bluuebunny/crossref_metadata_2025 huggingface dataset:
Is there an Association between Psychological Factors and Developing Complex Regional Pain Syndrome after an Ankle Fracture?
Authors: Alluri Ram , Bouz Gabriel , Foster Brock , Wang Christopher , Marecek Geoffrey , Tan Eric
Published: September 2017

Category:

Ankle, Trauma, Mental Health

Introduction/Purpose:

Recognizing psychological risk factors for developing Complex Regional Pain Syndrome (CRPS) may facilitate the diagnosis of CRPS and can be critical in its prevention and treatment. The purpose of this study was to evaluate the association between psychological dysfunction and developing CRPS after sustaining an ankle fracture.

Methods:

The PearlDiver patient record database was used to identify patients who sustained an ankle fracture between 2005 and 2015. These patients were screened for development of CRPS based on the presence or absence of psychological disorders including anxiety disorder, bipolar disorder, delirium, psychosis, depression, chronic pain syndrome, and fibromyalgia. A substratification analysis was performed assessing the additional risk of developing CRPS by undergoing operative versus nonoperative management.

Results:

163,529 patients were identified who sustained an ankle fracture and CRPS was identified in 10,127 (6.2%) of these patients. The risk of developing CRPS after sustaining an ankle fracture was significantly elevated with an OR of 5.44 (P<0.001) in patients with a psychological disorder. The psychological disorders that were most predictive of developing CRPS included delirium (OR 5.60, P<0.001), bipolar disorder (OR 5.64, P<0.001), and anxiety disorder (OR 5.08, P<0.001) (Table I). The OR for developing CRPS in patients with a psychological disorder was 5.57 (P<0.001) for patients who received operative treatment and 5.30 (P<0.001) for patients who received closed treatment. There was no additional risk (OR 0.98, P= 0.31) for developing CRPS in patients with a psychological disorder who underwent operative management.

Conclusion:

Patients with a known psychological disorder were five times more likely to develop CRPS after sustaining an ankle fracture. There was no additional risk due to operative management. This information may be useful in the diagnosis and treatment of patients with mental health disorders who sustain an ankle fracture and subsequently develop CRPS.
Topographic Pain Mapping versus Radiological Inter-observer Variation in Ankle Arthritis
Authors: Ashton Fiona , Ramaskandhan Jayasree Ramas , Farrier Adam , Siddique Malik
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Topographic pain mapping has gained popularity during 20th century, providing opportunities for patients to demonstrate spatial distribution of pain. Despite this, evidence of clinical application in orthopaedics remains largely limited to spinal pathologies. We investigate how clinician interpretation of routine radiological studies compares to patient pain mapping in ankle arthritis.

Methods:

Between 2014 and 2016 we identified 21 patients ultimately diagnosed with ankle arthritis, who underwent comprehensive gait analysis (including topographic pain mapping) on referral to our institution. Patients were requested to map up to three pain areas, assigning a visual analogue score (VAS) of 0-10, to signify severity of pain in each area. A consultant orthopaedic foot and ankle surgeon, and orthopaedic trainees undertook blinded evaluation of relevant radiological studies, estimating patients’ mapping and VAS scores on the basis of radiological pathology. For the purpose of analysis findings were applied to five distinct regions around the ankle: three anterior (antero-medial; central; and antero-lateral), lateral and medial. Results were correlated between the different assessors, as well as to the patients’ pain mapping, using Spearman’s Rho & Kendall Tau correlation statistics, significance taken as p=<0.05.

Results:

There is a strong radiological inter-observer correlation for anterior ankle pain in ankle arthritis [Antero-lateral 0.751(p=0.012); Central 0.912(p=<0.001)]. These findings also correlate well with patient pain mapping [Central consultant-patient 0.920(p=<0.001); trainee-patient 0.982(p=<0.001)]. Assessment of medial (tibialis posterior) and lateral (subtalar/peroneal) pathology demonstrates poorer inter-observer correlations (p>0.05). Correlation to patient pain mapping was even poorer, with radiological assessment consistently over- estimating symptom severity (p=>0.05).

Conclusion:

There is a statistically strong correlation between topographic pain mapping and radiological evaluation of ankle arthritis. We strongly recommend that additional pathology around the ankle is excluded by use of pre-operative MRI imaging prior to surgery for ankle arthritis. Pain from ankle arthritis appears to mask additional soft tissue pathology surrounding the ankle noted on MRI scan.
Outcomes Following Surgical Treatment of Hallux Valgus Deformity
Authors: Barg Alexej , Saltzman Charles
Published: September 2017

Category:

Bunion

Introduction/Purpose:

Hallux valgus (HV) deformity is one of the most common chronic disorders. Surgical correction plays a central role in the treatment of painful HV deformity with over 100 different surgical techniques described in the current literature. In this report we performed a systematic literature review on studies that addressed clinical outcomes following surgical treatment of hallux valgus. The objectives of our study were to (1) describe available study characteristics on surgical HV deformity treatment; (2) determine patients’ postoperative satisfaction including postoperative pain and recurrence of HV deformity; (3) determine rate of postoperative complications by surgery type; and (4) analyze the relationship between radiographic HV deformity parameters and postoperative complication rate.

