bluuebunny/crossref_metadata_2025 huggingface dataset:
Early versus Delayed Mobilization Post-Operative Protocols for Primary Lateral Ankle Ligament Repair: A Systematic Review and Meta-analysis
Authors: Vopat Matthew L. , Tarakemeh Armin , Morris Brandon , Hassan Maaz , Garvin Pat , Zackula Rosalee , Mullen Scott , Schroeppel Paul , Vopat Bryan G.
Published: October 2019

Category:

Ankle, Sports, Post-op protocol

Introduction/Purpose:

Lateral ankle instability represents a common orthopaedic diagnosis. Nonoperative treatment through focused physical therapy provides satisfactory results in most patients. Some patients, however, experience persistent chronic lateral ankle instability despite appropriate nonoperative treatment. These patients may require stabilization which can include primary lateral ligament repair to restore ankle stability. Optimal post-operative rehabilitation of lateral ankle ligament repairs remains unknown, as surgeon vary in how they balance protection of surgical repair with immobilization with the need for ankle joint mobilization to restore range of motion. The aim of this review is to provide insight into early and delayed mobilization post- operative protocols in patients undergoing primary lateral ankle ligament repairs to determine if an optimal evidence-based post- operative rehabilitation protocol exists in the literature.

Methods:

Following PRIMSA criteria, a meta-analysis using the PubMed/Ovid Medline database was performed (10/11/1947- 10/16/2017). Manuscripts that were duplicates, non-lateral ligament repair, biomechanical and non-English language were excluded. Protocols were reviewed and divided into two categories; early mobilization (within 3 weeks of surgery) and delayed mobilization (after 4 weeks of surgery). Return to sport, outcome scores (AOFAS, Karlsson scores) and complications of both populations were recorded and statistically analyzed.

Results:

31 out of 1,844 studies met the criteria for the final analysis, representing 1,608 patients undergoing primary lateral ligament repair. There was no statistical difference in pre-operative AOFAS scores with delayed mobilization having a score of 67.3 and early mobilization having a score of 67.6 (p<0.639). There was statistical significance in the post-operative AOFAS score comparing delayed mobilization group versus early mobilization group with 91.8 versus 98.8, respectively (p<0.001) and post- operative Karlsson scores with values of 90.0 vs. 92.2 in delayed versus early respectively (p<0.001). Return to sport in the delayed group was 11.8 weeks versus 10.9 in early (p<0.044). No significant difference was found in complication rates between groups with delayed having a rate of 3.7% and early 4.8% (p<0.389).

Conclusion:

Patients may benefit from early mobilization protocols after lateral ankle ligament repair. The early mobilization protocols group had improved functional outcomes and decreased time until return to sport without a difference in complications. More studies are needed to definitively evaluate early versus delayed rehabilitation protocols due to heterogeneity of the studies.
Opioid Consumption after Foot and Ankle Surgery: The Influence of Payer Status
Authors: Acebo Joshua , Lam Kenrick , Khan Shamis , Jain Rishabh , Panchbhavi Vinod
Published: October 2019

Category:

Ankle, Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

Opioid utilization after foot and ankle surgery has received more attention recently with several papers publishing guidelines on the number of opioids to prescribe following surgery. To our knowledge the patient populations that have been studied in all of these papers are all private payer mixes, with a low amount of indigent patients. Social factors often have a large influence over surgical outcomes and therefore we aimed to see if this held true for post-operative opioid utilization as well. In this study we investigated differences in opioid utilization among patients with either Medicaid, Medicare or commercial insurance.

Methods:

All bony foot and ankle procedures performed by a single foot and ankle surgeon were reviewed between the dates of 7/1/2017 - 6/30/2018. Inclusion criteria were age over 18, did not have a history of chronic pain, and not incarcerated. Bony procedures included any osteotomy, fracture fixation, or arthrodesis. The number of narcotic prescriptions filled by the patient within 6 months following surgery was retrieved via the Texas Prescription Monitoring Program Database. Patients were also called and surveyed about their post-operative pain. The patients were then divided into 3 groups by payer status: commercial insurance including workman’s compensation, Medicaid including county insurance and self pay patients, and Medicare.

Results:

92 patients met inclusion criteria, 22 Medicare, 26 Medicaid, and 44 commercial. Medicaid patients filled more narcotic prescriptions than commercial and medicare patients (870 mg morphine equivalent vs 781 mg morphine equivalent for commercial and 649 mg morphine equivalent for medicare) however this difference was not statistically significant (Medicaid vs Medicare p = 0.07). Medicaid patients also needed a greater number of refills per patient (0.27 for Medicaid vs 0.20 and 0.09 for commercial and Medicare, p = 0.22) and had a larger number of telephone encounters for pain (p = 0.02) than the other payer types.

