in their perioperative and postsurgical complications. Increased age, increased number of comorbidities, and decreased bone quality present a significant challenge when treating geriatric fractures, including ankle fractures. Recent studies have hypothesized using locking plates will lead to better outcomes compared to non-locking plates in geriatric ankle fractures. Conventional non-locking plates depend on the bone quality and screw-plate friction in order to achieve proper fixation and stability whereas locking plates do not. Locking plates are common in this patient population due to greater rigidity and biomechanical stability while not relying on bone quality to maintain fixation. This study aims to determine if locking plates are necessary to maintain reduction in geriatric ankle fractures.

Methods:

After approval from the Institutional Review Board, a retrospective chart review was performed on all patients 60 years or older sustaining an ankle fracture between 2012-2018. Patients with less than 3 months follow-up at the time of injury were excluded. Each patient underwent surgical fixation at the discretion of the attending surgeon for bimalleolar or trimalleolar ankle fractures. The following patient information was collected from the charts: age, mechanism of injury, and comorbidities. Radiographic review was performed to determine open or closed fracture status, the type of fracture pattern and presence or absence of a syndesmotic injury. Patient radiographs from the most recent follow-up were analyzed for maintenance of reduction and use of a locking or non-locking plate. Statistical analysis was performed using the Chi Square Test for significance and the Fisher’s Exact Test when necessary.

Results:

Out of 218 patients, 143 received locking plates (L) and 75 received non-locking plates (NL). There were 99 bimalleolar fractures (69.2%) and 44 trimalleolar fractures (30.8%) in the L group. The NL group had a higher percentage of trimalleolar fractures, 50.7% (38), with 37 bimalleolar fractures (49.3%) (p=0.004). The two groups did not differ in terms of mechanism of injury (p=0.906), high energy (39.2% in L and 41.3% in NL, p=0.773), and open fractures (24.5% in L and 17.3% in NL, p=0.227). Upon radiographic review, 142 patients in the L group (0.7%) and 72 patients in the NL group (4.0%) maintained reduction (p=0.119). Loss of reduction in the L group was a trimalleolar fracture whereas 2 bimalleolar and 1 trimalleolar fractures in the NL group.

Conclusion:

Our study demonstrates that there is not a greater loss of reduction when utilizing locking plates. Surgeons should keep this in mind when choosing constructs for fixation of geriatric ankle fractures.
Impact of Socioeconomic Status on Return to Work after Acute Ankle Fracture
Authors: Falk Alessandra L. , Hanstein Regina , Kulsakdinun Chaiyaporn
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

Socioeconomic status has been recognized throughout the medical literature, both within orthopedics and beyond, as a factor that influences outcomes after surgery, and can result in substandard care. Within the foot and ankle subspecialty, there is limited data regarding socioeconomic status and post-operative outcomes, with the current literature focusing on outcomes for diabetic feet. However, ankle fractures are among the most common fractures encountered by orthopedic surgeons. While a few studies have explored the impact of ankle fractures on employment and disability status, the effect of socioeconomic status on return to work post operatively has not yet been investigated. The purpose of this study was to determine the impact of low socioeconomic status on return to work.

Methods:

We retrospectively reviewed 592 medical charts of patients with CPT code 27766, 27792, 27814, 27822, 27823, 27827, 27829, 27826, 27828 from 2015-2018. Included were patients >18 yrs of age who sustained an acute ankle fracture, were employed prior to the injury, and with information on return to work after ankle surgery, zip code, race, ethnicity and insurance status. Excluded were patients who were not employed prior to their injury. Socioeconomic status was either defined by insurance status - Medicaid/Medicare, commercial, or workman’s compensation -, or by assessing socioeconomic status (SES) using medial household per capita income by zip code as generated and reported by the US National Census Bureau’s 2013-2017 American Community Survey 5-Year Estimates. The national dataset was divided into quartiles with the lowest quartile defined as low SES. Patients who had income that fell within this income category were classified as low SES.