Methods:

We reviewed the literature using common data bases. All searches were unlimited. Study demographics were collected and analyzed. Gender distribution was estimated using an inverse-variance weighting method and patient age and follow-up time were summarized using a simple weighted average due to an absence of reporting variance in the majority of studies. A chi- squared Q test, or heterogeneity test, was used to test for differences across surgery types for patient dissatisfaction, deformity recurrence, removal of hardware, reoperation, nonunion, hallux varus, nerve injury, infection, metatarsalgia, and VAS>5. Outcome estimates and 95% confidence intervals (CIs) for each surgery type were pooled across studies using the inverse-variance weighting method. A random effects model was used when study variance was estimated using the DerSimonian-Laird method.

Results:

In total, 269 studies with 13,112 patients and 16,594 feet were included. Patients treated by simple buniectomy had the highest dissatisfaction rate with 25.5% (95%CI 17.5-35.6). Deformity recurrence was highest in patients treated by proximal osteotomy with 10.5% (95%CI 5.6-18.7). The highest rate of secondary surgery was in patients treated by simple buniectomy with 6.1% (95%CI 2.4-14.7). In the same patient group the highest rate of hallux varus deformity was observed with 9.1% (95%CI 2.9- 24.9). Patients treated by hemi-joint resection had the highest rate of postoperative metatarsalgia with 16.2% (95%CI 11.3-22.8) and persisting pain VAS>5 with 6.5% (95%CI 3.3-12.3).

Conclusion:

Patients with buniectomy and hemi-joint resection demonstrated the highest rates of postoperative complications including dissatisfaction, need for secondary surgery, postoperative metatarsalgia, and persisting pain.
What Factors Are Predictive of Outcome in the Treatment of Soft Tissue Sarcomas of the Foot and Ankle?
Authors: Beahrs Taylor , Turner Norman , Wyles Cody
Published: September 2017

Category:

Tumor

Introduction/Purpose:

Soft tissue sarcomas (STS) of the foot and ankle are common, accounting for 10% of sarcomas; however, there exists little published data on the outcome of treatment. Because of the unique anatomy of the foot and ankle, and the fact that benign lesions in this area are 200-fold more common than malignant lesions, these tumors can be frequently misdiagnosed, leading to unplanned excision and poor outcomes. The purpose of this study was to describe outcomes of the surgical treatment of STS of the foot and ankle at our institution, with an analysis on risk factors for local and distant recurrence, as well as overall survival.

Methods:

We reviewed the records of 62 foot and ankle soft tissue sarcomas treated with definitive surgery at our institution between 1992 and 2013. The cohort consisted of 35 males and 27 females with a mean age at diagnosis of 45 years and a mean follow-up of 7 years. Age, gender, anatomic location, tumor size, subtype, stage, neoadjuvant and adjuvant treatments, previous surgery, surgical procedure, and disease status at latest follow-up was recorded.

Results:

The most common tumor subtype was synovial sarcoma (n = 16). The overall limb salvage rate was 53%. Local recurrence was observed in 9 patients and distant metastases in 15 patients. Tumor size >=3 cm in maximal dimension was the greatest risk factor in mortality. Post treatment complications occurred in 15 patients. Local recurrence and development of distant disease was relatively common following wide excision of a soft tissue sarcoma of the foot and ankle. Tumors that were >=3 cm in maximal dimension were associated with a worse overall survival and patients with neoadjuvant radiation were at increased risk of complications.

Conclusion:

The results of our study highlight the aggressive nature of soft tissue sarcomas of the foot and ankle, with smaller tumors than previously reported (<5 cm) behaving like high-grade advanced disease.
Total Ankle Arthroplasty
Authors: Beck David , Raikin Steven , Pedowitz David , Padegimas Eric
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

The number of total ankle arthroplasties (TAA) performed in the United States has risen significantly in recent years. Additionally, utilization of an orthopaedic specialty hospital (OSH) to treat healthy patients undergoing elective surgery is becoming more common. The effect of OSH utilization on post-operative outcomes following TAA has yet to be investigated. The purpose of this study is to compare post-operative outcomes following TAA at an OSH when compared to a matching population of patients undergoing TAA at an academic teaching hospital (ATH).

Methods:

We identified all primary, atraumatic TAA from January 2014 to December 2014 at the OSH and January 2010 to January 2016 at the ATH. Each OSH patient was manually matched to a corresponding ATH patient by clinical variables (age adjusted Charlson comorbidity index [AACCI], 17 individual comorbidity categories, and body mass index [BMI] and demographic variable (age, gender, and insurance type). Matching was performed in a blinded fashion to outcomes. Outcomes analyzed were LOS, 30-day readmissions, mortality, reoperation, and inpatient rehabilitation utilization.

Results:

There were 40 TAA patients in each group. OSH and ATH patients were similar in age (66.7 versus 66.8 yo, p=0.95), BMI (both 28.4, p=1.00), age-adjusted Charlson Comorbidity Index (both 3.3, p=1.00), and gender (both 45.0% male, p=1.00). Average LOS for TAA at the OSH was 1.28+/-0.51 compared to 2.03+/-0.89 (p<0.001) at the ATH. No OSH patients were readmitted within 30 days, compared to 2 ATH (5.0%; p=0.15). Two OSH patients (5.0%) and two ATH patients (5.0%; p=1.00) required reoperation. There were no mortalities in either group. No OSH patients utilized inpatient rehabilitation compared to 3 ATH patients (7.5%; p=0.078). When excluding patients utilizing inpatient rehabilitation, patients at the OSH still demonstrated significantly lower LOS (1.28+/-0.51 vs 1.81+/-0.69 days; p<0.001). No OSH patients required transfer.