Conclusion:

Although not statistically significant, there was a trend toward greater opioid utilization within the Medicaid and county insured patient population.
The Navicular Prosthesis Template: A Cadaveric Study of the Talonavicular Morphometric Profiles and Side-to-side Differences
Authors: Angthong Chayanin , Stufkens Sjoerd Antoine Sebastian , Rajbhandari Prasit
Published: October 2019

Category:

Hindfoot, Midfoot/Forefoot, Trauma

Introduction/Purpose:

The navicular bone destruction is a challenging condition in the foot surgery. This can be occurred from severe comminuted fracture, avascular necrosis from steroid used or Mueller-Weiss Syndrome, etc. However, little is known about the treatment option which can spare the talonavicular or naviculocuneiform joint regarding this condition. The navicular prosthesis replacement may be the promising option in the future. This study is to present the talonavicular (TN) ratio, other morphometric profiles, and side-to-side differences for the template of customized navicular prosthesis manufacturing.

Methods:

A total of eight matched pairs of the ankle (16 ankles) were collected in this study. The measurements were performed regarding the morphometric profiles of navicular and talar head. All data were recorded and analyzed to determine the TN ratio to be the template of navicular prosthesis manufacturing. The TN width ratio was calculated as talar head width was divided by navicular width in axial view. The TN height ratios were calculated as talar head height was divided by navicular height at the central arc in sagittal view. Medial and lateral navicular heights were also recorded in sagittal view. The medial, lateral, and central arc lengths of navicular were recorded from the cadaveric specimens.

Results:

The average talar head width was 28.5 +/- 3.2 mm. The average talar head height at central arc was 26.6 +/- 2.2 mm. The average navicular heights at medial, lateral rims, and central arc were 16.8, 21.4, and 24.5 mm respectively. The average navicular lengths at medial, lateral rims, and central arc were 18.6, 15.3, and 18.4 mm respectively. The average navicular width was 40.4 +/-2.7 mm. The average TN width ratio was 0.7 +/- 0.1. The average TN height ratio at central arc was 1.2 +/- 0.2. The side-to-side differences were insignificantly found on all talonavicular morphometric profiles (P>0.05).

Conclusion:

Based on this study, the talonavicular ratios and the morphometric profiles were demonstrated in the cadaveric specimens. The contralateral side of navicular can be the template for the manufacturing of the customized navicular prosthesis for the pathologic side due to the insignificant differences of side-to-side morphometric profiles. These data may help develop the customized navicular prosthesis to replace in the challenging pathologic condition of navicular.
Two-Year Follow Up after Autologous Matrix-induced Chondrogenesis (AMIC) in Patients with an Osteochondral Lesion of the Talus
Authors: Anwander Helen , Krause Fabian Götz
Published: October 2019

Category:

Sports

Introduction/Purpose:

The treatment of osteochondral lesions in the talus remains challenging. In recent years a promising technique, the autologous matrix-induced chondrogenesis (AMIC) has been described, a technique combining micro fracturing with application of a collagen matrix. The aim was to analyze the clinical follow up two years after surgery and define risk factors for inferior outcome.

Methods:

This prospective study included 16 consecutive patients, who underwent AMIC for an osteochondral lesion of the talus at our institution. We compared preoperative and at two years follow up the following clinical scores: AOFAS (American Orthopeadic foot and ankle score), FFI (foot functional index) and VAS (visual analogue scale) pain and satisfaction. Further, clinical scores at two years were correlated with BMI, age, gender and size and stage osteochondral lesion according to Hepple. Additionally outcome after primary AMIC and revision surgery was compared.

Results:

FFI increased from 50 ± 16 preoperative to 30 ± 24 at follow-up (p-value: 0.017). VAS pain increased from 5.6 ± 2.0 to 2.8 ± 2.7 (p-value: <0.001). AOFAS (67 ± 12 to 78 ± 21) and VAS satisfaction (7.2 ± 2.6 to 7.6 ± 2.8) change was not significant. AOFAS and FFI did not correlate with BMI, age, gender or size and grade of the osteochondral lesion. Patients with primary AMIC or revision surgery had a similar preoperative AOFAS (69 ± 11 versus 64 ± 14) and FFI (54 ± 14 versus 42 ± 17). At follow-up, patients with primary AMIC showed superior AOFAS (86 ± 11 versus 65 ± 27, p-value: 0.049) and FFI (17 ± 16 versus 52 ± 20; p- value: 0.001).

Conclusion:

Increased clinical outcome was found two years after AMIC in patients with talus cartilage lesion without previous surgery.
The Impact of Torque on Assessment of Syndesmotic Injuries Using Weightbearing CT Scans: A Cadaver Study
Authors: Barg Alexej , Weinberg Maxwell W. , Davidson Nathan P. , Hintermann Beat , Saltzman Charles L. , Krähenbühl Nicola
Published: October 2019

Category:

Ankle, Basic Sciences/Biologics, Trauma

Introduction/Purpose:

Injury to the distal tibio-fibular syndesmosis can occur as an isolated ligamentous injury or can be associated with bony ankle trauma. The missed diagnosis of such injuries is believed to lead to chronic pain and early degeneration. Weightbearing CT (WBCT) has increased in popularity among foot and ankle surgeons as it offers an accurate representation of joint alignment under weightbearing conditions. However, the use of this imaging modality to diagnose syndesmotic injuries has not been investigated. The purpose of this study was to assess the influence of torque on the assessment of syndesmotic injuries using axial CT images under weightbearing conditions. We hypothesized that torque application would improve the ability to detect syndesmotic injuries.