Results:

174 patients were included with an average follow-up of 10.2months. 22/174 (12.6%) patients didn’t return to work post-operatively. Univariate analysis identified non-sedentary work to decrease the likelihood of return to work (HR:0.637; p=0.03). Patients with a low SES were more prevalent in the no return group compared to the return to work group (86% vs 60%; p=0.028). 95% of patients with low SES were a minority compared to 56% with average/high SES (p<0.005). Patients with low SES had a higher BMI (p=0.026), a longer hospitalization (p=0.04) and more wound complications (p=0.032). Insurance type didn’t affect return to work (p=0.158). Patients with workman’s compensation had a longer follow-up time and a longer time to return to work compared to other insurances (p<0.005 for each comparison).

Conclusion:

Low socioeconomic status based on income, not insurance type, affected return to work after an ankle fracture ORIF. Patients with workman’s compensation took a longer time to return to work compared to other insurance types. These findings warrants the need to consider socioeconomic status when allocating resources to treat these patients.
The Efficacy of Unfocused Extracorporeal Shock Waves for the Treatment of Achilles Tendinopathy
Authors: Fansa Ashraf M. , O’Malley Martin J. , Hurley Eoghan T. , Kennedy John G.
Published: November 2020

Category:

Sports

Introduction/Purpose:

Extracorporeal shock wave therapy (ESWT) may be a viable non-invasive treatment modality for patients suffering from Achilles Tendinopathy. There seems to be a relationship between the ESWT protocol and patient outcomes. Data suggest that higher energy levels of shock waves together with adequate treatment delivery to the affected area is necessary to achieve favorable outcomes. The aim of this study is present our experience with the use of electrohydraulically produced unfocused extracorporeal shock waves for the treatment of Achilles Tendinopathy.

Methods:

A retrospective analysis of prospectively collected data was performed, including all patients who had received ESWT for plantar fasciitis heel pain between January 2013 and September 2018. The primary outcomes included change in pain intensity on the visual analog pain scale and patient satisfaction at final follow-up. Pre and post-procedure Foot and Ankle Outcome Scores were also assessed for change.

Results:

A total of 158 patients (179 heels) were followed-up for a mean duration of 17 +- 6.8 months post ESWT. The mean pre-ESWT pain VAS improved from 7.2 +- 1.4 to 2.3 +- 2.1 (p< 0.001) at final follow-up. The FAOS Symptoms, Pain, Function of Daily Living, Function of Sports and Recreational activities and Quality of Life domains improved from 57.7 +- 12.7 to 79.7 +- 13.6 (p< 0.001), from 35 +- 15.8 to 72.6 +- 22 (p< 0.001), from 43.8 +- 15.3 to 81.4 +- 11 (p< 0.001), from 41.2 +- 21.3 to 66.4 +- 18.3 (p< 0.001) and from 33.9 +- 17.4 to 78 +- 24.4 (p< 0.001), respectively. Overall, 85.4% were satisfied with the procedure at final follow-up.

Conclusion:

For patients with Achilles tendinopathy, unfocussed extracorporeal shock wave therapy appears to be a safe and viable non-invasive treatment option with a patient satisfaction rate of 85.4% and a 68% reduction in patient reported pain intensity.
All-Inside Arthroscopic Cancellous Allograft for the Large Cystic Osteochondral Defect of the Talus
Authors: Feng Shi-Ming
Published: November 2020

Category:

Arthroscopy; Sports; Trauma

Introduction/Purpose:

The purpose of this study was to evaluate the surgical technique and long-term clinical outcomes of all- inside arthroscopic treatment for large cystic osteochondral defect of the talus with the use of cancellous allograft.

Methods:

Eight patients admitted from January 2016 to October 2018 by our hospital for large cystic osteochondral defect of the talus was retrospectively analyzed with their complete follow-up data. The subjects consisted of 5 males and 3 females, aged between 27 to 50 years, and with an average age of 34.2 years. All of these cystic osteochondral defects were larger than 15 mm in diameter, sized 1.3cm3 to 5.2cm3. The visual analogue scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS) score, The Karlsson Ankle Functional Score (KAFS) and subjective satisfaction survey rating were obtained. CT scan and magnetic resonance imaging of the ankle were obtained before and after surgery.

Results:

All incisions were healed in the first stage, and no complications such as nerve, blood vessel and tendon injuries occurred. All patients were available for follow-up at a mean of 26.2 months (range, 18 to 48 months). By the last follow-up, the postoperatively AOFAS 、 KAFS scores were 86.5 and 84.2 compared with 60.8 and 59.3 preoperatively, respectively. And the mean VAS score decreased from 6.4 preoperatively to 1.1. The range of motion of the ankle joint was normal and returned to the pre-pain state for these patients. Six patients rated their result as excellent, 2 as good and none as fair.