Conclusion:

Primary TAA performed at an OSH had significantly shorter LOS when compared to a matched patient treated at an ATH with no significant difference in readmission or reoperation rates. Additionally, patients who had their procedure performed at an OSH utilized inpatient rehabilitation less frequently than those at an ATH. This study suggests that performing TAA at an OSH offers a potential source of significant healthcare savings.
Invisible Injuries in Ankle Fractures
Authors: Blom Robin , Knupp Markus , Hintermann Beat , Stufkens Sjoerd
Published: September 2017

Category:

Ankle, Trauma, Biomechanical

Introduction/Purpose:

Ankle fractures are often associated with ligamentous injuries of the distal tibiofibular syndesmosis, the deltoid ligament and are predictive of ankle instability, early joint degeneration and long-term ankle dysfunction. Detection of ligamentous injuries and the need for treatment remain subject of ongoing debate. In the classic article of Boden it was made clear that injuries of the syndesmotic ligaments were of no importance in the absence of a deltoid ligament rupture. Even in the presence of a deltoid ligament rupture, the interosseous membrane withstood lateralization of the fibula in fractures up to 4.5 mm above the ankle joint. Generally, syndesmotic ligamentous injuries are treated operatively by temporary fixation performed with positioning screws. But do syndesmotic injuries need to be treated operatively at all?

Methods:

The purpose of this biomechanical cadaveric study was to investigate the relative movements of the tibia and fibula, under normal physiological conditions and after sequential sectioning of the syndesmotic ligaments. Ten fresh-frozen below-knee human cadaveric specimens were tested under normal physiological loading conditions. Axial loads of 50 Newton (N) and 700 N were provided in an intact state and after sequential sectioning of the following ligaments: anterior-inferior tibiofibular (AITFL), posterior-inferior tibiofibular (PITFL), interosseous (IOL), and whole deltoid (DL). In each condition the specimens were tested in neutral position, 10 degrees of dorsiflexion, 30 degrees of plantar flexion, 10 degrees of inversion, 5 degrees of eversion, and externally rotated up to 10 Nm torque. Finally, after sectioning of the deltoid ligament, we triangulated Boden’s classic findings with modern instruments. We hypothesized that only after sectioning of the deltoid ligament; the lateralization of the talus will push the fibula away from the tibia.

Results:

During dorsiflexion and external rotation the ankle syndesmosis widened, and the fibula externally rotated after sequential sectioning of the syndesmotic ligaments. After the AITFL was sectioned the fibula starts rotating externally. However, the external rotation of the fibula significantly reduced when the external rotation torque was combined with axial loading up to 700 N as compared to the external rotation torque alone. The most relative moments between the tibia and fibula were observed after the deltoid ligament was sectioned.

Conclusion:

Significant increases in movements of the fibula relative to the tibia occur when an external rotation torque is provided. However, axial pressure seemed to limit external rotation because of the bony congruence of the tibiotalar surface. The AITFL is necessary to prevent the fibula to rotate externally when the foot is rotating externally. The deltoid ligament is the main stabilizer of the ankle mortise.
Phalangeal Osteotomy…To Perform or Not to Perform
Authors: Chambers Monique , Hogan MaCalus , LaBaze Dukens
Published: September 2017

Category:

Bunion

Introduction/Purpose:

As the hallux valgus deformity progresses, patients can get mild to moderate arthritis of the metatarsophalangeal (MTP) joint. The degenerative process of MTP arthritis results in reactive tissue formation and proliferation of osseous and cartilaginous structures. For some patients, the results in dorsal bone spurs and pain with great toe dorsiflexion of irritation from shoes. Reconstructive procedures provide a surgical option for patients to address pain and functional limitations, prior to subchondral bone cyst formation and loss of joint space. Patients who underwent cheilectomy alone have been shown to have a high failure rate and progress to advanced disease. A phalangeal dorsiflexion osteotomy has become increasingly more popular amongst foot and ankle surgeons with the hopes of decreasing failure rate and improving early outcomes.

Methods:

This study was a retrospective review of prospectively collected data from 385 patients treated for hallux rigidus at a large academic medical center between July 2015 and November 2016. All patients underwent either a cheilectomy or cheilectomy with phalangeal osteotomy of the MTP joint. Collected patient reported outcomes (PROs) included in this study were SF12 M, SF12P, FAAM, VAS and PASS scores. Mann-Whitney t-test was performed using GraphPad Prism version 7.0b for Mac to compare procedure groups. Exclusion criteria included poly-trauma, revision of same procedure, and lack of pre or post- operative.

Results:

Eighteen patients met criteria, 8 underwent cheilectomy and 10 had a cheilectomy with osteotomy procedure. The average age was 51.9 amongst the cohort, with a total of 13 female and 5 males. Patients who underwent cheilectomy with osteotomy procedure had better outcomes across all outcome measure scores. When comparing postoperative scores, cheilectomy with osteotomy patients showed significantly higher scores compared to cheilectomy alone patients: SF12-M (56 vs 36, respectively; p=0.0333), and SF12P (52 vs 30, respectively p=0.0095). VAS scores and FAAM scores showed no statistical difference between the two cohorts. Despite surgical intervention, 50% of patients who received cheilectomy alone reported more pain post-operatively compared to no reports of worsening pain in patients who received cheilectomy with osteotomy.

