bluuebunny/crossref_metadata_2025 huggingface dataset:
Disclosures Undisclosed
Authors: Janney Cory F. , Safavi Kiya Shazadeh , Schneider Greg , Jupiter Daniel , Panchbhavi Vinod
Published: October 2019

Category:

Ethics

Introduction/Purpose:

The objective of our study was to analyze COI nondisclosure for US based research articles that were published to three prevalent orthopaedic journals from the beginning of 2014 to the end of 2016.

Methods:

All US-based research articles published to FAI, JBJS, and JOA from the beginning of 2014 to the end of 2016 were reviewed. COI disclosure sections were analyzed to determine if a disclosure was made for first and/or last authors. Authors disclosing any financial relationship involving employment, royalties/licensing, speaking, and consulting fees were recorded as having disclosed a potential COI. First and last authors were then searched for using CMS Open Payments search tool to determine if they had received any of the aforementioned payment types. To determine if a COI nondisclosure (disclosure discrepancy) was present, an author’s disclosure statement for a published article was compared to CMS Open Payments data from the year prior to publication of the article. We used CMS data from the year prior to a publication to account for the time it takes to construct a paper and have it published.

Results:

Across all journals and years, we obtained disclosure accuracy data for 3,465 total first and last authors publishing 1,770 research articles. Within this sample, 7.1% (245/3,465) of the authors had a recorded undisclosed conflict-of-interest and 13.2% (233/1,770) of articles had a first and/or last author with an undisclosed potential conflict-of-interest. When looking at each journal individually over the three-year period, FAI contained the highest percentage of authors with undisclosed COI’s (42.3%), JBJS contained the lowest percent of authors with an undisclosed COI (4.6%), and JOA had an intermediate amount of authors with an undisclosed COI (7.0%).

Conclusion:

Discrepancies between payment disclosures made by authors and those published in the CMS database were present in all three journals reviewed in this study. The percentage of articles containing an author with a disclosure discrepancy varies widely between these journals. However, when analyzing the percentage of disclosure discrepancies by year, no trend was found.
The Outcomes of Bone Grafting of Peri-Prosthetic Total Ankle Osteolytic Lesions: A Meta-Analysis
Authors: Mahmoud Karim , Alhammoud Abduljabbar , Metikala Sreenivasulu , O’Connor Kathryn , Farber Daniel
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Total ankle replacement (TAR) has become an increasingly popular alternative to ankle arthrodesis as a treatment option for end-stage ankle arthritis. However, total ankle implants are not without short and long-term complications and one of the most common is peri-prosthetic osteolysis, Many studies have been done on the incidence of peri-prosthetic bone cysts as well as the etiology, but there have been limited reports on the optimal management of these lesions. The most widely accepted method of treatment is curettage and grafting of the lesion with or without polyethylene exchange. Our aim was to perform a systematic review of the literature on the outcome of bone grafting in the management of periprosthetic osteolytic following TAR.

Methods:

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, Medline, PubMed, Scopus, and Google Scholar databases were searched in November and December 2018 for all observational or experimental studies that evaluated bone grafting of peri-prosthethic total ankle osteolytic cysts. The primary outcome was the rate of major revision to either component replacement or ankle arthrodesis and the secondary outcome was the rate of radiological cyst progression after grafting. Descriptive, quantitative, and qualitative data were extracted.

Results:

Of the 70 articles identified, 6 studies were eligible for the meta-analysis for a total of 120 patients with 123 total ankle replacements. Average age of subjects was 58.5 years. 4 papers included details of patient gender revealing 50 males and 26 females in those studies. The most common type of total ankle replacement was the Ankle Evolutive System(AES) followed by the Scandinavian total ankle replacement (STAR). With an average follow up 5.1 years (1.4-15.4), the rate of conversion to major revision after curettage and bone grafting was 15% (7.6%- 22.4%). Despite that apparent success, there was a 40.4% (5.4%-75.4%) rate of radiological cyst progression after grafting

Conclusion:

Our systematic review shows that curettage and bone grafting of the osteolytic lesions around TAR is safe procedure which can increase the survivorship of the implant and delay the need for further major surgeries. Providing better bone stock for later revision may also be of benefit. However, the high rate of cyst progression is worrisome for future complications. This highlights the need to further research the etiology of the cyst and to explore treatments aimed at eliminating the cause of cysts to prevent the need for repeat procedures and the potential for implant failure.
Three-Dimensional Displacement after a Medializing Calcaneal Osteotomy in Relation to the Hindfoot Alignment and Osteotomy Angle
Authors: Peiffer Matthias , Belvedere C. , Clockaerts S. , Leenders T. , Barg Alexej , de Cesar Netto Cesar , Lintz Francois , Richter Martinus , Leardini A. , Burssens Arne
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

An adult-acquired flatfoot deformity is a three-dimensional (3D) condition characterized by a loss of the medial longitudinal arch, valgus alignment of the hindfoot, and abduction of the midfoot. When conservative measures are not sufficient, a medializing calcaneal osteotomy (MCO) is frequently performed to correct the deformity, but there is lack of data on the associated three-dimensional variables defining the final correction. A possible reason for this shortcoming could be the current image-based analyses, mainly performed on bi-dimensional radiographs. These are hampered by errors in 3D rotations and superimposition of bony structures. The aim of this study was therefore to assess the correlation between the preoperative hindfoot valgus deformity and calcaneal osteotomy angle and the postoperative calcaneal displacement by use of weightbearing CT (WBCT).

