bluuebunny/crossref_metadata_2025 huggingface dataset:
The outcome of a single percutaneous cannulated screw fixation in posterior malleolus fracture accompanied by medial or lateral malleolus fracture
Authors: Park Yoo Jung , Won Yougun
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Posterior malleolus fractures occur most commonly in the setting of a rotational ankle fracture. In the treatment of posterior malleolus fractures, the indications for the surgical procedure are determined by the size of the fragment and the articular congruity of the tibiotalar joint. In general, the size of the bone fragment is known to be an indication of surgery if it involves more than 25% of the joint surface, and if it is less than that, anatomical reduction and fixation of only lateral or medial malleolus was suggested. We evaluate the clinical and radiological results of fixation and early range of motion exercise using a single cannulated screw when the fragment of the posterior malleolus fracture is less than 25%.

Methods:

Among 60 patients with SER stage 3 or 4 who had undergone surgery from March 2010 to March 2014, percutaneous cannulated screw fixation was performed for posterior malleolus in 30 cases (Group 1). In the other 30 cases (Group 2), we did not perform the fixation for posterior malleolus fracture and only cast immobilization was done after fixation for lateral or medial malleolus. Mean follow-up period was 14.8 weeks(12~18) for the Group 1, 12.9 weeks(12~18) for Group 2. Mean age of patients was 46.6(19~78) for Group 1, 50.2(19~74) for Group 2. The range of motion was checked at week 2, 4, 12, and at last follow-up.

Results:

There was no significant difference of time to union and union rate between two groups, and AOFAS score between two groups also showed no significant difference(91.94(83~100) vs 90.8(85~100), p = 0.45). The range of motion of ankle joint at the final follow-up showed significant difference (Ankle ROM 52.7’ (45’~65’) vs 45.3’(35’~65’), (p<0.01) and complications between two groups also showed no significant difference.

Conclusion:

A single percutaneous cannulated screw fixation in posterior malleolus fracture accompanied by medial or lateral malleolus fracture can be performed in fractures with small fragment size and minimal displacement. We found that it can be a effective method to achieve early and wide range of motion of ankle joint after posterior mallolus fracture.
Improvement in Quality of Life Following Surgical Correction of Midtarsal Charcot Foot Deformity
Authors: Pinzur Michael , Kroin Ellen
Published: September 2018

Category:

Diabetes

Introduction/Purpose:

Patients with Charcot Foot Arthropathy objectively report a poor quality of life following the development of deformity. It has recently been demonstrated that their quality of life is not improved with historic accommodative treatment. The recent interest in surgical reconstruction of the acquired deformity is directed at improving quality of life in addition to traditional goals of resolution of infection and limb retention. The Short Musculoskeletal Functional Assessment (SMFA) has been proven to be a valid tool for evaluating this complex patient population.

Methods:

Twenty-five consecutive patients undergoing surgical reconstruction for non-plantigrade midtarsal charcot foot arthropathy completed the SMFA patient reported outcomes instrument prior to surgery, with twenty-four completing it at one year following the surgery. One patient died during the year following surgery due to unrelated causes.

Results:

There was an 11.47 (95% CI: -19.70 to -3.23) point decrease in the standardized functional index. (p = .01) Similarly, there was a 12.38 (95% CI: -22.48 to -2.29) point de-crease in the standardized bother index. (p = .02) There was a 19.58 (95% CI: -30.53 to -8.63) point decrease in the standardized daily activity index. (p = .002), and there was an 14.68 (95% CI: -24.06 to - 5.31) point decrease in the standardized emotion index (p = .004). There was no meaningful change in the standardized arm/hand index. (p = .81)

Conclusion:

The results of this investigation demonstrate that successful surgical reconstruction of midtarsal Charcot Foot Arthropathy substantially improves quality of life. This supports the modern paradigm shift from immobilization during the active phase of the disease process followed by simple accommodation of the acquired deformity, to the modern approach of surgical correction to allow the use of commercially-available therapeutic footwear.
Open operative treatment of chronic ankle instability
Authors: Purcell Chad , Matsui Kentaro , Glazebrook Mark
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Ankle sprains are one of the most common musculoskeletal injuries. Though most patients recover fully without intervention, 10-30% will develop chronic ankle instability and require conservative or surgical management. The aim of this article is to provide an evidence-based literature review and assessment of the quality of literature regarding open operative interventions for chronic ankle instability.

Methods:

A comprehensive evidence-based literature review of Pubmed, Embase, Cochrane and Web of Science databases, conducted March 9, 2016; and updated February 22, 2017 identified 1635 articles, of which, 71 were relevant in assessing the efficacy of common open operative interventions for treatment of chronic ankle instability. The open operative procedures described in included articles were classified into the following four main categories: Anatomic repair, Non-anatomic repair, Anatomic reconstruction and Non-anatomic reconstruction. The 71 studies were then assigned a level of evidence (I-V) to denote quality. They were then reviewed to provide a grade of recommendation (A-C, I) in support of or against the operative intervention in treatment of chronic ankle instability.

Results:

Among the open operative treatment options available for chronic ankle instability, there is good evidence (Grade A) in support of anatomic reconstructive procedures. There is fair evidence (Grade B) from level II and III studies in support of anatomic repair and non-anatomic reconstruction procedures. Insufficient evidence was available to grade internal brace and non-anatomic repair procedures.

