bluuebunny/crossref_metadata_2025 huggingface dataset:
Mid- to Long-Term Results of Total Ankle Replacement in Patients with Hemophilic Arthropathy
Authors: Eckers Franziska , Hingsammer Andreas , Sutter Reto , Wirth Stephan , Brand-Staufer Brigitte , Viehöfer Arnd
Published: September 2017

Category:

Ankle Arthritis

Introduction/Purpose:

Hemophilia is a rare hematological disease associated with spontaneous joint hemorrhaging causing hemophilic arthropathy. Symptoms comprise joint pain and deformity, paired with loss of function. In the presence of advanced joint deterioration, therapeutic options are confined to either arthroplasty or arthrodesis. For the ankle, the latter is still referred to as the procedure of choice. However - in light of its capacity to reduce pain while preserving ankle motion - total ankle replacement (TAR) has recently gained acceptance as an alternative. The aim of this study was to investigate the mid- to long-term results of TAR in hemophilic ankle arthropathy.

Methods:

Seventeen TARs were implanted between 1998 and 2012 (mean age: 43 years). Preoperative demographic and disease specific data, complications and revision surgeries were recorded. With a mean follow-up of 9.3 years (range, 2.2-17.8) implant survival was estimated using Kaplan-Meier analysis. Follow-up assessment of 12 TARs was performed after 9.6 years (5 lost to follow-up). Satisfaction and pain scales, the AOFAS hindfoot-score, and the SF-36 were obtained to assess clinical outcome. Radiographic evaluation of pre- and follow-up radiographs was conducted.

Results:

Three cases (17.6%) had undergone TAR removal secondary to loosening at an average interval of 7.5 years. The estimated implant survival was 94% at 5, 85% at 10, and 70% at 15 years (95% CI, 11.9-17.7). The mean estimated implant survival was 14.77 years (95% CI, 11.9-17.7). The mean level of satisfaction was 76%, and of pain 2/10 (VAS). ROM had increased significantly (p=0.037). The SF-36 summary scores were comparable to those of a matched standard population. The AOFAS hindfoot-score averaged 81/100 points.

Conclusion:

TAR is a viable treatment option for advanced hemophilic ankle arthropathy. Based on the herein presented follow- up, implant survival compares to that of non-hemophilic populations. Clinical mid- to long-term results are favorable. However, the majority of follow-up radiographs revealed component loosening and/or periprosthetic lucency. Considering the study population’s young age and specific risk factors, need for revision surgery secondary to symptomatic component loosening may arise.
Proximity of the Lateral Calcaneal Artery With a Modified Extensile Lateral Approach Compared to Standard Extensile Approach
Authors: Kwon John , Ghorbanhoseini Mohammad , Gonzalez Tyler , Riedel Matthew , Nazarian Ara
Published: September 2017

Category:

Ankle, Basic Sciences/Biologics, Trauma

Introduction/Purpose:

The extensile lateral approach (EL) has been associated with increased wound complications such as apical necrosis which may be due partially from violation of the lateral calcaneal artery (LCA). Traditionally, the vertical limb has been placed half-way between the fibula and Achilles tendon, which may be suboptimal given the proximity to the LCA. We hypothesized that placing the vertical limb further posterior (ie, modified EL [MEL]) would increase the distance from the LCA. The purposes of this study were to quantify the location of the LCA in relation to the vertical limb of the traditional EL approach and to determine if utilizing the MEL approach endangered the LCA to a lesser extent.

Methods:

20 cadavers were used. For the EL approach, the fibula and Achilles tendon were palpated and a line parallel to the plantar foot was drawn between the two. A vertical line (VL), representing the vertical limb of the approach, was drawn at the midway point as a perpendicular extending proximally from the junction of the glabrous/non-glabrous skin (JGNG). For the MEL approach, the anterior border of the Achilles tendon was palpated and a similar vertical line (MVL) was drawn 0.75 cm anterior. Dissection was performed and if the LCA was identified crossing the line VL/MVL, the distance from the JGNG was documented.

Results:

For the EL approach, the LCA was identified in 17/20 (85%) cadavers at an average distance of 5.0 cm (range 3-7 cm, SD = 1.3 cm) from JGNG. For the ML approach, the LCA was identified in 4/20 (20%) cadavers at an average distance of 5.9 cm (range 3-6.5 cm, SD = 1.7 cm) from the JGNG (P < .001).

Conclusion:

The LCA was encountered 4 times more often during the EL approach as compared to the MEL approach.
Weightbearing CT Analysis of Hindfoot Alignment in Chronic Lateral Ankle Instability
Authors: Lintz Francois , Bernasconi Alessio , Mehdi Nazim , de Cesar Netto Cesar , Baschet Louise , Richter Martinus
Published: September 2017

Category:

Ankle, Hindfoot, Imaging, Ankle Instability

Introduction/Purpose:

Varus hindfoot deformity may increase the risk of chronic ankle instability (CAI).Weightbearing CT (WBCT) semi-automated measurements and built-in databases may contribute to investigate the relationship between clinical and radiographic data. The objective of this study was to analyze hindfoot alignment (HA) in relation with CAI in a series of patients using these new tools. We hypothesized that there would be a positive correlation between a varus morphotype and a history of CAI.