Methods:

Weight-bearing CT scans obtained pre- and post-operatively were analyzed for sixteen patients with a mean age of 49.4 years (range: 18-66 years). Indication for surgery was adult-acquired flat foot deformity stage II. Based on the WBCT images, pre- and post-operative 3D bone morphological models of the tibia, talus, calcaneus, and the second metatarsal were created, on which anatomical bony landmarks were computationally identified to define a Foot Anatomical reference Frame (FAF). This FAF was used to measure valgus deformity pre- and post-operatively, inclination of the osteotomy plane, and displacement of the calcaneus (Fig. 1). Linear regression was conducted to assess the relationship between these measurements.

Results:

On average, the hindfoot valgus changed from 13.1° (±4.6) preoperatively to 5.7° (±4.3) postoperatively. A mean inferior displacement of 3.2 mm (±1.3) was observed along the osteotomy with a mean inclination angle of 54.6° (±5.6), 80.5° (±10.7), - 13.7° (±15.7) in the axial, sagittal and coronal planes, respectively. A statistically significant positive relationship (P < .05, R2 = 0.6) was found between the preoperative valgus, the axial osteotomy inclination, and the inferior displacement.

Conclusion:

This study shows that the degree of preoperative valgus of the hindfoot and the axial osteotomy angle are predictive factors for the amount of postoperative plantar displacement of the calcaneus. These findings contrast the general recommendation of performing a 90° calcaneal osteotomy angle, i.e. perpendicular to the lateral calcaneal wall in every patient. The obtained factors should be taken into account when performing a MCO and could be integrated in a computer-based pre- operative planning.
Outcomes of Isolated Peroneal Tendoscopy for Treatment of Peroneal Tendon Disorders
Authors: Smith Jeremy T. , Abdurrob Abdurrahman , Sangeorzan Adam , O’Donnell Seth , Bluman Eric M.
Published: October 2019

Category:

Arthroscopy

Introduction/Purpose:

Peroneal tendoscopy may be used to treat patients with peroneal tendinopathy. It is typically used for diagnostic purposes and to address tendinopathy in the absence of large tendon tears. Its value includes preservation of the superior peroneal retinaculum, small incision size, and faster postoperative recovery compared to open treatment. The goal of this study is to explore the functional outcomes of patients who have undergone isolated peroneal tendoscopy.

Methods:

Consecutive adult patients who underwent isolated peroneal tendoscopy between January 2010 and January 2018 at a single Foot and Ankle center were identified. The electronic medical record and operative notes were reviewed to identify patients with a minimum 12-month follow-up. Those undergoing open tendon repair, tendon transfer, peroneal groove deepening, and any other concurrent foot or ankle procedure were excluded from the study. Eligible patients were administered the PROMIS Physical Function-Short Form 10A (PF SF10A), Foot and Ankle Ability Measure (FAAM), and the Visual Analog Scale (VAS). Demographic information was also collected. Data was pooled, and descriptive analyses and unpaired T-tests were conducted.

Results:

Thirty patients met inclusion criteria and 22/30 patients (73%) were able to be reached. Our patient cohort was predominantly female (90.9%), had a mean age of 46.4 years, and an average BMI of 27.6. The mean pre-operative FAAM and PROMIS PF SF10A for patients were 58.3 and 39.7, while the mean post-operative FAAM and PROMIS PF SF10A were 83.3 and 50.5, respectively. There was a statistically significant improvement between the mean pre-operative and post-operative FAAM and PROMIS PF SF10A scores for patients (p =0.0050 and 0.0025, respectively) with a mean improvement of 25.0 in FAAM and 10.8 for PROMIS PF SF10A scoring. At an average of 33.4 month follow-up, the mean VAS for pain was 20.9 out of 100.

Conclusion:

Isolated peroneal tendoscopy is an effective treatment for patients who have peroneal pain in the absence of frank tears or tendon instability. The improvement in FAAM and PF SF10A scores was statistically significant and exceeds published MCIDs for both FAAM and PROMIS PF SF10A. Additional research is required to further evaluate the effectiveness of peroneal tendoscopy as compared to other methods of treating peroneal tendinopathy, such as open peroneal tenosynovectomy.
Incidental Findings on Foot and Ankle Radiographs as Compared to Other Anatomic Regions
Authors: Velasco Brian , Ye Michael , Chien Bonnie , Kwon John Y. , Miller Christopher P.
Published: October 2019

Category:

Orthopedic Radiology

Introduction/Purpose:

Radiographs are one of the most common and widely available diagnostic imaging techniques that are used to evaluate orthopedic conditions. However, incidental findings on imaging may be observed as well, some of which may be very serious and have significant heath as well as legal ramifications if missed. This study evaluates the number of clinically relevant incidental findings reported for orthopaedic radiographs ordered in an academic orthopedic multispecialty group over one year.