Conclusion:

Patients with moderate to severe hallux rigidus demonstrate improved functional outcomes with phalangeal osteotomy in conjunction with cheilectomy compared to cheilectomy alone. Further research with larger cohorts would be beneficial to confirm the reports of this study and expand upon aspects of care that contribute to patient satisfaction and performance.
Intermediated-term Results of Salvage Procedure using Tibiocalcaneal Fusion and Strut-fibular Graft for Ankle Arthropathy with Severe Bone Defect
Authors: Cho Byung-Ki , Choi Seung-Myung
Published: September 2017

Category:

Ankle Arthritis, Diabetes

Introduction/Purpose:

Severe bone defect around the ankle joint is a challenging problem in salvage operation. It has been considered as one of major factors leading to the failed fusion, because it can be difficult to make the rigid internal fixation and the compact bone filling. This retrospective study was performed to evaluate the clinical outcomes of the tibiocalcaneal fusion combined with strut-fibular graft as a salvage procedure for end-stage ankle arthropathy with severe bone defect.

Methods:

Twenty-eight patients were followed for more than 3 years after tibiocalcaneal fusion using the locking compression intramedullary(IM) nail and strut-fibular graft. The mean age was 57.6 years, and the mean follow-up period was 4.2 years. The clinical evaluation consisted of the American Orthopaedic Foot and Ankle Society(AOFAS) scores, Foot and Ankle Ability Measure(FAAM) score. The subjective satisfaction score, postoperative complications, and the reoperation rate were evaluated. As the radiographic evaluation, the period to fusion, the degree of shortening compared with contralateral limb, and the degenerative change on adjacent joints were analysed.

Results:

AOFAS score significantly improved from preoperative average 28.8 points to 80.4 points at final follow-up (p<0.001). FAAM score had significantly improved from preoperative average 33.5 points (daily activity), 15.4 points (sports activity) to 79.8 points, 68.4 points at final follow-up (p<0.001). The period to fusion were average 18.2 weeks (tibia-fibular graft) and 19.5 weeks (calcaneus-fibular graft), respectively. 26 patients (92.8%) except for 2 patients achieved complete fusion. The degree of limb shortening was maintained from preoperative average 12.8 mm to 14.5 mm at final follow-up (p=0.236). There were 3 cases of postoperative wound infection, 3 cases of superficial peroneal nerve injury, 4 cases of metal irritation, 3 cases of degenerative changes on adjacent joint, and 2 cases of reoperation following the failed fusion.

Conclusion:

Tibiocalcaneal fusion using the locking compression IM nail and strut-fibular graft appear to be an effective salvage procedure for end-stage ankle arthropathy with severe bone defect. Although longer operation time and more postoperative complications have happened as compared to the cancellous bone graft alone, this surgical technique can contribute to the pain relief and improvement of gait ability through a satisfactory fusion rate and minimization of limb shortening.
Effectiveness of the Plantar Aponeurosis Release for Limitation of the First Metatarsophalangeal Joint Extension after Hallux Valgus Surgery
Authors: Choi Hongjoon , Kim Daewook , Kang Yeong Hun , Park Jong Ho
Published: September 2017

Category:

Midfoot/Forefoot

Introduction/Purpose:

Even though stiffness of the first metatarsophalangeal joint (1MTP) is not a common complication, reduced dorsiflexion range of motion at the 1MTP after surgery for hallux valgus was reported as a complication. However, few clinical studies have investigated this issue and no clinical resolution has been reached thus far. We hypothesized that tightness of the gastrocnemius-plantar aponeurosis complex is one of the factors that limits the extension of 1MTP after hallux valgus surgery. Thus, an additional procedure of the plantar aponeurosis release during hallux valgus surgery may improve the range of extension at 1MTP. The purpose of this study was to test the efficacy of plantar aponeurosis release in improving the range of extension when a limitation is detected after hallux valgus surgery.

Methods:

Thirteen patients (17 feet) with limited 1MTP extension after hallux valgus surgery, underwent an additional procedure of plantar aponeurosis release. The inclusion criterion was limitation of 1MTP extension showed more than 15 degrees difference between knee extension and flexion position, measured after completing all procedures of the hallux valgus surgery. The passive range of 1MTP extension was evaluated by a goniometer while the first metatarsal head was supported with a palm, assuming a weightbearing position with knee extension and flexion, after completing all procedures of the hallux valgus surgery (Barouk test). A silfverskiold test was performed in all cases preoperatively. The weightbearing dorsoplantar and lateral radiographs of the foot were performed to measure the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, and the talo-first metatarsal angle.

Results:

The mean range of 1MTP extension significantly improved from 2.53 degrees to 40.88 degrees in the knee extension position (p<0.0000). The mean range of the 1MTP extension also improved from 18.24 degrees to 43.24 degrees in the knee flexion position. The silfverskiold test was positive in 12 cases. In all patients, congruence of 1MTP was corrected. There were no surgery-related complications such as plantar aponeurosis rupture or nerve injury.

Conclusion:

Our study supports tightness of the gastrocnemius-plantar aponeurosis complex is one of the factors that limit the extension of 1MTP after hallux valgus surgery. Hence, plantar aponeurosis release can be considered as an effective additional procedure to improve the range of 1MTP extension when a limitation is presented after hallux valgus surgery.
Patient reported disability of ankle, hindfoot, midfoot and hallux metatarsophalangeal arthritis
Authors: Christian Matthew , Jeng Clifford , Cerrato Rebecca , Campbell John T. , Koenig Scott , O’Hara Nathan , Hull Michael
Published: September 2017

Category:

Ankle, Ankle Arthritis, Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

There has been in increased interest in foot and ankle arthritis in the literature in recent years. A significant focus of the literature has been which operative techniques are best for managing these problems. Some work has been done analogizing disability due to ankle arthritis to more familiar joints such as the hip. There is little data explaining how much patient reported disability is associated with each type of isolated foot and ankle arthritis. Various clinical rating scales have proven how debilitating foot and ankle arthritides can be to patients. The purpose of our study was to use Functional Foot Index (FFI) and Short Form-12 (SF-12) rating scales to compare the patient reported disability associated with ankle, hindfoot, midfoot, and hallux metatarsalphalangeal (MTP) arthritides.