Conclusion:

All-inside arthroscopic cancellous allograft was an effective option for the treatment of large cystic talus osteochondral defects.
Chronic Lateral Ankle Instability with Subtalar Instability: Does Lateral Ligaments Reconstruction Reliable?
Authors: Feng Shi-Ming
Published: November 2020

Category:

Ankle; Arthroscopy; Sports

Introduction/Purpose:

To evaluate the functional outcomes of arthroscopic anatomical reconstruction of anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in the treatment of chronic lateral ankle instability with subtalar instability during short term follow-up

Methods:

We retrospectively analyzed data in 8 patients (5 males, 3 females; 2 left ankles, 6 right ankles) aged between 21 and 49 years, with an average age of 31.74 +- 8.48 years presenting with CLAI with subtalar instability from Auguse 2015 to October 2018. The duration of the symptoms lasted for 12 to 43 months, with an average of 24.26 +- 10.17 months. All patients underwent arthroscopic anatomical reconstruction of ATFL and CFL. Pre- and postoperative visual analogue scales (VAS), the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score (AOFAS) and the Karlsson Ankle Functional Score (KAFS) were compared to evaluate the curative effect of the operation

Results:

After surgery, all incisions healed in stage I and there were no complications. All patients were followed for 12 to 36 months, averaging 26.15 +- 9.34 months. At the final follow-up, the ankle varus stress test and ankle anterior drawer test were both negative. Range of joint motion was good. There was no lateral instability of the ankle and subtalar, and all patients returned to normal gait. The mean VAS score decreased to 1.06 +- 0.27, the AOFAS score increased to 93.16 +- 5.26 and the KAFS score increased to 92.01 +- 6.73. All the follow-up indexes were significantly different from those before surgery

Conclusion:

Arthroscopic anatomical reconstruction of ATFL and CFL in the treatment of chronic lateral ankle instability with subtalar instability is reliable in short term
Hindfoot Arthrodesis using the Medial Approach to Correct Adult Acquired Valgus Flat Feet: A Series of Cases
Authors: Ferraz Gabriel F. , Filho Miguel V. Pereira , Oksman Daniel
Published: November 2020

Category:

Hindfoot

Introduction/Purpose:

Hindfoot arthrodesis is used in patients with flat feet acquired in advanced stages, usually associated with degenerative joint disease. The objective of the study is to evaluate the clinical and radiographic results of hindfoot arthrodesis using the medial approach.

Methods:

A prospective cohort of 23 consecutive patients who underwent surgical correction between the years 2012 and 2018 through the hindfoot modeling arthrodesis was evaluated. Clinical assessment was performed using the visual analogue pain scale (VAS), AOFAS score for the hindfoot, SF-36 and FFI (Foot Function Index). Radiographic images were also analyzed, as well as satisfaction criteria.

Results:

In six procedures, calcanecuboid arthrodesis was included, with a small lateral access route. The average pain score decreased by 6.04 points (p <0.001), with an average final AOFAS of 75.63. Two cases presented talus necrosis, in three there was no consolidation of talonavicular arthrodesis, and in three others, synthesis material was removed. No case presented wound dehiscence and only one needed to treat superficial infection with antibiotics.

Conclusion:

Arthrodesis to correct adult acquired valgus flat feet can be performed using the medial approach with good clinical results and low rates of healing complications. However, about 25% of the patients had other complications that led to the need for a surgical approach.
Outcomes of Suture-Button Fixation for Treatment of Maisonneuve Injuries
Authors: Fox Rabun S. , Rogero Ryan G. , Corr Daniel , Raikin Steven M. , Pedowitz David I. , Larwa Joseph , O’Neil Joseph T. , Fuchs Daniel J.
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

The purpose of this study was to evaluate the radiographic and functional outcomes of suture-button devices for treatment of Maisonneuve injuries, which present unique considerations due to the proximal one-third fibular fracture, through which the distal fibular segment can potentially shorten.