Methods:

A retrospective review was conducted of 13,948 eligible radiographs recorded at our institution over a 12-month period. Reports were categorized based on exam type. Incidental findings were first categorized as either concern for malignancy or non-malignancy. The possibly malignant findings were further subdivided into malignancies in Bone or Lung tissues. The non- malignant findings were categorized into the following groups: Benign Bone Disease, Gastrointestinal Pathology, Gynecologic Pathology, Incidental Fracture, Infection, Inflammation, Respiratory Pathology, Soft Tissue Mass, Urologic Pathology, Vascular Pathology or Other.

Results:

Of the 13,948 radiographs, 286 radiographs reported at least one incidental finding totaling to 287 (2.06%) incidental findings. The 3 studies with the highest rates of incidental findings were Leg Length Alignment films (3.94%), Spine (3.88%), and Pelvis & Hip (2.76%). The three categories with the lowest rates of incidental findings were Hand & Wrist (0.56%), Tibia/Fibula Foot & Ankle (0.84%), and Forearm & Elbow (1.13%). Over one-third of incidental findings concerned malignancy or metastases with 87 (30.1%) and 18 (6.23%) identified in bone tissue and lung tissue, respectively. Benign Bone Disease (24.9%), Gastrointestinal Pathology (6.57%), and Gynecologic Pathology (5.88%) were categories with the highest rates of non-malignant incidental findings. Follow-up was recommended for 122 (42.5%) incidental findings.

Conclusion:

This study describes the rates of incidental findings on orthopedic radiographs. Radiographs of midline structures are more likely to report an incidental finding as opposed to radiographs of distal extremities. The exception is leg alignment films because these image the entirety of the lower extremity and the pelvis and thus a far larger volume of the body. Over one-third of incidental findings concerned possible malignancy or metastases and therefore follow-up with focused imaging should be recommended if suspicious. This information will be particularly useful for orthopaedic surgeons who read their own radiographs without a radiologist formally reviewing the films.
Learning Curve for Open Reduction and Internal Fixation of Displaced Intra-Articular Calcaneal Fracture by Extensile Lateral Approach Using the Cumulative Summation Control Chart
Authors: Ahn Jungtae , Kim Tae Yong , Kim Tae Wook , Jeong Bi O
Published: October 2019

Category:

Trauma

Introduction/Purpose:

Open reduction and internal fixation (ORIF) of displaced intra-articular calcaneal fracture (DIACF) by extensile lateral approach is widely used but is technically challenging. In this study, the learning curve for ORIF of DIACF by extensile lateral approach was investigated.

Methods:

Between March 2014 and July 2018, 45 cases consisting of 40 patients underwent operative treatment for DIACF by the extensile lateral approach performed in all instances by a single surgeon. A moving average and cumulative summation control chart (CUSUM) were used for learning curve analyses. Operative failure was defined when at least one of the following parameters were unsatisfactory: reduction of Gissane angle and Böhler angle, posterior facet congruency, calcaneal width, subfibular impingement, axial alignment, or calcaneocuboid joint congruency.

Results:

The mean operating time was 117.4 min. Regarding the quality of reduction, the mean preoperative sum of the 7 parameters was 5.1 and improved to 0.6 postoperatively. The CUSUM for operative success peaked in the 20th case. The CUSUM and moving average graphics of operating time peaked at the 9th case and registered nadirs at the 34th case, with slight ascent and decent. The operating time for twenty cases in phase 1 (1–20) and for twenty-five cases in phase 2 (21–45) of the learning curve did not differ significantly. There was no statistical difference in the severity of fracture pattern. By comparison, significant differences in phase 2 patients showed a better postoperative reduction quality.

Conclusion:

As indicated by multidimensional statistical analyses, primary technical competence in improving the reduction quality of DIACF was achieved after the initial learning period with 20 cases. After the learning curve for ORIF of DIACF, a better reduction quality in the sum of reduction parameters was observed.
Change in Bone Mineral Density after Total Ankle Replacement: Two Year Follow Up
Authors: Alkhreisat Mohammad , Al-Maiyah M , Ramaskandhan Jayasree Ramas , Nicolas Andrea Pujol , Rawlings D , Purushothaman B , Farrier A , Siddique Malik
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Bone strength about the components is an important factor in Arthroplasty survival. This importance has been studied in total hip & knee replacement. However, there is paucity of literature Where little has been published regarding the quality of the bone and bone mineral content postoperatively surrounding Ankle Arthroplasty and circumstances surrounding the development of stress fracture. This prospective study used a method to quantify Bone Mineral Density BMD in different regions of the surrounding bones adjacent to tibia and talar components of uncemented Mobility ankle prosthesis, and to study the effect of loading on local ankle bone in the presence of un-cemented three components ankle replacement, by analyzing the BMD of the areas around tibia and talus before and after Mobility total ankle replacement.

Methods:

Twenty three Ankles (7Females, 15 Males) who underwent a Mobility Total Ankle Arthroplasty (TAA) between March 2008 and April 2009 were included prospectively in this study. They underwent a Bone Density Scan using the DEXA HOLIGIC Scanner with the specific method designed for measuring BMD. Seven areas (R1-R7) around the prosthesis were studied (Please see attached figure). Scans were carried out pre-operatively and repeated at 1 and 2 years post-operatively. The results were also compared with clinical outcomes, using (AOFAS scores) both pre, 1 and 2 years post-op.