Methods:

Seven pairs of male cadavers (tibia plateau to toe-tip) were included. CT scans with axial load application (85 kilograms, kg) and with (10 newton meters, Nm) or without torque to the tibia (corresponding to external rotation of the foot and ankle) were taken during four test conditions. First, intact ankles (Native) were scanned. Second, one specimen from each pair underwent anterior inferior tibio-fibular ligament (AITFL) transection (Condition 1A) while the contralateral underwent deltoid transection (Condition 1B). Third, the lesions were reversed on the same specimens and the remaining intact deltoid or AITFL was transected (Condition 2). Finally, the distal tibiofibular interosseous membrane (IOM) was transected in all ankles (Condition 3). Eight different measurements were performed to assess the integrity of the distal tibio-fibular syndesmosis on axial CT scans.

Results:

Torque impacted axial CT scan measurements in almost all conditions (Table I). The ability to diagnose syndesmotic injuries using axial CT measurements improved when torque was applied. No significant syndesmotic morphological change was observed with or without torque for either isolated AITFL or deltoid ligament transection.

Conclusion:

Low magnitude torque rotational stress application had a notable impact on 2D measurements used to diagnose syndesmotic injuries with axial CT scans (cadaveric model). Two dimensional measurements are not effective to distinguish between single AITFL and single deltoid ligament injuries. Because weightbearing conditions allow for a standardized positioning of the foot while radiographs or CT scans are taken, a combination of axial load and torque application is desirable. Further studies including patients with syndesmotic injuries will be necessary to clarify the clinical potential of WBCT scans with torque applied to identify syndesmotic widening.
Cartiva Synthetic Cartilage Implant Hemiarthroplasty for Treatment of Hallux Rigidus
Authors: Brandao Bernardo , Aljawadi Ahmed , Fox Anna , Pillai Anand
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

The Cartiva synthetic cartilage implant (SCI) is licenced for use in management of symptomatic hallux rigidus in several countries including the UK. As of now, there are no independent comparative series for treatment of hallux rigidus utilising polyvinyl alcohol implants.

Methods:

Patients at a single centre with symptomatic hallux rigidus who underwent Cartiva SCI implant procedure were identified. First metatarsophalangeal joint arthritis was radiographically graded according to the Hattrup and Johnson (HJ) classification. Pre-operative and post-operative patient-reported outcomes were evaluated using the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale and the Manchester-Oxford Foot Questionnaire (MOXFQ).

Results:

66 patients (19 M, 47F) (43 R and 23 L) were followed up for an average of 14 months (min=2, max=36). 17 patients suffered from HJ2/moderate arthritis and 49 patients with grade HJ3/severe arthritis. Post-operative mean FAAM scores showed statistically significant improvement (p< 0.0001). Patients reported a 40% increase in functionality during activities of daily living. All 3 MOXFQ Domain scores improved significantly (p< 0.02). The Index score improved by 28 points (p< 0.0001). There was no correlation between length of follow up or age and PROMs (r=0.129). No statistical difference was demonstrated between sexes. However clinically, males and older patients exhibit better outcomes. There was a 89.4% patient satisfaction with the use of Cartiva.

Conclusion:

Our study shows excellent results with statistically significant improvements in functional outcomes, and promising short-term follow-up with low early revision rates. Pain in particular was significantly reduced. One third of patients developed post-operative stiffness requiring a manipulation under anaesthesia. Patient selection is key. Additional imaging may be required to assess sesamoid osteoarthritis. At 3 years the implant has demonstrated to be safe and efficacious in the management of hallux rigidus. Durability and survivability of the implant will continue to be studied in this cohort.
The Anteromedial Cortex of the Calcaneus: A Cadaveric Study
Authors: Briceño Jorge , Moura Bruno , Velasco Brian , McMillan Dayton , Kwon John Y.
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

The irregular morphology of the calcaneus obstructs its clear visualization on radiographic imaging. Particularly challenging is identifying the medial cortex given its concavity and bony overlap of the calcaneal body. Iatrogenic screw penetration of the medial wall of the calcaneus comes with increased risk of injuring the neurovascular bundle and the flexor hallucis longus tendon. Despite all intraoperative precautions, it is not infrequent to see misplaced screws in postoperative imaging. The objective of the present study is to evaluate the normal proportion of the calcaneus width to radiographically define the extent of the medial cortex on axial fluoroscopic imaging.

Methods:

Eight left sided fresh-frozen below-the-knee amputated cadaveric specimens were utilized for this study. Each specimen was dissected on the medial side of the hindfoot to allow visualization of the medial cortex of the calcaneus. A partial cuboid ostectomy was performed to visualize the calcaneocuboid joint and to install radiopaque markers on the borders of the anterior calcaneal facet. Finally, Harris axial views were obtained. Two independent observers measured the widths of the calcaneus on digital fluoroscopic Harris views at two levels: the maximal width at the sustentaculum tali and the maximal width at the anterior process. A ratio was calculated between these measurements.

Results:

The ratio between the maximal width at the anterior process and the sustentaculum ranged between 0.42 and 0.52 with an average ratio of 0.47 +/- 0.04.