Conclusion:

Good quality evidence exists in support of open operative treatment of chronic ankle instability. Future studies should aim to elucidate roles for each of the classifications of open operative intervention in specific circumstances and patient populations. Furthermore, with good evidence to support more traditional techniques for repair of chronic ankle instability, high quality studies should be conducted on more novel minimally invasive and arthroscopic operative techniques to assure equal efficacy and safety to open techniques summarized here.
Mid-term Prospective Follow-up of Ankle Fracture Fixation Using Patient Reported Outcome Measures
Authors: Rai Paul , Mangwani Jitendra
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Open reduction and internal fixation (ORIF) is a common procedure to stabilise unstable ankle fractures. Anatomical reduction and stable fixation is desirable to achieve good clinical and radiological outcome after this injury. This prospective study examines the correlation between mid-term patient reported outcome measures (PROMs) and quality of fracture reduction of adult patients with ankle fractures treated with ORIF.

Methods:

A total of 100 patients with unstable ankle fracture who underwent ORIF were prospectively entered into the study between Nov 2013 to Oct 2014. Exclusion criteria were: age <18 years, pathological or open fractures and patients with cognitive impairment. Two independent observers assessed fracture patterns and quality of reduction. Fixations were analysed using Pettrone’s criteria including assessment of fracture displacement, medial clear space and tibiofibular overlap. Patients were followed up at two years post-operatively with postal questionnaires. Validated PROMs, Olerud-Molander Score (OMAS) and the Lower Extremity Functional Scale (LEFS) were used. For both scores a higher number indicated a better result. Co-morbidities and infection data were collated from Hospital records.

Results:

At 2 years post-op there were 5 deceased patients,17 did not have accessible radiographs and there was a 65% response rate to questionnaires. 46 patients were included in the final study group with a mean age of 45 (16-90). There was 1 Weber A fracture, 26 Weber B, 16 Weber C and 3 Medial malleolus fractures. 7% had Diabetes Mellitus, 22% were smokers. The mean OMAS score was 71.4(SD26.9) and LEFS score 56.7(SD25.9). There was no significant difference in PROM scores when fracture fragment reduction was optimised. There was a significant improvement in PROMs with low medial clear space and high tibiofibular overlap.

Conclusion:

This study reports a good correlation between quality of reduction and favourable PROMs at 2 years post ORIF ankle fracture. Reduced medial clear space and increased tibiofibular overlap were most associated with good outcome scores. Anatomical reduction of fracture fragments did not appear to affect PROMs on its own. There was very little infection in this cohort to confound the results. We would advise careful consideration of medial clear space and tibiofibular overlap in particular at time of fixation of unstable ankle fractures.
A Comparison of Foot Strengthening versus Minimal Footwear Use on Intrinsic Muscle Size and Strength
Authors: Ridge Sarah , Bruening Dustin , Jurgensmeier Kevin , Olsen Mark , Griffin David , Johnson A. Wayne , Davis Irene
Published: September 2018

Category:

Other

Introduction/Purpose:

The intrinsic muscles of the arch have been classified as the core of the foot. Intrinsic foot muscles (IFM) work as local stabilizers and extrinsic foot muscles (EFM) work as global movers to help control the pronation of the foot. These muscles prevent excessive strain of the MLA. Previous research has shown that strengthening IFM may reduce pain and improve function in people with plantar fasciitis. Additionally, habitual use of minimal shoes that lack support of the arch require greater demand on the intrinsic muscles. The purpose of this study was to determine the effectiveness of two different strengthening interventions on IFM and EFM size and strength.

Methods:

57 healthy runners (avg 15-30 mpw) were randomly assigned to a foot strengthening (FS, n=19), a minimal shoe walking (MSW, n=19), or a control group (C, n=19). Baseline cross-sectional areas of abductor hallucis, quadratus plantae, flexor digitorum brevis, and flexor digitorum longus, and thickness of the flexor hallucis brevis, tibialis posterior, and tibialis anterior were obtained with ultrasound using a 10 MHz linear probe. Doming, great toe flexion and lateral toes flexion strength were also measured using a custom-built dynamometer. The FS group then underwent an 8 wk foot and ankle strengthening program. The MSW group progressively walked in minimal footwear from 2,500-7,000 over the course of 8 wks. All groups, including C, maintained normal running mileage in conventional footwear throughout the 8 wks. Size and strength measures were then repeated. A repeated measures ANCOVA with a post-hoc test was used to determine differences in size and strength between groups.

Results:

All muscles measured in the FS and MSW groups increased significantly in size from weeks 0-8. There were no changes in muscle size in the C group. The FS group experienced significantly greater size changes for the flexor hallucis brevis than the MSW group. All other changes in muscle size were not significant between the FS and MSW groups. The FS and MSW groups showed significant increases in strength in all 3 tests from week 0-8. Strength of the control group did not change at any time. The increases in strength in the FS and MSW groups were not significantly different than each other.