Results:

Mean age of patients was 63.3 years (SD 9, range 43 to 80). AOFAS scores showed significant improvement (from 28.8 pre-op to 78.7,76.9 at 12 and 24 months post-op respectively; p<0.05). BMD within the lateral malleolus decreased significantly from 0.5g/cm2 to 0.42g/cm2 (17%, P < 0.01), at one and two years postoperatively - R2. There was an insignificant increase in Mean BMD at medial side metaphysis of tibia increased by,7% (+0.07 g cm -2, R6), but this just failed to reach statistical significance, mean BMD within medial malleolus decreased slightly from 0.67g/cm2 to 0.64 g/cm2 at the same period which was statistically insignificant. There was little insignificant increase in BMD in tibia just proximal to implant (R7) and at talus (R5).

Conclusion:

Stemmed implant causes changes in Tibial BMD around prosthesis. There was stress shielding over the lateral malleolus resulting in decrease BMD in lateral malleolus and to a lesser extent of the medial malleolus. The increase in BMD at tibial metaphysis indicates an increase in mechanical stresses at that region, which may explain occasional postoperative stress fracture of medial malleolus or medial sided ankle pain. There is no further change in BMD from year 1 to year 2 following TAR.
Patients Reported Outcomes (PROMS) in Hallux Valgus and Rigidus Surgery, Is There Any Difference?
Authors: Alkhreisat Mohammad , Nicolas Andrea Pujol , Ramaskandhan Jayasree Ramas , Mousa Adham , Qasim Sultan , Siddique Malik
Published: October 2019

Category:

Bunion

Introduction/Purpose:

There is paucity of literature comparing foot and general health status including quality of life between patients presenting with Hallux Valgus and Hallux Rigidus and to compare the outcomes of people how had surgery in either one. We compared foot specific patient reported disability and general health status between patients presenting with Hallux Valgus and Hallux Rigidus pre and post-surgery.

Methods:

All patients operated between June 2016 and December 2017 with a diagnosis of primary Hallux Valgus or Hallux Rigidus were invited to the study. Patients were grouped based on diagnosis into Group A (Hallux Valgus) and Group B (Hallux Rigidus). All patients received a Pre-Operative and post-operative questionnaire with a minimum of 6 months follow up. Differences were studied between groups for scores of MOX-FQ, EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) comparing both pre and post-operative.

Results:

There were 53 patients with Hallux Valgus and 46 patients with Hallux Rigidus of 1st MTPJ. Pre-operatively in MOX-FQ both groups reported similar level of pain (p=0.776), difficulty with walking/ standing (p= 0.960) and restriction with social activity because of foot symptoms (p=0.683). Following surgery both groups significantly improved in all domains (p< 0.001). Post- operatively there was no difference between both groups for MOX-FQ (pain, walking, social domains; p>0.05), EQ-5D general health score (p=0.404) and FAOS domains for pain (p=0.653), symptoms (p=0.230), ADL (p=0.587), and quality of life (p=0.876). But all scores improved significantly from pre-op to post-op for both groups (p<0.001).

Conclusion:

There is no difference in foot related quality of life, general health status and higher functional disability levels between patients presenting with Hallux Valgus vs. Hallux Rigidus before surgical intervention. The impact of these conditions on disability levels remain the same, amidst the difference in pathology. Surgery for both pathologies equally improves foot related quality of life and functional disability levels equally between the 2 pathologies keeping in mind the difference in surgical indications as well as type of surgery performed.
Intra- and Intraobserver Reliability of Radiologic Flatfoot Parameters Before and After Surgery
Authors: Bock Peter
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

Various radiological parameters are used to evaluate a flatfoot deformity and their measurements may differ. The aims of this study were to answer the following questions: 1) Which of the 11 parameters have the best inter- and intraobserver reliability in a standardized radiological setting? 2) Are pre- and postoperative assessments equally reliable? 3) What are the identifiable sources of variation?

Methods:

Measurements of the 11 parameters were recorded on anteroposterior and lateral weightbearing radiographs of 38 feet before and after surgery for flatfoot, by three observers with different experience in foot surgery (A, ten years; B, three years; C, third-year orthopaedic resident). The inter- and intraobserver reliability was calculated.

Results:

Preoperative interobserver reliability was high for four, moderate for five, and low for two parameters. Postoperative interobserver reliability was high for four, moderate for five, and low for two parameters. Intraobserver reliability was excellent for all parameters preoperatively as recorded by observer A (PB) and B (MP), and for eight parameters as recorded by observer C (SR). Intraobserver reliability was excellent for ten parameters postoperatively as recorded by observer A and B, and for eight parameters as recorded by observer C.