Methods:

Patients undergoing operative management of Maisonneuve injuries from 2014-2018 utilizing suture-button devices with 2 fellowship-trained foot and ankle orthopedic surgeons were included. Exclusion criteria included use of a transosseous syndesmotic screw, fixation of the proximal fibular fracture, or less than 12 months follow-up. Medial clear space, tibiofibular clear space, tibiofibular overlap, talocrural angle, and distal fibular congruency on the injured and non-injured ankles were measured. Patients also completed the Foot & Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and -Sports subscales and Visual Analog Scale (VAS) for pain (n/100). Thirty-three patients were included.

Results:

Three (9.1%) patients experienced a postoperative complication, including 1 wound dehiscence and 2 requiring hardware removal. No significant differences were demonstrated in radiographic parameters measured between 6-week and final radiographs on the injured ankle, as well between final radiographs taken of the injured and uninjured ankles (Table 1). At mean follow-up of 34.7 (range, 12-58) months, patients had a mean FAAM-ADL of 91.1, FAAM-Sports of 81.7, and VAS pain of 14.3.

Conclusion:

This study demonstrates that isolated use of suture-button devices for syndesmotic fixation in Maisonneuve injury patterns is effective at maintaining fibular length and reduction of the syndesmosis, as well as achieving satisfactory patient outcomes. [Table: see text]
2.4mm Non-Cannulated Screws are Non-Inferior to 4.0mm Cannulated Screws for Medial Malleolar Fixation in Unstable Ankle Fractures
Authors: Fram Brianna R. , Schmitz Joseph L. , Rogero Ryan G. , Chang Gerard , Krieg James
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

Ankles fractures are the third most common adult fractures, representing significant cost to society. This makes the effectiveness of ankle open reduction internal fixation (ORIF) an important area for study. The majority of existing literature on medial malleolus fracture fixation involves biomechanical testing in synthetic bone or cadaveric models. We sought to compare the clinical efficacy of medial malleolar fixation with 2.4mm non-cannulated screws to 4.0mm cannulated screws by evaluating rates of loss of reduction and hardware failure.

Methods:

We performed a propensity-score-matched retrospective cohort study on patients who underwent ORIF of an unstable ankle fracture with fixation of the medial malleolus with either 2.4mm non-cannulated (N=51 ankles in 51 patients) or 4.0mm cannulated (N=60 ankles in 60 patients) screws. Vertically oriented medial malleolus fractures or those in which additional fixation was used were excluded. We identified post-operative complications and compared follow-up radiographs with immediate post-operative radiographs for signs of hardware failure or loss of reduction. Mean age was 50.2 years (SD 13.9). There was no significant difference between groups in age, BMI, Charleston Comorbidity Index (CCI), smoking or diabetes status. The 2.4mm patients were more likely to require syndesmosis fixation (56.9% 2.4mm, 30.0% 4.0mm, p=0.007) but not posterior malleolus fixation (25.5% 2.4mm, 28.3% 4.0mm, p=0.831). Most medial malleoli were fixed with 2 screws (1 screw 9.8%, 2 screws 90.2% 2.4mm, 1 screw 7.0%, 2 screws 93.0% 4.0mm, p=0.60).

Results:

There was no significant difference in total complications (7.8% 2.4mm, 15.0% 4.0mm, p=0.375), operative complications (5.9% 2.4mm, 5.0% 4.0mm, p=1.00), loss of medial reduction (3.9% 2.4mm, 6.7% 4.0mm, p=0.69), or medial hardware breakage (2.0% 2.4mm, 0% 4.0mm, p=0.45). The two patients in the 2.4mm screw group with loss of medial malleolus fixation were noncompliant with non-weight bearing restrictions and failed by screw backing out, while the 4 patients in the 4.0mm group failed by medial fracture fragment displacement around stable screws. The 4.0mm group had more nonoperative complications (0% 2.4mm, 10.0% 4.0mm, p=0.031); one of these was delayed union of the medial malleolus, while the remainder were delayed lateral wound healing or sural or superficial peroneal distribution paresthesias, which appeared unrelated to medial fixation type.