Conclusion:

Exercises that target the intrinsic and extrinsic foot muscles are effective in increased strength and size of the muscles. However, similar increases in strength and size can be obtained by progressive walking in minimal footwear. Combining both these approaches may have an even greater effect. Stronger feet may offer greater protection against overuse injuries such as plantar fasciitis.
Value of Supine Positioning in Repair of Achilles Tendon Ruptures
Authors: Rogero Ryan , Beck David , Nicholson Kristen , Shakked Rachel , Pedowitz David , Raikin Steven
Published: September 2018

Category:

Hindfoot

Introduction/Purpose:

The optimal method of Achilles tendon repair remains undefined. Few previous studies have quantified the financial expenses of Achilles tendon repairs in relation to functional outcomes in order to assess the overall value of the accepted repair techniques. The purpose of this study is to demonstrate the value of supine positioning during open repair (OS) of acute Achilles tendon ruptures through the quantification of operative times, costs, and outcomes in comparison to the commonly performed percutaneous prone (PP) repair technique.

Methods:

A retrospective review was conducted on 67 patients undergoing OS and 67 patients undergoing PP primary Achilles tendon repair with two surgeons at four surgical locations. Total operating room usage times and operating times were collected from surgical site records. Total operating room times were used to estimate the costs of room usage and anesthesia, while costs of repair equipment were collected from the respective manufacturers. Patients undergoing OS repair completed the Foot and Ankle Ability Measure (FAAM) questionnaire, with activities of daily living (ADL) and sports subscales, Short Form-12 (SF-12), with mental (MCS) and physical (PCS) health subcategories, and the visual analog scale (VAS) for pain preoperatively and at final follow-up.

Results:

Even with a significantly longer mean surgical time (P=.035), OS repairs had a shorter duration of total operating room time when compared to that of PP repairs (58.4 versus 69.7 minutes, P<.001). Estimated time-dependent costs were lower in OS repairs ($739 versus $861 per procedure, P<.001), while the estimated average total per procedure cost was also lower for OS repairs ($801 versus $1,910 per procedure, P<.001). For patients undergoing OS repair, FAAM-ADL (P<.001), FAAM-Sports (P<.001), SF-12-PCS (P<.001) all increased and VAS grades (P<0.001) decreased from time of initial encounter to final follow-up and were comparable to reported outcomes in the current literature. The complication rate in OS repairs (6.0%) was lower than PP repairs (11.9%), with revisions only occurring in the latter technique.

Conclusion:

Performing open Achilles tendon repair in the supine position offers substantial value, or “health outcomes achieved per dollar spent”, to providers due to decreased total operating room times and costs with satisfactory functional outcomes.
Anterior tibial tendon repair with polycaprolactone-based polyurethane urea based graft (Artelon)
Authors: Sanders Thomas , Cuttica Dan , Neufeld Steven
Published: September 2018

Category:

Sports

Introduction/Purpose:

Ruptures of the anterior tibial tendon are rare injuries usually occurring in patients over the age of 40. Delayed diagnosis is common and reconstruction often involves the use of autograft or allografts. This paper reports on the use of a polycaprolactone-based polyurethane urea (PUUR) hyperelastic polymer (Artelon) in the repair or reconstruction of anterior tibial tendon ruptures.

Methods:

Artelon® is a knitted textile matrix that is manufactured from fibers of polycaprolactone-based polyurethane urea (PUUR), a hyperelastic and creep-resistant polymer. Previous studies have demonstrated that Artelon integrates without immune reaction, has mechanical properties that resemble healing tendons and ligaments, and degrades benignly through hydrolysis over a 5-6 year span. This is a retrospective examination of the first 6 cases of anterior tibial tendon reconstruction using the Artelon PUUR graft. Patient outcomes are measured with AOFAS scores. In addition, range of motion and strength of the injured side is compared to the native, uninjured side.

Results:

There were no complications using the Artelon graft to augment anterior tibial tendon reconstruction and repair. Patient outcomes at 6 months were significantly improved compared to preoperative. Range of motion and strength were similar to the contralateral, uninjured side.

Conclusion:

Artelon is a safe, effective soft tissue augmentation device that can be used in the setting of anterior tibial tendon repaair or reconstruction.
Safe Zone for Percutaneous Screw Fixation - Talonavicular Fusion
Authors: Shah Ashish , Lee Sung , Naranje Sameer , Pinter Zachariah , Stibolt Robert , Patel Harshadkumar , DeBell Henry , Lehtonen Eva , Moon Andrew
Published: September 2018

Category:

Hindfoot

Introduction/Purpose:

Talonavicular fusion has been established as a reliable intervention for degenerative, inflammatory, and traumatic joint lesions as well as hindfoot deformities. In order to achieve optimal fusion, various versions of the procedure have been introduced in literature and have remained a topic of contention, with the most common variation involving the insertion of 1 to 3 screws dorsomedially and dorsolaterally. Dorsolateral screw placements commonly cause neurovasculature injury. The purpose of our cadaveric study was first to establish the safety of the dorsolateral percutaneous screw insertion in relation to these dorsal neurovascular structures, and then subsequently to standardize the ideal placement of the dorsolateral screw by comparing two insertion sites based on consistent bony landmarks.