Conclusion:

Calcaneal screw misplacement, particularly from lateral to medial, can lead to damage of the neurovascular bundle and the flexor hallucis long tendon ultimately affecting clinical outcomes. The measurements in the present study suggest a lower risk of violating the medial cortex when the length of the screw placed in the anterior process of the calcaneus is less than half of the maximal width of the calcaneus at the sustentaculum tali. As the medial cortex is difficult to visualize on intraoperative fluoroscopy, the clinical use of this normal ratio in axial views could help surgeons to avoid calcaneal screw misplacement.
Minimally Invasive Retrograde Method of Harvesting the Flexor Hallucis Longus Tendon: A Cadaveric Study
Authors: Bull Patrick , Goss David , Halverson Adam
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Utilization of the flexor hallucis longus (FHL) tendon is well described for several tendon augmentation procedures. Recently, several authors have described a minimally invasive (MI) technique to harvest the tendon utilizing a hamstring tendon stripper. The purpose of this study was to evaluate the safety and effectiveness of harvesting the FHL tendon utilizing this novel technique.

Methods:

The FHL tendon was harvested through a transverse plantar incision over the interphalangeal joint of the great toe in 10 fresh-frozen cadaver lower extremities. Complications, tendon length and interconnections between the FHL and flexor digitorum longus (FDL) were recorded. The specimens were then dissected by a single surgeon in a standardized fashion and damage to any surrounding structures was recorded.

Results:

The average length of the FHL tendon from the distal stump to the 1st inter-tendinous connection was 13.33 cm (range 8.8-16 cm, SD: 2.28 cm). Eight cadavers demonstrated Plaass Type 1 interconnections while 2 were Type 3. There was no injury to the medial and lateral plantar arteries or nerves, plantar plate or FDL tendons. One FHL tendon was amputated during graft harvesting.

Conclusion:

Care must be taken when approaching the sustentaculum with the tendon harvester in order to avoid amputation of the graft against a hard bony endpoint. Additionally, flexion and extension of the lateral toes can aid in successful tendon harvest when tendon interconnections are encountered. Utilizing this MI technique appears to be a safe and effective way to obtain a long FHL tendon graft tissue augmentation.
Interpositional Arthroplasty for Hallux Rigidus: A Systematic Review
Authors: Butler James , Shimozono Yoshiharu , Gianakos Arianna L , Kennedy John G
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Hallux rigidus is a common degenerative joint condition of the foot. In advanced stages of the disease, extensive procedures have been utilized including Keller arthroplasty, interpositional arthroplasty (IPA), arthrodesis, total joint replacement or synthetic cartilage replacement. IPA is a surgical procedure that attempts to maintain joint motion through insertion of a biologic spacer into the joint. However, there is still a paucity of overall clinical data regarding outcomes and complication rates following IPA procedure for the treatment of hallux rigidus.The purpose of the current study was to systematically review the outcomes of IPA in the treatment of hallux rigidus.

Methods:

A systematic search of the MEDLINE, EMBASE and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes collected and analysed included: AOFAS score, VAS score, SF36 score, range of motion, radiographic parameters, and postoperative complications. The level and quality of evidence were recorded and assessed.

Results:

Sixteen studies with a total of 433 patients met inclusion/exclusion criteria. The mean AOFAS improved from 56.8±7.3 (range, 43.2-64.3) preoperatively to 84.0±6.7 (range, 71.6-90.0) postoperatively. The preoperative weighted mean total ROM was 37.7±16.2 degrees and the postoperative weighted mean total ROM was 60.3±13.4 degrees. Five studies examined joint space narrowing on plain radiographs. The mean preoperative joint space was 1.2±0.2 mm (range, 1 -1.5) and the mean postoperative joint space was 2.5±0.5 mm (range, 1.9-3). The complication rate was 18.2% with metatarsalgia as the most commonly reported complication. One study was Level III and 15 studies were Level IV.

Conclusion:

This systematic review demonstrates improvement in functional and ROM outcomes following IPA. The procedure however has a high complication rate. There is a low level and quality of evidence in the current literature with inconsistent reporting of data. Therefore, further well designed studies must be carried out to determine the efficacy of IPA in the treatment of hallux rigidus.
Subtalar Joint Preparation Using 2 Portal Posterior Arthroscopic Technique vs Sinus Tarsi Open Approach: A Cadaveric Study
Authors: Chinnakannu Karthikeyan , Abyar Eildar , McKissack Haley M. , Pinto Martim , Jha Aaradhana J. , Moraes Leonardo V. , Naranje Sameer M. , Shah Ashish B.
Published: October 2019

Category:

Ankle, Arthroscopy, Basic Sciences/Biologics

Introduction/Purpose:

Subtalar fusion is the treatment of choice for subtalar arthritis when conservative management fails. Subtalar fusion can be done through open approach or arthroscopic technique. Arthroscopic technique is associated with rapid recovery; however, it requires adequate training and skill. Arthroscopic technique can be done through lateral or posterior portals. Sometimes it may be necessary to use accessory portal to open or distract the joint for adequate joint preparation. Use of accessory portal may result in injury to the neurovascular structure. Whatever the technique, one of the most important aspects of fusion is adequate preparation of the joint. Aim of our study is to compare the preparation of subtalar joint using sinus tarsi open approach and posterior subtalar scopy using 2 portal technique in cadaveric specimens.