Conclusion:

When used for medial malleolus fixation in unstable ankle fractures, 2.4mm non-cannulated screws do not have higher rates of loss of reduction or hardware failure compared to 4.0mm cannulated screws. Given their decreased cost and equivalent ease of insertion, surgeons should consider their use when fixing unstable ankle fractures.
Immediate Weight Bearing and Range of Motion After Internal Fixation of Unstable Ankle Fractures: A Retrospective Controlled Study
Authors: Fram Brianna R. , Rogero Ryan G. , Corr Daniel , Chang Gerard , Krieg James , Raikin Steven M.
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

Ankle fractures are the third most common adult fractures. Further, they are the second most common fracture type to require inpatient admission, behind only hip fractures, despite occurring in a population on average nearly 30 years younger. There is evidence that early or immediate weight bearing and range of motion may be safe following ankle fracture fixation, but existing studies are small and largely exclude patients with syndesmotic or posterior malleolar fixation. We therefore studied the safety of immediate weight bearing as tolerated (IWBAT) and immediate range of motion (IROM) following open reduction internal fixation (ORIF) of unstable ankle fractures in a diverse cohort and attempted to identify risk factors for complications.

Methods:

We performed a retrospective case-control study. Out of 268 patients who underwent primary ORIF of an unstable ankle fracture from 2013-18, we identified 133 (49.6%) who were IWBAT and IROM. The treating surgeon excluded patients from IWBAT if they had an ipsilateral leg injury requiring non-weight bearing, a large displaced posterior malleolus fragment, or Maisonneuve injury with fracture of the proximal fibula. We used propensity-score matching to identify 172 controls who were non-weight bearing (NWB) and no range of motion for 6 weeks post-op. We reviewed medical records and radiographs for demographic, injury and treatment characteristics. Our primary outcome was complications. We compared demographics, injury characteristics, treatment episode, and complications between the IWBAT and NWB groups and performed within group analysis to identify risk factors for complications. A p-value <0.05 was considered significant.

Results:

The groups did not differ significantly in age, BMI, Charleston Comorbidity Index (CCI), smoking status, diabetes status, malleoli involved, percentages undergoing medial malleolus (60.9% IWBAT vs. 51.7% NWB, p=0.11), posterior malleolus (24.1% IWBAT, 26.7% NWB, p=0.59), or syndesmosis fixation (41.4% IWBAT, 42.4% NWB, p=0.85). There was no significant difference in total complications (9.8% IWBAT vs. 12.8% NWB, p=0.41), nonoperative complications (6.8% IWBAT vs. 8.7% NWB, p=0.53), or operative complications (3.8% IWBAT vs. 4.1% NWB, p=0.89). We did not identify any factors associated with increased complication risk, including posterior malleolus or syndesmosis fixation, diabetes, age, CCI or pre-injury assisted ambulation.

Conclusion:

IWBAT and IROM may be safe following ankle fracture ORIF in a broader patient population than previously believed. We did not identify specific risk factors for post-operative complications. Further study on patient selection may allow for more extensive use of this protocol to reduce the morbidity associated with unstable ankle fractures. [Table: see text]
Can Reducing Implant Costs Increase Revenue for Surgically Treated Ankle Fractures: Time Driven Activity Based Costing for 1 year Episode of Care
Authors: Freking Will , Okelana Bandele , McMillan Logan J. , Kibble Kendra , Parikh Harsh R. , Cunningham Brian P.
Published: November 2020

Category:

Ankle; Trauma; Other

Introduction/Purpose:

Implant selection may provide an opportunity to reduce costs and improve value in healthcare, but most orthopaedic surgeons are unfamiliar with the cost of surgical implants. Large variation has been reported in the overall cost of the surgical treatment of ankle fractures, largely due to variations in implant selection. The purpose of this study is to evaluate the relationship between implant selection and the Reimbursed Cost of Care (RCC) over the total cost-of-care over the entire care episode.

Methods:

A single payer database was queried for isolated ankle fractures from 2010-2017. Patient characteristics, implant cost, RCC and total cost of care for one-year episodes were collected. Total cost of care was determined via Time Driven Activity Based Costing (TDABC). Analysis consisted of multivariable linear regression and goodness-of-fit tests. The relative proportion of the implant cost to the RCC was defined as Ic/RCC.