Methods:

Ten fresh-frozen cadaver legs amputated at the knee were used for this study. Percutaneous cannulated screws were inserted to perform isolated talonavicular arthrodesis. The screws were inserted at 3 consistent sites: “medial screw” at dorsomedial navicular where it intersected at the medial plane of the first cuneiform, “central screw” at the edge of dorsal navicular between medial and intermediate cuneiforms, and “lateral screw” at the edge of dorsal navicular between intermediate and lateral cuneiforms. Superficial and deep dissections were carried out to identify any injured nerves, arteries, and tendons.

Results:

The mean age at death in our sample of cadavers was 80.1 ± 7.5 years (range 68 to 92) and had the BMI of 21.8 ± 2.4 (range 18.1 to 25.1). There were 5 males (50.0%) and 5 females (50.0%). The medial screw injured the anterior tibialis tendon in 2 cases (20.0%), the central screw injured the extensor hallucis longus tendon in 3 cases (30.0%), and the lateral screw injured the anterior branch of SPN, lateral branch of SPN, and medial branch of DPN once each in a total of 3 cases (30.0%).

Conclusion:

TN fusion with central screw placement at the interspace between the medial and intermediate cuneiforms protects the neurovasculatures of the foot to a superior extent than lateral screws between the intermediate and lateral cuneiforms.
Arthroscopic Repair of Lateral Ankle Ligament for Chronic Lateral Ankle Instability
Authors: Shimozono Yoshiharu , Hurley Eoghan , Kennedy John
Published: September 2018

Category:

Ankle

Introduction/Purpose:

There has a been recent increase in the use of the arthroscopic approach to lateral ankle ligament repair for chronic lateral ankle instability. However, the clinical outcomes of this technique are still unclear. The purpose of this systematic review was to evaluate the current studies on arthroscopic lateral ankle ligament repair for chronic lateral ankle instability. Our hypothesis was that arthroscopic lateral ligament repair would result in excellent outcomes with a low complication rate.

Methods:

A systematic search of MEDLINE, EMBASE and Cochrane Library databases, based on the PRISMA guidelines, was performed during August 2017 by 2 independent reviewers. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Variable reporting outcome data, clinical outcomes, and percentage of patients who returned to sport at previous level were also evaluated.

Results:

Twelve studies for a total of 421 ankles were included; 92% of studies were LOE III or IV and the QOE in all studies was of poor or fair quality. The weighted mean preoperative AOFAS score improved from 59.6 to 95.0 at a mean follow-up of 14.8 months in 8 studies. Five studies utilized Karlsson-Peterson scores with mean postoperative score of 88.5 at a mean follow-up of 21.2 months. Three comparative studies were reported. The comparative studies showed similar clinical outcomes between arthroscopic and open procedures. The overall complication rate was 13.4% in the included studies. . Only 2 studies reported patients returning to sport and demonstrated that 100% of patients returned to sport at pre-injury level.

Conclusion:

The current systematic review demonstrated that arthroscopic lateral ankle ligament repair yields favorable clinical outcomes in the short-term. However, there is no clinical evidence to support the advantages of the arthroscopic procedure over the open procedure, and there is no long-term data currently available for the arthroscopic procedure. There was a relatively high complication rate associated with the arthroscopic procedures, with a 13.4% complication rate, although recent comparative studies demonstrated similar complication rates for both open and arthroscopic techniques.
First Metatarsal Pronation, Distal metatarsal articular angle and sesamoid reduction after Modified scarf osteotomy with single screw fixation
Authors: Sun Chao , Wang Zhi
Published: September 2018

Category:

Bunion

Introduction/Purpose:

Scarf osteotomy is a very popular procedure to hallux valgus surgical correction. No literature reported the correction of rotation of first metatarsal after a Scarf osteotomy. First metatarsal rotation correction is important for better results. A retrospective research shows that the modified single screw scarf osteotomy was powerful procedure to correct the rotation.

Methods:

We study 20 patients, 27 feet. All patients were hallux valgus and a modified scarf osteotomy was used for correction. Weight bearing radiographs of anteroposterior view and weight bearing sesamoid axis view were recorded. A retrospective review with patient follow-up for 3 months compared with the parameters before the surgery. All the data is analyzed with SPSS.

Results:

The radiographs measured and IMA, HVA, DMAA, first metatarsal rotation angle, the sesamoid grading from the AP view and sesamoid axis view has a significant difference between the before and the after follow-up.

Conclusion:

The modified single screw scarf osteotomy has an ability to change the rotation of first metatarsal. It is more powerful osteotomy than traditional scarf.
Clinical comparison of ankle arthrodesis with distal tibial oblique osteotomy for the patient with stage 3b ankle arthritis
Authors: Taniguchi Akira , Tanaka Yasuhito , Kurokawa Hiroaki , Takakura Yoshinori
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthrodesis (AA) has been applied for end-stage ankle arthritis. On the other hand, low tibial osteotomy has been applied for mild to moderate ankle arthritis, however distal tibial oblique osteotomy (DTOO) has come to be applied for end-stage arthritis and clinical results were reported to be favorable. The purpose of this study was to compare clinical outcomes after AA and DTOO.