Conclusion:

The following parameters can be recommended. For preoperative and postoperative evaluation of flatfoot: anteroposterior, talonavicular coverage angle; lateral, talometatarsal I angle, calcaneal pitch angle, and cuneiform medial height (high interobserver reliability); and anteroposterior, talometatarsal II angle; lateral, talocalcaneal angle, tibiocalcaneal angle (moderate interobserver reliability). For more experienced observers, we also recommend the anteroposterior talometatarsal I angle (moderate reliability). The inter- and intraobserver reliability for most parameters were similar pre- and postoperatively. The experience of the observer and the definition and ability to measure the parameters themselves were sources of variation.
Ankle Gravity Stress View in the Seated Position: A Technical Tip
Authors: Briceño Jorge , Chien Bonnie , Miller Christopher , Velasco Brian , Kwon John Y.
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Diagnosis of mortise instability in the apparent isolated lateral malleolus fracture can be challenging and often relies on stress radiography. While the gravity stress view (GSV) is commonly utilized, it traditionally requires the patient to assume the lateral decubitus position for imaging of the ankle. This can be difficult and uncomfortable for the patient and may be unsafe in particular situations. Furthermore, transferring the patient back and forth to obtain this positioning is time-intensive for the radiology technician and disruptive to clinic throughput. Therefore, we describe a simple technique that allows acquisition of the GSV of the ankle while the patient remains seated. The technique involves minimal patient movement and is simple for the staff to position appropriately.

Methods:

The patient is seated on either a stable office chair with arms for safety or in a wheelchair. The affected limb is then placed on a padded stool with the foot extended past the edge of the stool. The patient is instructed to maintain the ankle in a comfortable resting position. They are then encouraged to externally rotate at the ipsilateral hip. If needed, a small bump can be placed underneath the contralateral hip to further increase external rotation of the affected limb at the hip. The ankle and foot should be approximately 15 degrees internally rotated relative to the plane of the floor once the leg has been appropriately positioned. The leg should be held straight with the ankle at the level of the chair seat. This places the ankle in an optimal angle for obtaining a mortise view. The radiograph is then obtained in standard fashion.

Results:

N/A

Conclusion:

Obtaining the GSV in the seated position offers several advantages. First, the patient is placed in a seated position, which is more time-efficient than transferring the patient to the radiology table and avoids the potential danger of patients falling. Second, external rotation of the hip is generally well-tolerated in isolated leg injuries. Third, this positioning more reliably places the ankle in approximately 15 degrees of internal rotation to obtain the optimal mortise view and assess mortise symmetry. Finally, patient comfort is increased as this technique obviates transferring patients or placing their hip directly on a rigid radiology table.
Displacement of Sequential Syndesmotic Ankle Injuries Assessed by a 3D Weightbearing CT
Authors: Burssens Arne , Krähenbühl Nicola , Vermue Hannes , Davidson Nathan , Weinberg Maxwell , Zhang Chong , Saltzman Charles L. , Barg Alexej
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Syndesmotic ankle injuries are challenging to diagnose, since current 2D imaging techniques try to quantify a 3D displacement. Therefore, our aim was two-fold: to determine displacement of sequential syndesmotic ankle injuries under various amounts of load using a 3D weightbearing CT (WBCT) and to assess the relation with current 2D imaging.

Methods:

Seven paired male cadaver specimens were included (tibia plateau to toe-tip) and mounted into a custom-built frame. WBCT scans were obtained after different patterns of load (0 kg or 85 kg) were combined with torque (0 Nm or 10 Nm external rotation). These conditions were repeated after each ligament condition: intact ligaments, sequential sectioning of the anterior inferior tibiofibular ligament (AITFL), deltoid ligament (DL), and interosseous membrane (IOM). CT images were segmented to obtain 3D models. These allowed quantification of displacement based on the position of computed anatomical landmarks in reference to the intact position of the fibula. A correlation analysis was performed between the 2D and 3D measurements.

Results:

The effect of torque caused significant displacements in all directions (P<0.05), except for shortening of the fibula (P>0.05). Weight caused a significant lateral (mean=-1.4 mm, SD=1.5) and posterior translation (mean=-0.6 mm, SD=1.8). The highest displacement consisted of external rotation (mean=-9.4°, SD=6.5) and posterior translation (mean=6.1 mm, SD=2.3) after IOL sectioning combined with torque (Fig. 1). Pearson correlation coefficients were moderate (range 0.31-0.51, P<0.05).

Conclusion:

Torque demonstrated superiority over weight in detecting syndesmotic ankle instability after 3D analysis. The clinical relevance of these findings can improve diagnosis by incorporating rotatory platforms during imaging and treatment strategies by providing appropriate stabilization against rotation.
The Hindfoot Alignment in Total Knee Arthroplasty: A Systematic Review
Authors: Burssens Arne , De Roo Dries , Barg Alexej , Van den Bossche T , Pfeufer Daniel , Saltzman Charles L. , Victor Jan
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

Patients with a hindfoot deformity pose a particular challenge when performing a total knee arthroplasty (TKA). This could be attributed to the lack of insights concerning hindfoot alignment outcome. Our objective was to perform a systematic review of the literature to investigate the influence of TKA on hindfoot alignment and vice-versa.

Methods:

This systematic review was performed in accordance to PRISMA guidelines; the original protocol is registered on PROSPERO (ID: 106980). The following electronic databases were searched to identify capable studies: Pubmed, EMBASE, Web of Science, Google Scholar, and Cochrane Library. To ensure the quality of the review, a quality assessment was performed according to the MINORS criteria. The mean MINORS score was 9.5 (range 7-12) and concurred with a good quality of the obtained studies.