Methods:

We retrospectively reviewed the FFI and SF-12 (both Physical Component Scores (PCS) and Mental Component Scores (MCS)) of patients who presented to a high volume orthopaedic foot and ankle practice between 2010 and 2016 with either ankle, hindfoot, midfoot or hallux MTP arthritis. We included patients between 18-65 years of age who underwent a surgical procedure for arthritis within 6 months of their initial presentation. We excluded patients with any medical or surgical co-morbidities known to affect disability scores. A total of 214 FFI and 195 SF-12 data sets were included.

Results:

Study population SF-12 PCS scores for all patients with ankle or foot arthritis were significantly lower than US age-based norms. Patients with ankle arthritis had the highest disability (FFI score 46.5, SF-12 PCS 32.3). Patients with midfoot and hindfoot arthritis had intermediate disability (Midfoot FFI score 34.9, SF-12 PCS 34.5; Hindfoot FFI score 44.3, SF-12 PCS 34.5). Patients with hallux MTP arthritis had the lowest disability (FFI score 32.9, SF-12 PCS 40.7). All FFI and SF-12 PCS scores were statistically significant. SF 12 MCS were not statistically significant.

Conclusion:

All patients with foot and ankle arthritis had increased disability compared to US age-based norms. Patients with ankle arthritis experience the most self-reported disability and patients with hallux MTP arthritis experience the least self- reported disability of the isolated types of arthritis in orthopaedic foot and ankle.
Short-term outcome of Lisfranc injuries treated with single dorsal plate fixation
Authors: Chun Sangho , Lee Kyoung min , Park Moon Seok , Sung Ki Hyuk , Koo Seungbum , Kim Sung Jin , Choi Hyun , Sangyeop Shin , Lee Seung Yeol
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Several methods like cortical screw, Kirschner (K) wire have been used for stabilizing the Lisfranc joint. We performed this study to assess whether single dorsal plating can be used as an alternative treatment method for a Lisfranc injury.

Methods:

Patients were followed up for more than 1 year after the initial surgery.Following open reduction of the joint with a bone reduction clamp, a single dorsal plate was used to perform Lisfranc joint fixation. The plate was fixed with 2.7-mm locking screws on the first metatarsal, second metatarsal, medial cuneiform, and intermediate cuneiform. Three weeks postoperatively, the cast was removed, and patients progressively advanced to full weight bearing while wearing a postoperative shoe. The plate was removed 3 months postoperatively. One year postoperatively, weight-bearing foot radiographs and the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score were obtained.

Results:

Eighteen patients with a Lisfranc injury who were treated with open reduction and internal fixation using a single dorsal plate were included. The average AOFAS midfoot score for pain was 35, and the total score was 80.8 (range, 67–95). Six patients (33.3%) had an excellent outcome (score =90); eight (44.4%) had a good outcome (90 > score = 75); and four (22.2%) had a fair outcome (75 > score = 50). Radiographs during the follow-up period showed no loss of reduction or arthritic change. Screw breakage occurred in 3 cases. But the injury ultimately healed anatomically.

Conclusion:

Single dorsal plating can be an alternative treatment method for a Lisfranc injury, as it provides a good short-term outcome without causing further joint injury.
Tenogenic differentiation of tonsil-derived mesenchymal stem cells
Authors: Chun Sangho , Lee Kyoung min , Lee Seung Yeol
Published: September 2017

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Human palatine tonsil-derived mesenchymal stem cells (T-MSCs) are known to be a new source of progenitor cells. Using waste tissue after tonsillectomy as a cell provider can be the biggest benefit of T-MSCs, compared with other stem cells. The purpose of this study was to investigate tenogenic differentiation of T-MSCs and to access the differential effects of TGF-ß3 on the tenogenesis of T-MSCs.

Methods:

Human tonsil was obtained after tonsillectomy.Using a cytometric analysis, we were able to find that the T-MSCs had typical mesenchymal stem cell markers: positive for CD73, CD90 and CD105, and negative for CD14, CD34 and CD45. Using a Transforming growth factor beta 3 (TGF-ß3), the expressions of tenocyte-specific genes and proteins, such as Collagen type I (COL1), Tenomodulin (TNMD), and Scleraxis (SCX), were measured by a quantitative polymerase chain reaction (PCR) assay, immunofluorescence staining, immunohistochemistry and Western blot analysis.

Results:

Quantitative PCR assay showed that TGF-ß3 significantly increased the expressions of tenocyte lineage marker genes, including Collagen type I (COL1), Tenomodulin (TNMD), and Scleraxis (SCX), at a 3-day treatment, compared with control. However, these increases were not found at long-term exposures (7 or 10 days), except that TNMD expression was maintained at 50 ng/ml at 7-day exposure to TGF-ß3 (Fig). Like genes, the protein expression levels of COL1, TNMD, and SCX were also induced in TGF-ß3-treated T-MSCsin 3-day treatments. Moreover, the protein levels were maintained for 10 days, as evidenced by immunofluorescence staining, immunohistochemistry and Western blot analyses.