Methods:

From 2011 to 2014, 37 patients with stage 3b ankle arthritis were treated surgically. In these patients, 25 whose talar tilting angle (TTW) was over 10 degrees with minimum follow-up of 1 year were investigated in this study. Seventeen patients were treated by AA and 8 were treated by DTOO. Clinical outcomes were assessed using the Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scale before surgery and at the latest follow up. The patient-based evaluation was performed at the latest follow up using Self-administered evaluation questionnaire (SAFE-Q). TTW and range of motion (ROM) of the ankle were also evaluated before surgery and at the latest follow up. In addition, rate of bony union and complications were investigated.

Results:

The average ages at the surgery were 60(41-77) years old in the AA group and 66(49-75) in the DTOO group. The average follow up periods were 32(15-49) months in the AA group and 29(13-52) in the DTOO group. Scores of the JSSF scale significantly improved at the latest follow up in both groups. In comparison between two groups, “Social functioning” and “General Health and Well-being” scores in SAFE-Q were significantly higher in the AA group than in the DTOO group. In contrast, ROM was higher in the DTOO group than in the AA group. There were no significant differences in TTW, bony union rate and complications.

Conclusion:

Ankle arthrodesis spoils the joint motion, however it restores stability and activity of the daily living, that leads to the higher levels of social functioning, general health and well-being.
Early Weightbearing After Operatively Treated Trimalleolar Ankle Fractures with Large Posterior Malleolar Fragments
Authors: Tartaglione Jason , Thamyongkit Sorawut , Abbasi Pooyan , Parks Brent , Hasenboehler Erik , Schon Lew
Published: September 2018

Category:

Trauma

Introduction/Purpose:

No consensus exists regarding postoperative rehabilitation protocols after surgical fixation of unstable trimalleolar ankle fractures with large posterior malleolar fragments. Additionally, no consensus exists regarding type of fixation of large posterior malleolar fragments in these fractures. It is unclear whether clinical results with early weightbearing differ between large posterior malleolar fragments fixed with either screws alone or a plate and screws construct. We evaluated fracture displacement with simulated early weightbearing in a cadaveric model.

Methods:

Sixteen fresh-frozen lower extremities were assigned to Group 1, trimalleolar ankle fracture with a large posterior malleolar fragment fixed with screws (n=8) or Group 2, trimalleolar ankle fracture with a large posterior malleolar fragment fixed with a plate and screws construct (n=8). Both Groups were tested with an axial compressive load at 3.2 Hz from 100 to 1,000 N and internal/external torque at 1.6 Hz at 0.5 Nm for 250,000 cycles to simulate 5 weeks of full weightbearing. Displacement was measured by differential variable reluctance transducer.

Results:

The average motion at all fracture sites in both groups was less than 1 mm. Group 1 displacement of the medial, lateral, and posterior malleolar fracture was 0.30 ± 0.27 mm, 0.12 ± 0.11 mm, and 0.87 ± 0.68 mm respectively. Group 2 displacement of the medial, lateral, and posterior malleolar fracture was 0.78 ± 1.52 mm, 0.12 ± 0.16 mm, and 0.87 ± 1.20 mm respectively. There was no significant difference between the average motion at all fractures sites between Group 1 and Group 2 (P > 0.05). There was no statistical correlation between fracture displacement and bone mineral density.

Conclusion:

This study supports early weightbearing after surgical fixation of unstable trimalleolar ankle fractures regardless of type of fixation of the posterior malleolus. Further investigation of early weightbearing protocols after surgical fixation of unstable trimalleolar ankle fractures are needed to help guide future treatment.
Does nerve injury following minimally invasive calcaneal osteotomy clinically correlate to Talusan’s Zone?
Authors: Teoh Kar , Hariharan Kartik
Published: September 2018

Category:

Hindfoot

Introduction/Purpose:

Talusan et al (FAI, 2005) described a safe zone for neural structures in medial displacement calcaneal osteotomy following a cadaveric and radiographic investigation. The safe zone was determined to be within the area 11.2 ± 2.7 mm anterior to the landmark line which is from the plantar fascia origin through the center of the posterosuperior aspect of the calcaneal tuberosity. Minimally invasive calcaneal osteotomies been gaining in popularity as it minimises soft tissue disruption and surgical morbidity. However, neural structures are at risk on both the medial and lateral side of the foot during this procedure. We aim to correlate our clinical results with Talusan’s Radiographic Zone (TRZ) following minimally invasive calcaneal osteotomies.

Methods:

Sixty-three calcaneal osteotomies were performed in our unit from 2010 and 2016. The type of osteotomies was as follows: Medialising, n = 34; Lateralising n =15; Zadek (Dorsal closing wedge), n =13; and Dwyer (lateral closing wedge), n = 1. Clinical data were recorded with any nerve injury noted. The calcaneal osteotomies were graded into whether they fell into TRZ. We also evaluated Talusan’s alternative method which he described and is based on alternative line 60% of the distance from the angle of Gissane to the tip of most posterior aspect of the calcaneal tuberosity where the safe zone is a window 5.6 mm anterior to this.

Results:

Five (8%) patients (Medialising, n = 2; Lateralising n =2; Zadek, n =1) reported sural nerve paraesthesia following surgery in our series. However, this was transient and they recovered fully. In total, seven patients (Medialising, n = 4; Lateralising n =1; Zadek, n =1; Dwyer, n=1) fell outside TRZ in our series, of which 2 reported transient sural nerve paraesthesia. Based on our results, TRZ clinically correlated with nerve injury (Chi square test, p=0.032). The other three patients who reported sural nerve paraesthesia but fell inside TRZ measured on average 10.4 mm from the landmark line (10.2, 10.4, 10.7 mm). However when we used the alternative method, they all fell outside the safe zone of this alternative line.