Results:

Sixteen identified articles met the review criteria: six prospective cohort studies, nine retrospective studies, and one case-control study. Five articles reporting on clinical outcomes were identified; a pre-operative hindfoot deformity negatively influenced TKP outcome (N=4) or demonstrated no influence (N=1). Thirteen articles reporting on radiographic outcomes were identified. Five studies reported a significant improvement (P < 0.05) of hindfoot alignment after TKA, two studies demonstrated improvement limited to valgus hindfeet, seven studies observed a significant (P < 0.05) correlation between knee and hindfoot alignment, and two studies reported the association between hindfoot OA in patients undergoing TKA. Two studies reporting biomechanical outcomes were identified; these reported a shift of the weighbearing axis after TKA as a result of the remaining hindfoot deformity.

Conclusion:

TKA can improve the alignment of valgus hindfeet, but improvement was less pronounced in varus hindfeet. Furthermore, a worse clinical outcome is expected after TKA in patients with concomitant ankle OA. A remaining hindfoot deformity shifts the weightbearing axis, which could shorten the survival of the total knee prosthesis.
Peripheral Nerve Block Use in Ankle Arthroplasty and Ankle Arthrodesis: Utilization Patterns and Impact on Outcomes
Authors: Chan Jimmy J. , Guzman Javier Z. , Chan Jesse C. , Zubizarreta Nicole , Poeran Jashvant , Vulcano Ettore
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Ankle arthrodesis (AA) and total ankle arthroplasty (TAA) are often associated with significant postoperative pain; this may be mitigated by the use of peripheral nerve blocks (PNB). While smaller studies suggest PNB to be an effective pain management option in foot and ankle procedures, large scale comparative effectiveness data in ankle arthrodesis and TAA is lacking. Therefore, the purpose of this national study was to evaluate PNB utilization patterns and its impact on outcomes such as opioid utilization.

Methods:

This retrospective cohort study utilized data from the nationwide Premier Perspective claims database (2006-2016) on AA (n=10,049) and TAA (n=4,977) procedures. Mixed-effects models estimated associations between PNB use (defined from inpatient billing) and opioid utilization (during the total hospitalization period and specified by each day), hospitalization costs, length of stay (LOS), admission to skilled nurse facility (SNF), opioid-related complications, and 90-day readmission. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI).

Results:

Overall, PNB was utilized in 8.6% of TAA and 8.5% of AA. Both procedures demonstrate increased utilization of PNB from 2006 to 2016 (2.7% to 11.7% and 5.5% to 11.7% for TAA and AA, respectively). In general, PNBs were utilized less in non- teaching and smaller hospitals and among surgeries performed by a podiatrist (compared to orthopaedic surgeon). After adjustment for relevant covariates, PNB use was significantly associated with decreased opioid utilization during the total hospitalization period for both TAA (-15.7%, CI 22.8; 7.9%) and AA (-16.0%, CI 21.9%; 9.7%); this was particularly driven by a decrease in opioid utilization on the day of surgery. PNB use was not associated with reductions in LOS, cost of hospitalization, discharge to SNF, complications, 90-day readmission.

Conclusion:

In this first national study on PNB use in ankle procedures we found an overall low use of PNB while an increasing trend in utilization was observed. Importantly, PNB use was associated with significant opioid-sparing effects (especially on the day of surgery), while no effects were seen for other outcomes. Given the current low utilization rate, increased use of this analgesic technique may translate into more benefits in terms of clinical outcomes and resource utilization.
Effect of BMP-2 with Microfracture on Osteochondral Defect in a Rabbits Talus
Authors: Dang Le Hoang Nam , Lee Kwang-Bok
Published: October 2019

Category:

Ankle, Basic Sciences/Biologics

Introduction/Purpose:

Microfracture is a technically safe, simple and cost-effective treatment option for osteochondral defect of the talus. However, fibrous tissue and fibrocartilage represent the predominant repairing tissues derived from these procedures and these tissues types do not exhibit the mechanical properties of native hyaline cartilage, long time for cartilage reconstruction and long-term failure results. Bone morphogenetic protein-2 (BMP-2) has been shown to stimulate matrix synthesis and increase in synthesis of cartilage-specific collagen type IIB thereby enhance regeneration of articular cartilage in vitro. The purpose of this study is to evaluate the treatment ability of combining BMP-2 with microfracture on osteochondral defect in rabbit talus.

Methods:

Full-thickness chondral defects (3 x 3 x 2 mm) was created in the center talus dome. Twenty four male white New Zealand rabbits were divided into four groups of 6 animals into each group dependent on treatment method; Group I (control, no treatment), II (microfracture only), III (10 µL rhBMP-2 treatment), IV (microfracture combine with 10 µL rhBMP-2 treatment). The animals were sacrificed at 2, 4, 6 weeks post operatively. The macroscopic assessment of the repaired tissue was evaluated using the International Cartilage Repair Society (ICRS) Macroscopic Score, which considers the degree of defect repair, the integration to the border zone, and the macroscopic appearance. Subchondral bone regeneration on defect was evaluated by micro-CT scan and the histological findings were scored by using a modified version of the established scoring system for osteochondral repair described by Wakitani, immunohistochemical staining was used for analysis of collagen type I and II.