Methods:

We used 20 below knee fresh-frozen cadaver legs for this cadaveric study. Subtalar joints of ten specimens were prepared through the lateral approach, while the remaining ten joints were prepared using sinus tarsi incisions. After the completion of preparation, all ankles were dissected open, photographic images of calcaneal and talar articular were taken. (Image)Surface areas of each articular facet and prepared area of the talus, distal tibia, and distal fibula were measured and analyzed.

Results:

Open technique results in better preparation of joint surface in calcaneus and overall. While open technique results in preparation of 92% joint surface (combined talus and calcaneus), arthroscopic technique results in in 80% of joint surface. Open technique results in better preparation of calcaneus (79vs 94%). The anterolateral corner of calcaneus was difficult to be reached using the scope and unprepared in most cases. There was no significant difference in the preparation of talar articular surface. (Table 1)

Conclusion:

Open sinus tarsi results in more joint preparation compared to 2 portal posterior arthroscopic technique. The less amount of joint preparation in arthroscopic technique is mostly due to less preparation of AL corner. Of calcaneus. When using posterior arthroscopic technique, it is advisable to use accessory portal to distract the joint to aid in adequate preparation.
The Effects of Lateral Ligaments Augmentation Using Suture-tape on Functional Ankle Instability
Authors: Cho Byung-Ki , Choi Seung-myung
Published: October 2019

Category:

Sports

Introduction/Purpose:

Although lateral ligaments augmentation using suture-tape has been effective for restoration of mechanical ankle stability, few data are available regarding changes of peroneal strength, proprioception and postural control. The aim of this study was to determine effects of suture-tape augmentation on functional ankle instability (FAI).

Methods:

Twenty-four patients that underwent suture-tape augmentation were eligible and were followed more than two years postoperatively. Functional outcomes were evaluated with the Cumberland Ankle Instability Tool (CAIT), Foot and Ankle Ability Measure (FAAM). Changes of peroneal strength, proprioception and postural control were analyzed with an isokinetic dynamometer and a modified Romberg test.

Results:

CAIT and FAAM significantly improved to average 27.2 points, 86.7 points at final followup. Peak torque for eversion in 60º/sec angular velocity significantly improved to 10.6 Nm at final followup. Deficit ratio of peak torque for eversion significantly improved from mean 39.5% to 20.9%, and significant side to side difference was revealed (P < .001). There were no significant differences in joint position sense. A significant improvement in balance retention time was revealed at final followup and relative deficit ratio compared to unaffected side was 30.9%.

Conclusion:

Patient-reported functional outcomes significantly improved after lateral ligaments augmentation using suture-tape. Although this procedure demonstrated significant effects on FAI based on improvement of isokinetic peroneal strength and postural control, recovery rates compared to the unaffected side were insufficient at the intermediate-term followup. In addition, there was no significantly positive effect on proprioception of the ankle.
Ten-Year Retrospective Study of Symptomatic Naviculo-Medial Cuneiform Coalition in 18 Young Adults: Hidden Features Observed on Computed Tomography
Authors: Choi Jun Young , Suh Jin Soo
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

To the best of our knowledge, there are no previous reports comparing the radiographic findings to CT findings for symptomatic naviculo-medial cuneiform (NC) coalition. The purpose of this study was to demonstrate and compare the features of symptomatic naviculo-medial cuneiform coalition between radiography and computed tomography (CT).

Methods:

We retrospectively reviewed the radiographic and CT findings of 25 symptomatic naviculo-medial cuneiform coalition cases in 18 patients. The existence of a large pit (depth >3 mm), irregular articular surface, joint space narrowing, dorsal bony spur, subchondral sclerosis, multiple subchondral bony cysts, and intra-articular loose bodies were evaluated on radiograph or CT. The size of the largest subchondral bony cyst was also measured using CT.

Results:

The proportion of large pit observed on radiograph (52.0%) was significantly different (P = .001) from that on CT (72.0%). Similarly, intra-articular loose bodies were observed more frequently on CT (P = .001). The mean size of the largest subchondral bony cyst on CT was 4.25 mm.

Conclusion:

While evaluating CT in patients with naviculo-medial cuneiform coalition, physicians should focus on detecting a large pit and intra-articular loose bodies since differences in these features were frequently observed between radiograph and CT, with these findings being more evident on CT. We believe that a large subchondral bony cyst could also be related to the symptoms of naviculo-medial cuneiform coalition.
Two-Year Outcomes of Total Ankle Replacement with the Cadence Total Ankle Replacement System
Authors: Daniels Timothy R. , Kayum Shahin , Khan Ryan M. , Sanjevic Anastasia
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Over the last few decades, total ankle replacement (TAR) emerged as a reliable treatment option in end-stage ankle osteoarthritis (OA) while preserving motion and physiological load. The Cadence™ prosthesis, manufactured by Integra LifeSciences, is a two-component, fixed-bearing implant with minimal tibial and talar resection and has been in clinical use since June 2016. The purpose of this study is to assess the two-year validated clinical outcome scores and radiological parameters of the Cadence™ prosthesis at our hospital.