Methods:

This is a Level 3 retrospective comparative study of a continuous series of 124 feet (63 patients) referred from July to December 2016. and subsequently assessed by WBCT (PedCAT®, CurveBeam LLC). The measurement software (Talas®, Curvebeam LLC), gave HA as a value of Foot and Ankle Offset (FAO). This measures the offset between the center of the ankle joint and the median line of the foot joining the centers of the calcaneus and forefoot weight bearing surfaces. Data was prospectively saved in a database (CubeView®, CurveBeam, PA, USA). The definition of CAI was a history of at least 3 ankle sprains during a 6 months period. Exclusion criteria were medial instability and syndesmotic injuries (2 cases).A univariate analysis was conducted to study CAI against the following variables: gender (Fisher), BMI and FAO (Kurskal-Wallis). The significant variables were subsequently included in a multivariate logistic model.

Results:

Nineteen feet had CAI, in 12 patients. Gender (p=0.0467 –the proportion of women for patients with CAI was 72.3%, compared to 33.3% without CAI) and FAO (p=0 .0002) were significant in the univariate analysis. The mean FAO was respectively -1.40 (SD: 5.50) and 3.56 (SD: 5.31) with and without a history of CAI. No significant difference of age or BMI was shown. After verification of log-linearity between odds of CAI and FAO, the multivariate logistic regression adjusted for gender demonstrated a 15% increase of odds of CAI per unit increase of varus (adjusted Odds Ratio (CI95%): 0.858 (0.771-0.943) p=0.003), and no more significant effect of gender after adjustment on FAO (Odds ratio (CI95%) Female versus Male: 0.548 (0.185 -1.669) p=0.277).

Conclusion:

A positive linear relationship was found between Varus Hindfoot Alignment measured using a semi-automatic tool in WBCT and the odds ratio for Chronic Ankle Instability, thus confirming and quantifying previous findings. The recent development of semi-automatic measurements and prospective databases opens future perspectives for big data and multivariate analysis in foot and ankle pathology.
Outpatient Total Ankle Arthroplasty is a Safe Alternative to Traditional Inpatient Admission or Overnight Observation
Authors: Mulligan Ryan , Parekh Selene
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Safe and cost-effective health care has become a priority in the United States. Total joint surgeons have successfully performed hip, knee, and shoulder arthroplasty procedures in the outpatient setting without compromising safety, satisfaction, or results. The purpose of this study was to evaluate outpatient total ankle arthroplasty (TAA) compared with overnight or more extended hospital stay, with regard to 90-day global period medical and surgical complications, reoperations, readmissions or emergency room visits, and pain control.

Methods:

The medical records of patients who underwent TAA over a three-and-a-half-year period with a single, fellowship- trained orthopedic foot and ankle surgeon were retrospectively reviewed. Outcome measures included surgical complications, adverse medical events, readmission or emergency room visit for any reason, reoperation within the first 90 days following surgery, any notation of phone call or email to the surgeon’s office prior to first-operative visit regarding pain or other issues, Visual Analog Scale (VAS) pain score at the first post-operative visit, and need for narcotic refill. Outcomes were assessed by admission status; outpatient (discharge home the same day), overnight observation, or inpatient admission (hospital stay of two or more nights). Standard statistical analysis was used and p < 0.05 was considered significant.

Results:

82 patients underwent TAA who met inclusion criteria. No statistical differences were found between outpatient, overnight observation, and inpatient admission groups with regard to age, preoperative American Society of Anesthesiologists (ASA) score, gender, laterality, operative indication, or additional number of procedures. A significant difference in complication rate was seen between the three groups (p=0.02), but not rate of readmission or reoperation. Five of sixteen patients (31.2%) admitted for two or more nights following surgery had a complication after discharge versus four of sixty-six (6.1%) in those who were outpatient or admitted overnight (p=0.01). There were no differences in frequency of post-operative phone calls, narcotic refills, or VAS pain score at the first post-operative visit. There were no adverse medical events in any group.