Conclusion:

This study demonstrated that T-MSCs in tenogenic stimulation with TGF-ß3 have high tenogenic differentiation potential.
Outcomes following repeat ankle arthroscopy for osteochondral lesions of the talus (OLTs)
Authors: Cusworth Brian , Nixon Devon , Klein Sandra , Johnson Jeffrey , McCormick Jeremy J.
Published: September 2017

Category:

Ankle, Arthroscopy

Introduction/Purpose:

Management of symptomatic osteochondral lesions of the talus (OLTs) previously treated with arthroscopy remains controversial. Many advocate for open surgical intervention, particularly in patients with larger OLTs. Minimal data, however, exists on the role for repeat ankle arthroscopy. Here, we describe our experience with repeat arthroscopy for symptomatic OLTs, hypothesizing similar pain and satisfaction scores regardless of OLT size.

Methods:

Our surgical database was queried to identify patients who underwent repeat arthroscopy from February, 1997 – May, 2015. From that cohort, we identified a subset of patients with a diagnosis of symptomatic OLT who were treated with arthroscopic debridement and microfracture. We then performed a retrospective chart review. Phone surveys were conducted to assess clinical outcomes including pain and satisfaction scores as well as to record any subsequent surgery reported by the patient. Using previously defined criteria for size threshold, OLTs were categorized as either small (=150 mm2) or large (> 150 mm2) based on operative dimensions noted at the time of repeat surgery.

Results:

We identified 15 patients who underwent repeat arthroscopy for symptomatic OLTs. Patients reported reasonable satisfaction (average: 7.3, SD: 2.7) but moderate residual pain (average: 4.6, SD: 3.3) at midterm follow-up (average: 5.0 years, SD: 2.8). Further surgery after repeat arthroscopy was performed in 20% (3/15) of patients. Only 1 patient developed a postoperative complication (superficial DVT treated with observation). Small (n=6) and large OLTs (n=9) had similar postoperative pain scores (4.2 ± 3.7 versus 4.9 ± 3.2), postoperative satisfaction levels (7.5 ± 3.4 versus 7.2 ± 2.3), and reoperation rates (33% versus 22%) (P>.05). Patients with larger OLTs were younger at the time of repeat arthroscopy (P=.026) with no differences in sex or BMI (P>.05) between groups.

Conclusion:

At midterm follow-up, repeat arthroscopy for symptomatic OLTs demonstrated reasonable satisfaction but with moderate residual pain and a 20% rate of subsequent surgery. There was no statistically significant difference in postoperative pain scores, satisfaction scores, or reoperation rates between small and large OLTs. Repeat arthroscopy for symptomatic OLTs can be done safely – however, patients should be educated to have guarded optimism regarding their outcome.
Retrospective Analysis of the Non-Union Rate Associated with the Peri-operative use of Toradol in Osseous Foot and Ankle Surgery
Authors: DiDomenico Lawrence , Butto Danielle , Flynn Zachary
Published: September 2017

Category:

Ankle, Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

To evaluate the risk for non-union in patients who received Toradol in the perioperative period following osseous foot & ankle surgery.We propose there is ni significant difference in non-union rate between patients who received Toradol in the perioperative period following osseous surgery, compared to those the literature reports of using NSAIDs in the post operative period.

Methods:

Study Design: Random, Retrospective Chart Review of a single surgeon. 186 met the inclusion criteria with 172 complete charts available for review Procedure: Osseous foot and ankle surgery including osteotomies, fusions, and fracture repair. (1st MPJ fusions, Lapidus, Ankle, TTC) Inclusion Criteria: Undergo osseous surgery including osteotomies, fusions, or fracture repair Received Toradol in the perioperative period Complete chart with radiographs Outcomes: Radiographic and chart analysis for non-union between the initial post-operative visit and the final visit

Results:

A total of 186 patients were identified in having undergone a boney procedure and having received Toradol in the post - operative period. Out of the 186 patients, 172 charts were available for review. 165 of the 172 patients underwent unremarkable post operative healing. Seven patients (4.1%) were identified to have a clinical, radiographic or advanced imaging confirmed non- union. This was found to be not statistically significant with a p-value of < 0.005

Conclusion:

Since the mainstream data available has been unable to draw a clear conclusion regarding NSAID use in bone surgery cases, our study aimed to present a large patient group that had no ill effects from its usage post operatively in osseous foot & ankle surgery. As the data demonstrates, there was no correlation that post operative use of potent NSAIDs increased the risk of non-union in the patient group.
Use of ankle resting angle as a surrogate for tendon elongation in individuals following Achilles tendon rupture
Authors: Gotha Heather , Zellers Jennifer , Silbernagel Karin
Published: September 2017

Category:

Ankle, Sports

Introduction/Purpose:

Tendon elongation is associated with poor functional outcome in individuals after Achilles tendon rupture. While imaging modalities are reliable to measure Achilles tendon length, alternative time- and cost-effective measures are of interest. The resting angle of the ankle in prone both with knee extended1 and knee flexed2 have been used in the literature as surrogates for measuring Achilles elongation, however, their relationship to tendon length is not well-established. The purpose of this study is to validate the ankle resting angle as a measure of tendon elongation and examine the relationship of ankle resting angle to tendon elongation and calf strength.