Results:

Construct costs (Inpatient: $1563.30 vs Outpatient: $1143.00; p<0.01)TDABC cost of care (Inpatient: $3670.90 vs Outpatient: $2941.90; p<0.01)RCC (Inpatient: $17350.00 vs Outpatient: $10895.80; p<0.01) were all significantly lower for the outpatient setting. Construct costs constituted an estimated 38.8% of the total TDABC cost and 14.5% of the RCC. The difference between RCC and implant costs presented a significant negative trend with the total construct costs for outpatient procedures (B=-$1.54; p=0.03), but non-significant for inpatient (B=-$0.37;p=0.79).

Conclusion:

This study investigated the effect of implant cost on the total cost of care in surgically treated ankle fractures. We found an overall higher reimbursed cost of care (RCC) in the outpatient setting and a higher TDABC cost of care in the inpatient setting, reinforcing the trend towards outpatient surgical management. Implant selection proved not only a significant portion of the overall cost of care, but a driver of overall revenue.
Union Rates and Deformity Correction Using the Hintermann Osteotomy in Type IIb Flatfoot Deformity
Authors: Gallagher Brian P. , Hembree Walter C. , Schon Lew C.
Published: November 2020

Category:

Ankle; Hindfoot

Introduction/Purpose:

Multiple Lateral column lengthening procedures have been described for the correction of the abduction component of stage II flatfoot deformity. The Hintermann osteotomy, although technically difficult, offers powerful lengthening of the lateral column with low risk of violating the articular cartilage of the subtalar joint as compared to the more widely performed Evans osteotomy. This study reports on the radiographic and clinical outcomes of the Hintermann osteotomy performed by a single surgeon.

Methods:

Patients who underwent reconstruction for stage II flatfoot deformity with a Hintermann lateral column lengthening were restrospectively identified. The talus-1st metatarsal angle, percent talus uncoverage, calcaneal pitch, lateral column length, CC joint subluxation, and distance from CC joint to the osteotomy were measured on pre and postop radiographs. Radiographic union was also assessed. The Kellgren-Lawrence scale was used to assess degenerative changes at the ST, CC, and TN joints. Charts were reviewed for comorbidities, clinical evidence of union, time to protected weightbearing, time to unrestricted weightbearing, signs of peroneal irritation, clinical signs of osteoarthritis progression, and complications. A paired students t test was used to identify differences in radiographic parameters.

Results:

Twenty-six patients (30 feet) met inclusion criteria. All osteotomies achieved union with only 1 (1/30) instance of delayed union. Average duration before clinical and radiographic union was 12.6 weeks (9-37). The AP Talus-1st metatarsal angle decreased on average of 12.3 degrees (STD 9.1) (p<0.0001). Percent talus uncoverage decreased on average 17.7 percent (STD 11.5%) (p<0.0001). Subluxation at the CC joint was found to increase on average 1.63mm (STD 1.99) (p<0.01). Only 3 patients (10%) had radiographic progression of osteoarthritis at either the CC or ST joint. No patients showed clinical signs of osteoarthritis and none went on to fusion. One patient had lateral hardware pain necessitating plate removal.

Conclusion:

The Hintermann osteotomy is a powerful tool for lateral column lengthening. In this series there was significant correction of the preoperative abduction deformity with no nonunions. Degenerative changes in the surrounding hindfoot joints were rare. One benefit of the Hintermann osteotomy is its ability to preserve the articular cartilage of the anterior and middle facets.
Cerclage Fixation of Navicular Fractures
Authors: Gallivan Robert E. , Kupcha Paul C.
Published: November 2020

Category:

Midfoot/Forefoot; Trauma

Introduction/Purpose:

Navicular fractures are commonly seen midfoot fractures that can be easily missed and difficult to treat. More severe fractures result from forces that compress the talar head into the navicular causing the navicular to displace radially like staves of a barrel. In a case report from Foot and Ankle International, Naidu and Singh (2005) showed a displaced comminuted intra-articular navicular fracture that was treated innovatively with a cerclage wiring technique. To our knowledge, this is the only published report of a navicular fracture treated with this approach. Since that time the senior author has treated over 25 of these severe fractures with a similar cerclage wiring technique. Over time this technique has evolved and now preferentially involves use of an Arthrex FiberTape cerclage system.