Methods:

Thirty-one consecutive patients who received the Cadence™ prosthesis between June 2016 and December 31st, 2016 were enrolled. All patients who underwent a primary TAR with the Cadence™ prosthesis and who had at least two years follow- up were included. All surgeries were performed by a single surgeon with experience in total ankle arthroplasty. At the yearly clinical evaluation, patients were administered the Ankle Osteoarthritis Scale (AOS) and the Short Form Health Survey (SF-36), and their radiological outcomes pre and post-surgery were assessed.

Results:

Thirty-one patients fulfilled the inclusion criteria. Forty ancillary procedures were performed on twenty-four TAR’s. Radiological analyses showed preoperative talar sagittal translation with 25 anterior, 2 posterior, and 4 neutral. Sagittal translation decreased from an average 3.11 mm to 1.0 mm. Eleven ankles had a perioperative talar Varus and Valgus deformity that was corrected, with neutral alignment in all. At the two-year clinic visit, x-rays showed no lucencies or stress fractures and none of the ankles required revision of metal components. The pre and post-operative pain and disability scores displayed major improvement wherein AOS pain scores decreased -20.28 ± 14.34 points from an average of 47.86 points while AOS disability scores decreased -32.11 ± 22.70 from an average of 57.15 points.

Conclusion:

The overall outcome of the total ankle arthroplasty with the Cadence™ prosthesis showed excellent clinical and radiological outcomes. Compelling clinical evidence shows that the quality of life, functional measures, and pain in patients suffering from end-stage arthritis significantly improved following surgery with the Cadence™ total ankle replacement system. The semi- constrained design of this two-component implant and utilization of biased polyethylene inserts allowed for correction of the talus in both the sagittal (talar anterior / posterior translation) and coronal planes (talar varus / valgus).
Initial Evaluation by a Nonoperative Provider Does Not Delay the Surgical Care of Operative Ankle Fractures in a Walk-in Orthopaedic Clinic
Authors: Fournier Matthew N , Cline Joseph T , Seal Adam , Smith Richard A , Bettin Clayton C , Murphy Garnett A
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Walk-in and “afterhours” clinics are a common setting in which patients may seek care for musculoskeletal complaints. These clinics may be staffed by orthopaedic surgeons, nonsurgical physicians, advanced practice nurses, or physician assistants. If orthopaedic surgeons are more efficient than nonoperative providers at facilitating the care of operative injuries in this setting is unknown. This study assesses whether evaluation by a nonoperative provider delays the care of patients with operative ankle fractures compared to those seen by an orthopaedic surgeon in an orthopaedic walk-in clinic.

Methods:

Following IRB approval, a cohort of patients who were seen in a walk-in setting and who subsequently underwent surgical treatment for an isolated ankle fracture were retrospectively identified. The cohort was divided based on whether the initial clinic visit had been conducted by an operative or nonoperative provider. A second cohort of patients who were evaluated and subsequently treated by a fellowship-trained foot and ankle surgeon in their private practice was used as a control group. Outcome measures included total number of clinic visits before surgery, total number of providers seen, days until evaluation by treating surgeon, and days until definitive surgical management.

Results:

138 patients were seen in a walk-in setting and subsequently underwent fixation of an ankle fracture. 61 were seen by an orthopaedic surgeon, and 77 were seen by a nonoperative provider. No significant differences were found between the operative and nonoperative groups when comparing days to evaluation by treating surgeon (4.1 vs 4.5, p=.31), or days until definitive surgical treatment (8.4 vs 8.8, p=.58). 62 patients who were seen and treated solely in a single surgeon’s practice had significantly fewer clinic visits (1.11 vs 2.03 and 2.09, p<.05), as well as days between evaluation and surgery compared to the walk-in groups (5.44 vs 8.44 and 8.78, p<.05).

Conclusion:

Initial evaluation in a walk-in orthopaedic clinic setting is associated with a longer duration between initial evaluation and treatment compared to a conventional foot and ankle surgeon’s clinic, but this difference may not be clinically significant. Evaluation by a nonoperative provider is not associated with an increased duration to definitive treatment compared to an operative provider.
A Prospective, Randomized Suture-button vs Screw Syndesmotic Fixation
Authors: Giza Eric , Oliver Todd , Kreulen Christopher , Sathy Ashoke , Faerber Wade , Lin Johnny , Stannard James , Barousse Patrick , Allen Tyler
Published: October 2019

Category:

Ankle, Arthroscopy, Sports

Introduction/Purpose:

Syndesmotic disruption occurs in 10 to 13% of all ankle fractures. It is present in 15 cases per 100,000 of the general population. There has been debate on the best treatment for syndesmotic injuries. The typical surgical treatments include fixation with either screws or suture button devices. The purpose of this study is to compare clinical outcomes of syndesmotic injuries treated surgically with either screws or suture button devices. It was hypothesized that suture button fixation would provide equal clinical results with less need for hardware removal.