Conclusion:

Our results suggest that TRZ clinically correlated with nerve injury. However, the alternative line (where the safe zone is a window 5.6 mm anterior to this line) might be more accurate than the landmark line (where the safe zone is 11.2 ± 2.7 mm anterior to this line). More clinical studies with larger numbers might be required to confirm this.
Minimally Invasive Dorsal Cheilectomy of the first metatarsal
Authors: Teoh Kar , Hariharan Kartik
Published: September 2018

Category:

Other

Introduction/Purpose:

Traditionally, a dorsal cheilectomy of the first metatarsophalangeal (MTP) joint is performed with an open approach through a dorsomedial or midmedial incision. It is now possible to perform minimally invasive dorsal cheilectomy (MIDC) of the first metatarsal with a wedge burr. The stab incision for MIDC needs to be dorsomedial to allow an ergonomic sweeping movement of the burr. This potentially puts the dorsomedial cutaneous nerve (DMCN) to the hallux at risk. There have been no clinical or cadaveric studies to date quantifying the risk to the DMCN and the surrounding structures when a Wedge burr was used for MIDC. We aim to determine this by using fresh-frozen cadaveric specimens in a “high-risk” situation in which most of the surgeons were novices to the technique.

Methods:

A total of 13 fresh-frozen cadaveric specimens (7 right, 6 left) amputated below the knee were obtained for this study. 13 foot and ankle surgeons (2 left handed, 11 right handed) who had no or minimal experience in MI surgery participated in this study. After a demonstration by an experienced MI surgeon and a practice on sawbones by participants, each surgeon performed a MIDC over the first metatarsal. Fluoroscopic guidance was available throughout the procedure. After the procedure, the specimens were dissected and the DMCN and the extensor hallucis longus (EHL) were inspected for damage. The same dissection steps were used for each specimen. The relationship of the DMCN to landmarks were measured. All measurements were made to the nearest millimetre.

Results:

Dissection of the specimens revealed that the DMCN to the hallux was cut completely in two specimens (15%). All the EHL tendon were intact, although in one specimen, the tendon showed some fraying on the underside of the tendon, estimated to be 15%. The average distance of the stab incision from the first MTP joint was 17.7 (range: 10 – 23) mm. In terms of the relationship of the DMCN to the stab incision in specimens where the DMCN was not cut, the DMCN was superior in five specimens and inferior in six specimens. The distance of the DMCN to the incision was 3.8 (range: 0 -7) mm.

Conclusion:

The DMCN to the hallux has been well studied by several authors and has a variable course. This nerve is at high risk of being damaged with open surgery and is a commonly reported complication of surgery to the hallux with rates reportedly as high as 45%. This nerve was damaged in 15% of our specimens following MIDC in a “high-risk” situation. Patients need to be specifically made aware of this risk when being consented for surgery. A carefully made working capsular pocket for the burr and marking this nerve before placing the incision if palpable could mitigate this risk.
Factors Related to the Occurrence of Osteochondral Lesions of the Talus by 3-dimensional Bone Morphology of the Ankle
Authors: Teramoto Atsushi , Shoji Hiroaki , Kura Hideji , Sakakibara Yuzuru , Kamiya Tomoaki , Watanabe Kota , Yamashita Toshihiko
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Repeated microtrauma is thought to play a major role in the occurrence of osteochondral lesions of the talus (OLTs), but much remains unknown. Two-dimensional assessments of the relationship between ankle bone morphology and OLTs are occasionally seen. The purpose of this study was to evaluate the bone morphology of the ankle in OLT 3-dimensionally using three-dimensional computed tomography (3DCT), and to investigate the factors related to the occurrence of OLTs.

Methods:

The subjects were 19 patients (19 ankles) who underwent surgery for medial OLTs (OLT group). They included 13 men and 6 women. A healthy group without ankle disease served as a control group with the same number of 19 ankles. Three-dimensional ankle joint models were made based on DICOM data obtained with CT images. In the 3D model, the medial malleolus articular surface and the tibial plafond surface, the medial surface of the trochlea of the talus, and the lateral surface of the trochlea of the talus were defined. The tibial axis-medial malleolus (TMM) angle, the medial malleolus surface area (MMA), the medial malleolus volume (MMV), and the anterior opening angle of the talus were measured 3-dimensionally and compared in the OLT and control groups.

Results:

The mean TMM angle was significantly larger in the OLT group (34.2 ± 4.4°) than in the control group (29.2 ± 4.8°; p = 0.002). The mean MMA was significantly smaller in the OLT group (219.8 ± 42.4 mm2) than in the control group (280.5 ± 38.2 mm2; p < 0.001). The mean MMV was significantly smaller in the OLT group (2119.9 ± 562.5 mm3) than in the control group (2646.4 ± 631.4 mm3; p = 0.01). The mean anterior opening angle of the talus was significantly larger in the OLT group (15.4 ± 3.9°) than in the control group (10.2 ± 3.6°; p < 0.001).