Methods:

The surgical technique is described as follows. First a small incision is made over the medial pole of the navicular. A lead suture is then passed after subperiosteal dissection along the plantar surface of the navicular and received at a similar incision at the lateral pole. The original technique we employed involved the use of a Dall-Miles cable and cable passer but has been supplanted by the lead suture technique or by using the needle of an Arthrex FiberTape. Once control of the plantar surface is accomplished, subperiosteal dissection is made along the dorsal surface with a Kelly clamp or small periosteal elevator. The lead suture is then delivered to the medial pole which then allows for circumferential control of the fracture fragments. The FiberTape is then passed by pulling the lead suture which delivers the FiberTape circumferentially. This provides indirect reduction by radial compression as it is sequentially tightened.

Results:

We have performed over 25 cases in a similar manner and in our experience have found this to be the best fixation and reduction technique available (Image 1 & 2).

Conclusion:

This approach demonstrates a safe, expedient, minimal incision surgical approach that provides optimal fixation of these difficult navicular fractures.
Safety and Efficacy of Tranexamic Acid in Total Ankle Arthroplasty
Authors: Ghobrial Philip G. , Schmitt Daniel , Brown Nicholas M. , Pinzur Michael S. , Schiff Adam P.
Published: November 2020

Category:

Ankle; Other

Introduction/Purpose:

Tranexamic acid (TXA) has been shown to significantly reduce blood loss in patients undergoing total knee arthroplasty and total hip arthroplasty. However, there is a paucity of data regarding its safety and efficacy in total ankle arthroplasty (TAA). In light of expanding indications for TAA and its growing utilization, there is a need for more data regarding interventions such as TXA that may reduce perioperative complications and improve patient outcomes for this procedure. The purpose of the current study was to determine if the use of TXA in patients undergoing total ankle arthroplasty impacts the blood loss or overall complication rate.

Methods:

A retrospective chart review was conducted for 34 patients who underwent TAA with (n=17) and without (n=17) intraoperative TXA from 2016 to 2019 at a single academic medical center. Inclusion criteria were patients who underwent TAA for any clinical indication and had quantified intraoperative blood loss. Patients were excluded if they had a contraindication to TXA (ie. impaired renal function), a history of coagulopathy, no recorded intraoperative blood loss, or intraoperative complications that resulted in excessive bleeding. Estimated blood loss, pre-to-postoperative hemoglobin changes, hidden blood loss and complication rates were recorded and compared between groups. Statistical analysis was performed using SPSS 21.0.

Results:

There was no statistically significant difference in recorded blood loss, total calculated blood loss, pre-to-postoperative hemoglobin difference or hidden blood loss between the groups (all, p>0.05). A lower rate of wound complications was observed in the TXA group. The difference between the overall complications rates observed for each group was not statistically significant (p>0.05).

Conclusion:

Intravenous tranexamic acid did not result in decreased blood loss during TAA, as measured in our study. However, tranexamic acid was not associated with any increase in overall complications while a lower rate of wound complications was seen in patients in which TXA was utilized. Based on our findings, further studies are needed to better elucidate the impact of TXA on blood loss and wound healing in TAA. [Table: see text]
Humanitarian Medical Trips after COVID-19: Perspectives from Volunteers
Authors: Gokcen Eric C. , Vosseller J. Turner
Published: November 2020

Category:

Other

Introduction/Purpose:

The COVID-19 pandemic has caused major disruption in all areas of life around the world. Volunteers that are involved in providing international humanitarian medical trips may have reservations about resuming these trips. The purpose of this study was to determine the perspectives of previous international humanitarian medical trip applicants regarding resuming these trips.

Methods:

A ten-question survey was given to 27 physicians that had previously applied to go on a humanitarian trip to Vietnam in 2020 with the American Orthopaedic Foot & Ankle Society. Recipients were given 3 weeks to complete the survey, with three reminders sent. 19 completed the survey for a 79% response rate.

Results:

47% of the respondents were ages 36-49, with 47% from the USA. 47% had been on 1-5 previous medical trips. All of the respondents are still considering going on a future trip. The majority (79%) anticipate being able to resume travel by June 2021. 74% will determine when to go based upon government clearance for travel and 79% will take into consideration the COVID-19 status at the host site. Only 2 respondents (11%) would wait for their practice to stabilize economically.