Methods:

This was a multi-center, randomized, prospective clinical trial comparing two surgical interventions for treatment of acute syndesmotic injury. At the time of surgical intervention, subjects were placed into either the screw fixation or the Suture-button device group by opening a randomized envelope in the operating room. Subjects with clinical signs or radiographic evidence of syndesmotic injury were asked to participate in this study. Inclusion criteria was ages 18 to 65 years old with confirmed syndesmotic instability. The primary outcomes of thestudy were VAS scores (activity, pain, satisfaction) and FFI scores (pain, disability, activity) which were collected at preoperative state, 6 weeks, and 12 months postoperatively.

Results:

Sixty-five subjects were enrolled in this study. Thirty-two subjects received Suture-button fixation (49%) and 33 received screw fixation (51%). VAS scores and FFI scores for subjects treated with the Suture-button device or screw fixation comparing preoperative, six-week, and 12-month scores all showed clinical improvement. There was no significant difference between the two treatment groups (p >0.05). Nine subjects (27%) in the syndesmotic screw fixation group experienced adverse events; four required repeat surgery for symptomatic syndesmotic screw removal, one for revision fixation, and four did not return to surgery despite hardware failure. One subject(3%) in the suture-button group required hardware removal.

Conclusion:

The short-term clinical outcomes suggest that both syndesmotic screws and suture-button devices are effective treatment options to address acute syndesmotic injuries. In the short-term (12-months), suture-button fixation resulted in significantly less adverse events compared to syndesmotic screw fixation group.
The “AdductoValgus” Foot: Description of Deformity and Technique for Surgical Reconstruction
Authors: Gorman Robert R.
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

The literature is replete with descriptions of metatarsus adductus (pediatric patients) and metatarsus primus varus (adult patients) deformities along with recommendations for treatment. For adult deformities isolated to the first ray, a technique involving a cuneiform-metatarsal arthrodesis (e.g. Lapidus procedure) is often employed. There is a paucity of literature describing adult manifestations of adduction deformities involving multiple metatarsals. The senior author has treated a number of adult patients with these types of deformities. This case series is presented here with a description of the deformity and a technique for surgical reconstruction.

Methods:

Five patients having undergone surgical reconstruction for symptomatic midfoot/forefoot deformities involving adduction of multiple metatarsals (and valgus metatarsophalangeal joints) were retrospectively reviewed. The first ray deformities were treated with arthrodesis of the first metatarsal to the medial cuneiform, along with a distal soft tissue release and medial eminence resection as appropriate. Lesser ray deformities were corrected with oblique osteotomies of the metatarsal shafts (and metatarsophalangeal joint capsulorraphies and/or pinning as appropriate).

Results:

All patients went on to radiographic union of their arthrodeses and osteotomies. The midfoot (metatarsus adductus) deformities, and hallux valgus deformities, maintained correction compared to preoperative alignment. There were some lesser metatarsophalangeal joint valgus recurrences. There were no severe complications of deep infection or revision surgery. Conclusion: The “AdductoValgus” foot deformity presents in adult patients with adduction of multiple metatarsals and corresponding metatarsophalangeal joint valgus. The deformity can result in pain with mobility and difficulty with shoewear. Surgical reconstruction including first ray tarsometatarsal arthrodesis and osteotomies of the involved lesser metatarsals appears a viable option for deformity correction and symptomatic relief.
Intramedullary Fixation of Distal Fibula Fractures
Authors: Hanselman Andrew , Scott Daniel , Adams Samuel
Published: October 2019

Category:

Trauma

Introduction/Purpose:

The current gold-standard for unstable distal fibula fractures is plate and screw fixation; however, intramedullary distal fibular fixation is becoming more commonplace. Although surgeons may consider this technique only for patients requiring extra soft tissue protection, recent studies are showing that it is a safe and effective technique for maintaining adequate reduction and promoting proper fracture healing in a wide-variety of ankle fractures. As newer techniques and equipment are developed, it is important to continue with analyzation of patient outcomes. Our study evaluates a intramedullary device that contains a unique proximal locking mechanism that deploys fins against the inner cortex to help maintain fracture length and control rotation. To our knowledge, no other study in the literature has evaluated this technique for distal fibula fractures.

Methods:

A retrospective case-series was conducted on all patients >18-years old with unstable ankle fractures treated with the same intramedullary distal fibular fixation, that contained the unique proximal locking system. Surgeries were performed at a single institution by a single surgeon between September 2015 and June 2018. Patient imaging was carefully assessed for quality of reduction using previously established guidelines classifying reductions as “good”, ”fair”, or “poor”. Patient charts were also assessed for comorbidities, initial fracture classification, postoperative complications, and need for additional surgery.

Results:

Forty-one patients were included in the study. Twenty-five patients were female and 16 patients were male. Average age was 52. Average follow-up was 10.0 months. Eleven fractures were bimalleolar (27%), eight were isolated distal fibula fractures (20%), eight were bimalleolar-equivalent fractures (20%), nine were trimalleolar fractures (22%), and five were pilon fractures (12%). Seventy-one percent were Weber B and 29% were Weber C. Based on the classification system, 37 fracture reductions (90%) were classified as ”good”, four were “fair” (10%), and no reductions were ”poor”. There were no instances of hardware failure, loss of reduction, or nonunion. One patient had a superficial wound infection, one patient had a deep wound infection, five patients require painful hardware removal, and one patient had a delayed union.