Conclusion:

It was shown with 3DCT measurements that, in medial OLT patients, the medial malleolus opens distally, the MMA and MMV are small, and the talus anterior opening angle was significantly larger than in controls. This study suggests the possibility that the 3D bone morphology of both the mortise and tenon of the ankle joint are closely related to the occurrence of OLTs.
Modified Scarf osteotomy for hallux valgus deformity in rheumatoid arthritis
Authors: Tsuboi Hideki , Hirao Makoto , Noguchi Takaaki , Hashimoto Jun
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

For severe hallux valgus (HV) deformity in rheumatoid arthritis (RA) cases, arthrodesis of the 1st metatarsophalangeal (MTP) joint has been recommended. However, with the progress of medical treatment of RA, joint preservation surgery has recently been performed. This study aimed to investigate the clinical and radiographic outcomes of modified Scarf osteotomy with medial capsule interposition for RA cases, including severe 1st MTP joint destruction, and to evaluate risk factors for recurrence.

Methods:

A retrospective observational study of 76 cases (60 patients) [mean follow-up period: 35.3 months (24-56 months)] that underwent the modified Scarf osteotomy was performed. Japanese Society for Surgery of the Foot (JSSF) RA foot ankle scale scores, hallux scale scores, and a self-administered foot evaluation questionnaire (SAFE-Q) were evaluated, along with preoperative and postoperative radiographic parameters.

Results:

The mean JSSF RA foot and ankle and hallux score improved significantly (RA: preoperative: 52.2, final follow-up: 76.9, hallux: preoperative: 38.2, final follow-up: 74.5). Recurrence (hallux valgus angle (HVA) >20°) occurred in 12 feet (15.8%). Preoperative DAS28-CRP (Disease activity score evaluated on 28 joints-C-reactive protein), intermetatarsal angle between the first and second metatarsal bone (M1M2A), and M1M5A, as well as HVA, M1M2A, M1M5A, and Hardy grade at 3 months after surgery, were significantly greater in the recurrence group. There was a significant negative correlation between preoperative DAS28-CRP and JSSF RA foot and ankle scores at final follow-up (ß = -0.39: p=0.02), while there was a significantly positive correlation between preoperative DAS28-CRP and HVA at the final follow-up (ß = 0.44: p=0.001).

Conclusion:

The modified Scarf osteotomy with medial capsule interposition for HV deformity improved clinical and radiographic outcomes in RA cases with severe 1st MTP joint destruction. Increased preoperative M1M2A and M1M5A, incomplete reduction of the sesamoid bone, HVA, M1M2A, and M1M5A at 3 months after surgery should be kept in mind for recurrence. The preoperative DAS28-CRP score was associated with clinical and radiographic outcomes after surgery.
Morphological change of OLT after excision of osteochondral fragment with microfracture on MRI
Authors: Tsuyuguchi Yusuke , Nakasa Tomoyuki , Sawa Mikiya , Yoshikawa Masahiro , Ota Yuki , Kanemitsu Munekazu , Adachi Nobuo
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Osteochondral lesion of talus (OLT) is treated by several procedures such as bone marrow stimulation technique, cartilage fragment fixation, or autologous osteochondoral bone implantation. The choice of surgical methods depends on the size of lesion and cartilage condition. For unstable small lesion, excision of osteochondral fragment is usually performed. Good clinical results after this procedure is reported, but it is unclear that the morphological repair of subchondral bone and cartilage like tissue at the lesion. The purpose of this study is to evaluate the restoration of subchondral bone and cartilage like tissue after arthroscopic microfracture with excision of osteochondral fragment, and to investigate the clinical outcomes of this operation for the athletes.

Methods:

From 2005 to 2015, 11 patients (6 men and 5 women) were performed arthroscopic microfracture with excision of osteochondral fragment for OLT. Average age was 28.6 years old (17 - 59 years old). The site of OLT was 10 medial and 1 lateral. The cases of athletes were 7 of 11 cases. The size of preoperative OLT by MRI, measure the depth of the resected site on 3-month postoperative MRI. And we evaluated the appearance of the repair site on 1 year postoperative MRI, clinical outcome using American Orthopaedic Foot and Ankle Society Clinical Rating System (AOFAS), return rate to sports, and period of return to the sports.

Results:

Preoperative size of lesion on MRI was 9.8 mm in sagittal view, and 6.0 mm in coronal view. Depth of the resected site in 3 months postoperative MRI was 3.1 mm. On one year postoperative MRI, the resected site was filled with cartilage like tissue, and the shape of restored site was good that mimicked the original shape (Figure 1). As for clinical outcome, AOFAS score was 65.4 points preoperatively, and it improved to 93.4 points 1 year postoperatively. In clinical outcomes of the athletes, all cases could return to sports. Average period to return sports was 5.6 months. Only in 1 case, mild pain during sports activity was remained. Preoperative AOFAS score of athletes was 71.4 points and it improved to 98.5 points postoperatively.