Conclusion:

Although the COVID-19 pandemic has severely limited the ability to travel for international humanitarian medical trips, previous volunteers and applicants are still anticipating resuming these trips within a year. Most are monitoring government restrictions and the COVID-19 status at the host site as the main determinants for going. Once these factors are favorable, humanitarian medical trips will be able to resume. Those that are planning these trips should continue their preparations.
Influence of Interventions on the Sural Complex like the Gastrocnemius Recession on the Calf Strength
Authors: Gottlieb Tonio , Klaue Kaj
Published: November 2020

Category:

Ankle; Hindfoot; Midfoot/Forefoot; Other

Introduction/Purpose:

Increasing evidence has shown that gastrocnemius tightness is related to various types of foot and ankle pathology. The recession and lengthening of the gastrocnemius has become an important ancillary procedure in many reconstructive operations, such as hallux valgus, pes plano-valgus and total ankle arthroplasty surgery. Additionally, isolated Gastrocnemius Recession is also performed alone to treat plantarfasciitis, achillestendinosis, metatarsalgia and diabetic forefoot ulceration. The reports about the clinical results are encouraging, but evident data about the resulting strength of the treated muscle is lacking.

Methods:

This study was designed to measure calf-strength of every patient before and after Gastrocnemius Tenotomy, Gastrocnemius Recession, Achillestendon lengthening. The data was taken before surgery and one year post-op. A Leonardo Mechanograph GRFP was used to measure calf-strength with bended and extended knee on both sites. 85 patients were measured before surgery. 58 of these patients underwent a intervention on the sural complex. The interventions included Gastrocnemius Tenotomy, Gastrocnemius Recession, Achillestendon lengthening combined with different types of foot and ankle reconstruction.

Results:

The results show that the calf strength decreased overall significantly. The force on the operated site decreases significantly with bended and extended knee. However, contralatrel forces diminish in the same dimension. The decrease in force was mainly related to the force during knee extension. There was no significant force difference postoperatively between ipsi- and contralateral.

Conclusion:

Apparently, a surgical intervention on the foot seems to cause a weakening of the flexor muscles on both lower legs. Not surprisingly, the greater reduction in strength is during knee extension. Apparently, however, the loss of strength on the operated foot is compensated, so that ultimately there is the same strength on both side.
The Jones Dressing Cast for Safe Aftercare of Foot and Ankle Surgery: A Modification of the Jones Dressing Bandage
Authors: Gottlieb Tonio , Klaue Kaj
Published: November 2020

Category:

Ankle; Basic Sciences/Biologics; Hindfoot; Midfoot/Forefoot; Trauma; Other

Introduction/Purpose:

The management of postoperative soft tissue healing is fundamental for the success of elective foot and ankle surgery. As postoperative edema is more relevant in such surgery due to its localization, soft tissue healing can take longer and pain can restrict function. There is no universal approach to surgery aftercare among foot and ankle surgeons. Although infections following foot and ankle surgery are rare, soft tissue healing can be jeopardized after extensive and multiple approaches. Postoperative edema, however, is common and contributes to unfavorable conditions for wound healing. Our study addresses the results of avoiding postoperative edema with the use of the Jones dressing cast.

Methods:

We defined a precise fixation technique of the foot and ankle in the immediate post-operative phase using what we call ‘the Jones dressing cast’. This technique is a modification of the Jones dressing bandage. In a previous study we compared two groups of patients (N = 20/23) who underwent similar reconstructive surgery with the application of the described cast for one week and without. At the twomonth follow-up we observed that the group treated with the cast required less pain relief, spent less time in hospital and achieved faster autonomy using crutches (Gottlieb and Klaue, 2013). In this study we considered a group of 45 patients who underwent similar reconstructive procedures to those in the first study and who were treated with the cast for two weeks post-operatively. There was no visual check of the soft tissues before removal of the cast.

Results:

Although patients in Group 2 had more complex surgery, mobility was achieved earlier and hospitalization time was shorter. The incidence of infection was lower in the group wearing the cast for 2 weeks. The patients treated with the cast for 2 weeks regained autonomous mobility significantly earlier than those in Group 1 (cast 1 week or less).

Conclusion:

The Jones dressing cast is a useful tool that can help minimize postoperative complication rates. Wearing the cast for two weeks is preferable. Our study suggests its effectiveness in reducing soft tissue complications and facilitating independent mobility.