Methods:

Individuals following unilateral Achilles tendon rupture, treated surgically, were included in this cross-sectional study. Individuals were excluded if they had deep wound infection or lumbar radiculopathy affecting the ankle plantar flexors. Ankle resting angle with knee extended and knee flexed to 90 degrees was measured using a digital inclinometer positioned on the lateral, plantar surface of the foot. Relative resting angle was calculated by subtracting the uninjured from the injured side. Tendon length to gastrocnemius was measured using B mode, extended field of view ultrasound imaging3 (tendon elongation = ruptured- uninjured). Calf strength was measured using the heel-rise test4. Limb symmetry indexes (LSI) were calculated (ruptured/uninjured sidex100) for total work performed on the heel-rise test.

Results:

Twenty-five individuals, a mean(SD) age of 44.2(13.6) years and mean(SD) of 22.5(39.1) months post-rupture, were included in this study. Mean(SD) relative resting angle with knee flexed was -5.4(6.4)° and mean (SD) relative resting angle with knee extended was -6.7(8.8)°. Mean(SD) tendon elongation was 1.56(1.20)cm. Mean(SD) heel-rise test work LSI was 45.8(23.8)%. Ankle resting angle with knee flexed related to elongation (r = -0.452, p = 0.027) and heel-rise test work LSI (r = 0.591, p=0.006). Ankle resting angle with knee extended related to elongation (r=-0.528, p=0.008) (Figure 1) but not heel-rise test work LSI.

Conclusion:

The results of this study suggest that ankle resting angle with knee extended and flexed are related to tendon elongation, however, calf strength also has a relationship to resting angle with knee flexed. This suggests that the ability of the calf to put passive tension on the foot is also a component of resting angle. The relationship between tendon elongation and resting angle with knee flexed may have been limited by methodological concerns, as tendon length was measured with the participant positioned with knees extended.
Location of Activation on Ankle SPECT CT Scan is Prognostic for a Successful Supramalleolar Osteotomy in Patients with Asymmetric Ankle Arthritis
Authors: Gross Christopher , Knupp Markus , Hirschmann Michael , Hintermann Beat , Rasch Helmut , Schweizer Christine
Published: September 2017

Category:

Ankle, Ankle Arthritis, Hindfoot

Introduction/Purpose:

Combined single-photon emission computed tomography and conventional computed tomography (SPECT/CT) is a hybrid imaging modality that shows a combination of metabolic and structural information about the ankle. Recently, its use has expanded for pre-operative evaluation of supramalleolar osteotomies (SMO) for asymmetric ankle arthritis. It is unclear if the location of bone scan activation is related the success of the operation. We hypothesize that uptake in specific locations within the ankle joint can be associated a failure of the supramalleolar osteotomy.

Methods:

85 pre-operative SMO patients with varus (37), valgus (41), or neutral (7) alignment of the hindfoot were assessed using SPECT/CT. The level of activation on SPECT/CT scans was measured. Activation was assessed on both the tibia and talus including 18 locations on axial scans, 8 locations sagittally, and 12 locations coronally on SPECT/CT imaging. Failure (conversion to total ankle arthroplasty (TAR) or arthrodesis) was recorded for each patient at an average of 3.7 years post-operatively. We compared the patients who had failures with those who did not with a chi-square analysis to look for any prognostic factors.

Results:

Ten patients (11.8%) had a treatment failure. Six patients were successfully converted to a TAR and another four to an arthrodesis. Pre or post-operative alignment did not correlate to a treatment failure. It was noted that the failures were more likely to have cystic lesions (20%), bipolar lesions (50%) anterocentral activation on tibia (30%), or anterocentral/media/dome activation on the talus (20%). 90% of the failure patients had post-traumatic lesions. The only statistically significant (p=.036) poor prognostic indicator was a bipolar lesion.

Conclusion:

Pre-operative SPECT/CT evaluation of an ankle before a SMO can be used to prognosticate on the success of the procedure. We caution against performing a SMO in patients with bipolar activation on a pre-operative SPECT-CT scan.
Comparative Cost of Surgical and Nonsurgical Treatment of Acute Achilles Tendon Rupture
Authors: Harkin Elizabeth , Schiff Adam , Pinzur Michael , Schiffman Corey
Published: September 2017

Category:

Sports, Practice Management

Introduction/Purpose:

Treatment of acute achilles tendon rupture (AATR) is controversial. Prospective clinical trials have demonstrated similar functional and quality of life outcomes following surgical repair and nonoperative care when a functional rehabilitation protocol is utilized. Meta-analysis would suggest that the apparent benefit of surgical treatment is an earlier return to function at the cost of an increased risk for surgical wound morbidity. The goal of this investigation was to perform a cost analysis of patients in a single orthopaedic clinic comparing operative and nonoperative treatment of acute achilles tendon rupture.

Methods:

After receiving IRB approval, patients whom were treated for acute Achilles tendon ruptures were retrospectively selected. A total of 13 adult patients with AATR, 6 non-operative and 7 operative, were identified in the period between June 1st 2014 and January 1st 2016. All patients participated in the same functional rehabilitation protocol. All patients had 1 year follow- up.

Results:

Operative treatment resulted in 3.7 times higher cost of total care compared to nonoperative treartment ($25,239 vs $6,785). Surgeon charges were 3.3 times higher in the operative group as well. ($4,543 vs $1,395). During the total length of treatment, patients in the operative group had an average of 7.4 physician visits and produced 11.9 surgeon relative value units (RVUs) while the non-operative group had 9.2 visits (p=0.0431) and produced 9.68 surgeon RVUs (p=0.102).