Results:

: Excessive bone formation that originated from the subchondral bone region was not observed in any sample. Micro-CT shows higher subchondral bone regeneration on defect in group III, IV than group I, II at 4 and 6 weeks, respectively. According to macroscopic and histological results, group V shows higher quality of cartilage and faster cartilage regeneration compare with another group. In immunohistochemical analysis, group IV shows stronger positive staining for collagen type II in the area of the defect.

Conclusion:

These findings indicate that the combination BMP-2 with microfracture is effective at accelerating and improving quality of full-thickness cartilage defect repair in a rabbit talus model.
Ankle Mortise Instability in Multiple Hereditary Exostoses
Authors: Ebaugh M Pierce , Grenier Greg , Singh Satbir , Abousamra Oussama , Klingele Kevin
Published: October 2019

Category:

Ankle, Ankle Arthritis, Pediatric Foot and Ankle

Introduction/Purpose:

Ankle valgus has been reported in 50% of patients with multiple hereditary exostoses (MHE) and, untreated, results in early arthrosis. Widening of the ankle mortise has also been reported; however, there has been a lack of data regarding its natural history and management. Alterations of mortise anatomy result in poor functional outcomes and accelerated arthrosis of the ankle. The aim of our study was to report the characteristics and outcomes of mortise widening in a group of patients with MHE.

Methods:

A total of 13 patients with MHE and mortise widening (16 ankles) were identified. Age, sex, BMI, laterality, origin of osteochondroma, pain, instability, clinical deformity, operative data, and complications were recorded. Mortise (M), Talocrural angle (TC), and Tibiotalar angle (TT) measurements were collected on preoperative and last follow up radiographs. The majority of patients underwent medial distal tibia hemiepiphysiodesis. Post-surgical AOFAS and SF36 scores were collected.

Results:

Preoperatively, no patient complained of instability, however, 9/16 ankles were painful and 14/16 were clinically in valgus. Patients underwent surgery at an age of 11.8 years (9.7-15). Radiographic and clinical follow up were 2.6 years (0.2-7.3) and 6 years (1.5-11.7), respectively. There were no significant differences between pre/postoperative M, TC, TT angles. Operative patients improved mean M (5.17 to 4.63 mm) and TT (8.71 to 4.54 degrees), neither angle reached normal values. TC (fibular length) was within normal limits (82.2 to 84.8). Questionnaires were obtained for 8/16 ankles, at a mean age of 19 years (13-25.1). The average AOFAS score was 66.7 out of 100. Patients scored 8.6/10 for alignment, 32/40 for pain, 25.6/50 for function. SF-36 scores were excellent.

Conclusion:

The improvement in M and TT was modest and their values remained outside the normal limits. TC angle was within normal limits but displayed an overall fibular shortening and thus, decreased lateral buttress with potential for talar shift. This was reflected in the mean functional and overall AOFAS score. However, our patients are functionally compensating as evidenced by SF36 scores. More studies are needed to optimize the management of MHE patients with ankle malalignment. Earlier valgus correction and possible addition of fibular lengthening to simultaneously address mortise widening may need to be considered to prevent early ankle arthritis.
Natural History of 321 Flatfoot Reconstruction Patients Over a 14 Year Period Performed at a Single Institution
Authors: Goss Madison , Stauch Chris , Lewcun Joseph , King Jesse , Fritsche Madelaine , Juliano Paul , Aynardi Michael
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Outcomes following surgical reconstruction for acquired flatfoot deformity secondary to posterior tibial tendon dysfunction have been well described. However, the majority of studies have a limited number of patients or short to mid- term follow-up. The purpose of this study was to report the natural history, demographics, and mechanisms of treatment failure for patients undergoing flatfoot reconstruction at a single institution by a single surgeon.

Methods:

With IRB approval, 321 consecutive patients undergoing flatfoot reconstruction during a 14-year period were included in this study (February 2002 through October 2016). All procedures were performed by a single surgeon (PJJ) at our institution. Demographic data, surgical data, clinic notes, and radiographs were available for review. Exclusion criteria included patients without electronic records or incomplete data. Failure was defined as a need to return to the operating room for revision surgery. Statistical analysis was performed.

Results:

321 consecutive patients underwent flatfoot reconstruction from 2002-2016. The majority of patients were female (83.2%) with left laterality (58.6%) & a body mass index classified as overweight (21.5%) or obese (56.4%). 13.7% of patients were diabetics, and 18.4% were current smokers. 54 patients (16.8%) experienced treatment failure. Painful calcaneal hardware requiring removal occurred in 11.8% of patients, conversion to triple arthrodesis occurred in 3.45%, and wound complications or infection requiring irrigation & debridement occurred in 1.87%. There were no mortalities reported within 90 days. There were 3 symptomatic deep vein thromboses, none requiring surgical intervention, & no pulmonary embolisms. A significant increase in relative risk of treatment failure was calculated for female gender, current cigarette use, & age under 60 (3.4 p=0.0005/1.9 p=0.0081/1.8 p=0.042).