Conclusion:

This large case-series is the first study, to our knowledge, in the Foot and Ankle literature to evaluate this specific intramedullary distal fibular fixation system that contains a unique-proximal fixation mechanism within the canal itself. This technique was used for a variety of unstable ankle fractures and was shown to be both safe and effective, and will help guide future prospective studies comparing outcomes with the gold-standard plate and screw fixation.
Comparison of Tibial and Talar Bone Density as a Function of Resection Level in Patients Undergoing Total Ankle Replacement vs Demographic-Matched Controls
Authors: Harnroongroj Thos , Volpert Lauren , Sturnick Daniel , Sofka Carolyn , Ellis Scott J. , Deland Jonathan , Demetracopoulos Constantine
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

Initial implant fixation is critical for long-term success of total ankle replacement (TAR). One important factor which contributes to implant stability is the quality of the surrounding bone. Previous studies characterized a decrease in bone density with increasing distance from the level of the joint in the tibia and talus in non-arthritic ankles. However, ankle arthritis affects bone density remains unclear. The objective of this study is to compare the bone density in patients with and without ankle arthritis as a function of resection level from the joint. We hypothesized that there would be no difference in bone densities at each resection level between groups and bone density would decrease with greater distance from articular surface in both groups.

Methods:

We retrospectively reviewed 93 end-stage ankle arthritis patients with available preoperative non-weight bearing ankle computed tomography scans (CT)(Group A) and identified another cohort of 83 patients with non-arthritic ankles as a demographic-matched control group(Group B). Patients with retained ankle hardware, history of osteomyelitis, osteoporosis, and cysts greater than 1 cm in diameter at the ankle were excluded. There was no difference in term of gender, age and body mass index (BMI) between the groups(Table 1). The ROI tool in Sectra IDS7 picture archiving and communication system (PACS) was used to calculate Hounsfield Unit (HU) values in the cancellous region of the tibia and talus around the ankle joint. Measurements were obtained on axial CTs from 6 mm to 12 mm above the distal tibial plafond, and from 1 mm to 4 mm below the talar dome. The HU measurements and percentage decrease of HU values at each level were compared between groups.

Results:

Patients with ankle arthritis demonstrated significantly greater bone density than the control group between 6 mm and 10 mm from the joint in the tibia. There was no significant difference in bone density between 10 mm and 12 mm from the joint on the tibia, and at all levels in the talus between groups (Table 1). In both groups, bone density decreased significantly at each successive level from the joint for the tibia and talus. In addition, the percentage decrease of HU values at each relative level was the same in both groups.

Conclusion:

Patients with ankle arthritis demonstrated greater bone density at 6 mm to 10 mm from the joint in the tibia compared to demographic-matched controls. The increased bone density close to the joint may stem from bone eburnation that occurs as part of the arthritic process. In TAR, a tibial bone resection between 6 mm and 10 mm may provide improved initial stability of the implant. Contrary to traditional thinking, fixation into the talus may be of less concern.
Tibial Sesamoidectomy: Indications and Outcomes
Authors: He Jun Kit , Christie Matthew , Robin Joseph , McKissack Haley , Shah Ashish
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Tibial sesamoidectomy has been reported to be a safe and effective procedure of treating a range of sesamoid pathologies including chronic sesamoiditis and fracture nonunion. The purpose of this retrospective case series was to determine common clinical indications for tibial sesamoidectomy and to evaluate the postoperative clinical course and outcomes.

Methods:

A retrospective chart review was conducted on patients who had isolated tibial sesamoidectomy after failed conservative treatment from 2009 to 2018. Demographics, comorbidities, physical exam variables, operative findings, radiographic measurements including hallux valgus angle (HVA) and intermetatarsal angle (IMA), and clinical outcomes including visual analog score (VAS), Foot Function Index (FFI), and complications were gathered.

Results:

Twenty-six patients (13 males and 13 females) were identified who have undergone tibial sesamoidectomy with a mean age of 49.8±18.5 years. For those 21 non-ulceration patients, VAS was significantly improved from 5.27±2.41 pre-operatively to 0.91±1.14 post-operatively (p<0.01). There was no statistically significant change in IMA (8.35±1.87º to 8.29±1.79º, p=0.93) or HVA (14.94±6.82º to 14.28±7.78º, p=0.79). Postoperative FFI was obtained for 10 patients with a mean of 132.75±50.68. For those five patients who had chronic ulceration on the plantar surface of the medial metatarsal head, four had complete healing at a mean of 15.6±5.37 weeks post-operatively. There was a 17% incidence of complications including neuritis, transfer metatarsalgia, and persistent cock-up deformity.

Conclusion:

When utilized judiciously and with the right indications, isolated tibial sesamoidectomy is a safe procedure which can improve pain and ulcer healing. HVA and IMA remained unchanged at final follow-up.