Conclusion:

Operative treatment of AATR had 3.7 times higher per patient treatment cost, 3.3 times higher billed surgeon charges, and slightly fewer physician visits, but with no statistically significant difference in the number of physician RVUs produced. This study questions the cost-effectiveness of operative treatment for AATR given previous long-term studies demonstrating equivalent 1-year patient outcomes.
Salto Talaris Total Ankle Arthroplasty
Authors: Hendy Benjamin , Pedowitz David , McDonald Elizabeth , Raikin Steven , Rogero Ryan , Shakked Rachel
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Reports of range of motion and how it affects patient outcomes following total ankle arthroplasty (TAA) have been mixed. Furthermore, recent studies have relied on clinical exam to obtain postoperative range of motion and have lacked preoperative functional scores. The purpose of our study was to analyze how preoperative range of motion and functional scores change with time following TAA using postoperative functional scores and radiographs for range of motion calculations.

Methods:

A retrospective chart review was performed on 145 consecutive patients (149 ankles) that had undergone Salto-Talaris fixed-bearing implant (Integra, Plainsboro, New Jersey) TAA by a single surgeon between 2010 and 2014. Preoperative range of motion was gathered clinically in office by the senior author. Postoperative range of motion through the ankle joint was evaluated with dedicated weight-bearing dorsiflexion and plantar-flexion lateral radiographs at 3 months, 6 months, 1 year and 2 years. The range of motion was measured using the angle measurement tool on the PACS system. Patients completed visual analogue scale (VAS) for and the Foot and Ankle Ability Measure (FAAM) questionnaire subcategorized into activities of daily (ADL) and sports subscale preoperatively and at postoperative intervals of 3 months, 6 months, 1 year and 2 years. The mean age was 65 years (range, 31-83 years). Mean BMI was 25.6 (range, 14.9-44.9). There were 73 males (50%).

Results:

The total arc of motion preoperatively was 17.7 degrees and improved significantly (p < 0.001) to 27.9, 33.8, 32.6, and 32.2 degrees at 3 months, 6 months, 1 year and 2 years, respectively (Figure 1). VAS score preoperatively was 67.7 and improve significantly (p < 0.001) to 27.8, 24.84, 23.7 and 24.46 at 3 months, 6 months, 1 year and 2 years, respectively. FAAM ADL score preoperatively was 48.0 and improved significantly (p < 0.001) to 55.7, 71.2, 76.7, and 77.6 at 3 months, 6 months, 1 year and 2 years. FAAM sports score preoperatively was 21.4 and decreased at 3 months to19.1 (p > 0.05), but then significantly improved (p < 0.001) thereafter to 41.5, 47.4, and 52.6 at the same aforementioned time intervals.

Conclusion:

Patients undergoing fixed-bearing TAA had continued and sustained improvement from preoperative total arc of motion, pain, and function at each postoperative visit, up to 2 years. Ankle range of motion was noted to peak at 6 months postoperatively. Though pain and function may continue to improve even as far out as 2 years postoperatively, it is not likely that range of motion will continue to increase.
Assessing the Quality and Content of Accessible Information on the Internet Regarding Hallux Rigidus
Authors: Holzer Lukas
Published: September 2017

Category:

Midfoot/Forefoot

Introduction/Purpose:

The internet has grown into one of the biggest resource of easy accessible health information for the general public. Hallux rigidus (HR) is the most common arthritic disease pattern of the foot. There is no mutual consent on the ideal operative intervention for this disease. State of knowledge is essential for a decision to proceed with a HR specific treatment, since this decision is ultimately a shared one between the patient and the physician. Therefore, many patients comb through the internet for medical information related to this specific topic. The purpose of this study was to assess the quality and integrity of the online available informative content about HR using acknowledged scoring instruments, proven quality markers and a novel designed specific HR score.

Methods:

In December 2016 the search term “hallux rigidus” was used to search Google (Google Inc., Mountain View, CA, USA) by three independent reviewers (two experienced orthopedic surgeons and one trained medical student). The content of the first 50 hits were analyzed by the use of specific scores including the DISCERN score, the Journal of the American Medical Association (JAMA) benchmark criteria and the Health On the Net code (HONcode) as a seal of quality for providing complete and transparent health-related information. Also the Flesch Reading Ease (FRE), the Flesch Kincaid Grade Level (FKGL), and the Gunning Fog Index (GFI) were recorded as indicators for readability. Websites were classified as follows: academic, commercial, government or non-profit organization (NPO), physician or group, and unspecified. A HR-specific content score was developed consisting of 19 specified items to evaluate the overall aspects about the procedure, management and potential complications.

Results:

Of the 50 screened websites, 37 (74%) were included for analysis. Of these 37 websites, 20 were from a physician or group, 8 were commercial, 6 were academic, 3 were governmental or NPO and 1 was unspecified. The mean DISCERN score of the websites was 46±10. The highest score was 65 points, whereas the lowest was 21. HON Code certification was present in six (16%) and HON seal in two websites (5%). The FRE, RKGL and GFI were 43,2±14, 8,1±2, and 6,7±2 respectively. The HR specific content score was 7±3.

Conclusion:

Quality and content of accessible information on the internet on HR was analyzed by three individuals by various objective scores. 37 websites were included in the analysis. The majority of websites provided poor information on the management of HR. Patients need to be aware of this fact. In the future measures need to be taken to improve quality and content of HR related websites.