Conclusion:

According to this study, even if a symptom is mild, an early operation will be more likely to result in the early return to sports and good outcomes. In addition, these good outcomes and good congruency on 1 year postoperative MRI suggest that the restored cartilage like tissue is enough for the high activities. The cartilage is repaired with maintaining original shape of talus cartilage. And this method was effective for athletes and was able to get them return to sports with good outcome.
Foot and Ankle Patients Prefer a Hands-Free Single Crutch Compared to Standard Axillary Crutches
Authors: Unangst Alicia , Martin Kevin , Mustovich Anthony , Chisholm Jaime
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Following lower extremity surgery patients are often required to utilize assistive devices in order to perform activities of daily living. As technology and assistive devices continue to improve, providers are faced with selecting a device that is safe while providing high patient satisfaction and a quick return to actives. The purpose of the current study was to compare physical exertion and subject preference between a hands-free single crutch and standard axillary crutches in foot and ankle patients.

Methods:

A prospective, randomized crossover study was performed using 35 orthopedic foot and ankle patients from within one treatment facility. Each participant had demographic data and heart rate recorded. The patients were then randomized to an assistive device. All participants completed a 6-minute walk test (6MWT); immediately following each 6MWT heart rate, self-selected walking velocity (SSWV), perceived exertion using OMNI Rating of Perceived Exertion (OMNI-RPE) and perceived dyspnea using Modified Borg Dyspnea Scale was obtained. The patients then completed another 6MWT using the other assistive device and was asked the same questions. After completing both 6MWTs participants were asked which assistive device they would prefer to use.

Results:

A total of 35 patients were included with a median age of 32-year-old. The hands-free crutch was preferred by 86% of participants. Regression analysis was used to test if factors such as gender, height, weight, BMI predicted patient preference of iWalk vs. Crutch. None of these factors were found to be significant. Student t-tests and ANOVAs were performed separately for dyspnea, fatigue ratings, distance (meters) and heart rate between iWalk and crutch all were found to be significant (p<0.05, p=1.13e-11, p=2.29e-13, p=5.21e-05, respectively). The axillary crutch group had higher SSWV (0.8 vs 0.77m/s) but was not found to be significant. Neither group had any falls, however, 58% of axillary participants complained of axillary/hand pain while the hands-free group had 14% complain of proximal strap discomfort.

Conclusion:

Patients preferred the hands-free crutch while reporting lower perceived dyspnea and fatigue. The hands-free group demonstrated lower physiologic demand, which correlated with patient perception.
Outcome of Helal osteotomy for chronic plantar foot ulcers
Authors: Waldecker Ute
Published: September 2018

Category:

Diabetes

Introduction/Purpose:

Chronic ulceration of the forefoot is a major problem in neuropathic and diabetic feet. Foot ulceration represents a risk factor for the development of osteomyelitis and increases the risk of amputation.The purpose of this study was to evaluate the effectiveness of Helal osteotomies concerning the development of plantar foot ulcers.

Methods:

Eighteen patients with a mean age of 69 years (min 55 yr, max 85 yrs) suffering from chronic, refractory ulcerations of the forefoot underwent Helal osteotomies. Demographic parameters, radiologic parameters, ulcer classification, complications, ulcer recurrence and ulcer healing were documented.The ulcerations were assessed according to the Wagner Armstrong classification.

Results:

The mean follow up was 30 months (min 6, max 68 months). Preoperatively, there were 3 grade 1A, 1 grade 1B,5 grade 2A, 8 grade 2B and 1 grade 3B ulcers. The most common site of ulceration was the MTP 3 joint, followed by the MTP 2 joint. All ulcers recovered with a mean healing time of 5.5 weeks (min: 1 week, max. 12 weeks). One ulcer recurred due to a secondary ossification of the osteotomy. After a reosteotomy, a permanent healing of the ulcer was achieved. There were 4 complications (1 hematoma, 2 wound infections, 1 ossification), of which only the ossification required revision surgery.

Conclusion:

The Helal osteotomy is a safe and effective method in treating neuropathic forefoot ulcerations. The procedure allows for rapid mobilization of the patient.
Delayed access to bunion correction surgery
Authors: Wing Kevin , Sutherland Jason , Younger Alastair , Veljkovic Andrea , crump Trafford , Liu Guiping
Published: September 2018

Category:

Bunion

Introduction/Purpose:

Little is known about the effect of delayed access to bunion correction (Hallux Valgus) surgery on patient-reported outcomes. The objective of this study is to measure the association between delayed access to bunion correction surgery and post-operative patient-reported outcomes.

Methods:

This study prospectively recruited patients to complete pre-operative patient-reported outcomes measuring pain, depression and foot and ankle health. Patients complete the same patient-reported outcomes six months post-operatively. Linear regression models measured outcomes, adjusting for baseline health, age category, sex, comorbidities and socio-economic status.

Results:

This study included 74 participants, a response rate of 53% among eligible patients. Among participants, 58.9% underwent a Lapidus procedure, the remainder underwent a corrective osteotomy. There was no relationship between post-operative depression and pain scores with duration of wait time, adjusting for patient characteristics. Longer waits for bunion correction surgery, adjusting for other factors, were associated with smaller gains in health in four of the five domains of measurement of foot and ankle health.

Conclusion:

At the six-month post-operative time point, prolonged wait times were detrimental to foot and ankle outcomes in four of the five domains of the foot and ankle specific PRO. Policies for expediting access for symptomatic hallux valgus are warranted to mitigate poorer long-term outcomes.