Conclusion:

This study represents the largest series of patients undergoing flatfoot reconstruction by a single surgeon at a single institution. Although retrospective, the results provide valuable insight to the natural history of patients undergoing this procedure. The overall complication rate and treatment failure rates are low and similar to those previously reported in the literature. Patients with female gender or under 60 years of age should be notified of their increased relative risk of treatment failure & counseled accordingly. Smoking cessation is recommended to reduce the risk of treatment failure.
Results after Percutaneous and Arthroscopically Assisted Osteosynthesis of Calcaneal Fractures
Authors: Grün Wolfram , Molund Marius , Nilsen Fredrik , Stødle Are
Published: October 2019

Category:

Arthroscopy, Trauma

Introduction/Purpose:

Surgical treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of infection and soft tissue complications. During the last years there was a trend towards less invasive fixation methods. Percutaneous and arthroscopically assisted calcaneal osteosynthesis (PACO) combines the advantages of good visualization of the posterior facet of the subtalar joint with a minimally invasive approach. We have performed this technique since 2014 in selected Sanders II and III fractures.

Methods:

We conducted a clinical and radiographic follow-up of 19 patients with 20 calcaneal fractures which had been treated by PACO with a minimum follow-up of 12 months. The follow-up rate was 66% (19 of 29 patients). 18 men and 1 woman with a median age of 44 years (range, 21-65) and a follow-up period of 18 months (12-33) were examined. There were 11 Sanders II and 9 Sanders III fractures. Radiographs of all feet were obtained at final follow-up to evaluate the reduction of the fractures as well as the presence of osteoarthritis of the subtalar joint. Our primary outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score. Secondary outcomes were the Calcaneus Fracture Scoring System (CFSS), the Manchester- Oxford Foot Questionaire (MOxFQ), the Visual Analog Scale (VAS) for pain and the incidence of complications.

Results:

The patients were operated on after a median of 4 days after injury (range, 1-12). The operation time was 139.5 minutes (98-234). The patients were discharged 3 days (1-6) postoperatively. Postoperative radiographs showed a Böhler angle of 29.5 degrees (0-40). However, the follow-up radiographs showed subsidence of the fractures and a Böhler angle of 21 degrees (-16-36). 95% of the operated feet showed signs of posttraumatic subtalar osteoarthritis. There were no wound healing complications. Two patients were reoperated with screw removal due to prominent screws. The AOFAS score was 85 (50-100), the CFSS score 85 (26-100), the MOxFQ score 26.6 (0-73.4). The VAS pain score was 0 (0-5.7) at rest and 4 (0-8.2) during activity.

Conclusion:

Only a few articles have reported the outcome after percutaneous artroscopically assisted calcaneal osteosynthesis. Our results suggest that PACO gives good clinical results and a reduced risk of complications in selected calcaneal fractures. However, since this technique is technically challenging and has a steep learning curve, we expect to be able to further improve our results over time. Prospective longterm studies will be necessary to better document the potential advantages and limitations of this operating technique.
Patient-Reported Outcomes after Exosym Bracing (Intrepid Dynamic Exoskeletal Orthosis (IDEO)) in the Civilian Population
Authors: Hadden Ryan , Meeker James , Weiss Jason , Thompson Austin
Published: October 2019

Category:

Ankle Arthritis, Orthosis

Introduction/Purpose:

When it comes to ambulation, the dynamic interplay of anatomy at the foot and ankle affords weight acceptance, stability and force production. The outcome is gait efficiency. Various musculoskeletal injuries challenge gait biomechanics. While surgical management may address the fault in kinetic chain, it may not fully address the problem of pain, functional outcome and patient satisfaction. Non-surgical interventions such as bracing using ankle foot orthoses (AFO) aim to assist, restore and redirect weightbearing forces with immobility in mind. As an energy-storing AFO, however, the IDEO was created to improve functional performance in veterans after limb salvage procedures. The goal of the study was to evaluate outcomes following use of Exosym (or IDEO) bracing for foot and ankle pathologies in the civilian population.

Methods:

Through review of one institution’s electronic medical record, 29 patients ages 18 years or older who were prescribed the Exosym brace by a single foot and ankle surgeon over a 5-year period were identified. A composite questionnaire including patient-reported outcomes of PROMIS SF Physical Function, PROMIS SF Pain Interference, Brace Use, and EQ-5D was obtained over the phone or by email.

Results:

A total of 29 patients were prescribed the brace over a 5-year period with only 18 patients receiving the brace. Insurance denying coverage was the most common reason (n=7) for patients not receiving the brace. Of the 18 patients that received the brace, 17 of them were willing to answer the questionnaire. The average age of patients with the Exosym brace was 42.3 (sd=13.8) years old with 6 (35%) being female. Patients with the Exosym brace reported an average score of 47.2 (sd=6.0) for the PROMIS Physical Function and 53.6 (sd=8.4) for the PROMIS Pain Interference. The average satisfaction with the Exosym brace was 65.5 (sd=17.6) out of a possible 100.

Conclusion:

Exosym bracing in various foot and ankle pathologies provides functionality and pain modulation in the civilian population that rivals respective subpopulation norms. One of the acknowledged limitations of the study is that not obtaining pre- bracing patient reported outcomes precluded evaluation of a minimum clinically important difference. However, the study was not designed to provide such data. It did, however, provide impetus to pursue a follow-up study evaluating plantar pressure changes with and without brace use, which is currently ongoing. Such knowledge may help identify which injuries would be best suited for Exosym bracing.