Conclusion:

With appropriate patient selection and proper instruction, TAA may be performed safely in the outpatient setting. Patients who were discharged home the day of surgery did not require more attention or care in the immediate post-operative period and adverse medical events did not occur. The inpatient group was more likely to have complications, but these mostly consisted of minor superficial wound problems, which may be attributed to patient factors unaccounted for in this study. As health care policy continues to evolve, efficient and cost-effective practices will be a priority and should be further studied.
Is Magnetic Resonance Imaging (MRI) Reliable in the Diagnosis of Osteochondral Lesions (OCL’s)?
Authors: Nurm Triin , Torres Paulo , Ramaskandhan Jayasree Ramas
Published: September 2017

Category:

Ankle, Arthroscopy

Introduction/Purpose:

MRI is the preferred modality for the diagnosis of ankle joint pathology. Musculoskeletal radiologists aim to determine and report both chondral and/or osseous stability/instability of each lesion. The aim of this study was to specifically analyse the reliability of MRI reported findings in predicting the stability of OCL’s in symptomatic patients.

Methods:

A single centre, single surgeon consecutive series of patients who had undergone an ankle arthroscopy procedure preceded by an MRI scan for symptomatic ankle pathology were included in this retrospective clinical study. All MRI scans were reported by a musculoskeletal radiologist. MRI reports and arthroscopic findings were extracted and analysed. Arthroscopy findings were taken as the gold standard.

Results:

Between April 2012 and July 2016, 48 patients who fulfilled the criteria were included. There were 27 male and 21 female patients, the average age was 43.4. Average time interval between MRI and arthroscopy was 9 months. There was a significant negative relationship between OCL’s reported as stable on MRI to arthroscopic findings, r=-.31, p=0.03. Of the 21 patients who had OCL’s reported as stable on the MRI, all had unstable lesions on arthroscopic evaluation (100%). One patient had an unstable OCL reported on the MRI and it was also unstable arthroscopically. In 27 patients, there was no mention of the stability of the reported OCL on the MRI, 22 patients (81.5%) had unstable lesions and 5 patients (18.5%) had stable lesions on arthroscopic findings.

Conclusion:

This study demonstrates that MRI has a poor predictive value for the stability of OCL’s of the ankle. Therefore we recommend that in the symptomatic patient an arthroscopy is indicated irrespective of MRI findings.
Early Weight Bearing on Weber C Fractures with Retained Syndesmotic Screws
Authors: Ortiz Cristian , Díaz Andres Keller , Mococain Pablo , Wagner Pablo , Radkievich Ruben , Wagner Emilio
Published: September 2017

Category:

Ankle, Sports, Trauma

Introduction/Purpose:

There is no consensus about when to allow weight bearing in ankle fractures treated with syndesmotic screw fixation. There has been no evaluation of the radiographic fate of the syndesmosis when syndesmotic screws are retained and early weight bearing is encouraged, or the clinical result depending on the screw status, which can be intact, broken or loose. Our objective was to evaluate the radiographic and clinical parameters of patients who had a screw fixation of the syndesmosis and early weight bearing was allowed. Our hypothesis was that no difference would be observed on syndesmotic reduction or clinical function depending on the screw status.

Methods:

We analyzed 42 patients with ankle fractures treated with syndesmotic screws in which early weight bearing was allowed (3 weeks postoperatively). Weight bearing radiographs were obtained at 2 weeks, 2 months and at final follow up (41.2 months). Radiologically we measured medial clear space (MCS), tibiofibular overlap (OL), tibiofibular clear space (CS), talar shift (TS) and screw condition (intact, broken, loose). Clinical function was measured with the AOFAS score and stratified by the screw condition. Statistical analysis was performed with the SPSS software and a non-inferiority confidence interval for the mean was calculated.

Results:

At final follow up, 66,6% of the screws were broken, 30,9% showed significant loosening and only 1 patient (4,7%) had a screw that remained solid with no signs of osteolysis. MCS at 2 weeks, 2 months and at final follow up was 2,94 mm; 3,03 mm; 3,02, respectively. OL was 6,76 mm; 6,78 mm; 6,83 and CS was 4,26 mm; 4,66 mm; 4,6 mm. No TS was detected. There was no difference in measurements along time (p>0,05). Relative to clinical function, the mean AOFAS score was 95 points. No difference was found between the clinical scores of patients stratified by the screw condition (p>0,05).

Conclusion:

Early weight bearing on a fixed syndesmosis appears to be safe, with no measurable radiographic or clinical consequences regarding ankle joint function. Despite screw breakage or loosening on x-rays, loss of reduction is seldom observed. We suggest that routine removal of syndesmotic screws is not necessary in these group of patients.
Polymorphisms of Alpha and Beta Estrogen Receptors in Post-Menopausal Women with Posterior Tibial Tendon Dysfunction
Authors: Pontin Pedro , de Cesar Netto Cesar , Dos Santos Alexandre Godoy , Carvalho Katia , Fernandes Tulio Diniz , Fonseca Fabio , Baracat Edmund Chada
Published: September 2017

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Posterior tibial tendon dysfunction (PTTD), the most common cause of flatfoot deformity in adults, is more frequent in the female gender with peak incidence in the sixth decade of life. Multiple risk factors - intrinsic and extrinsic - and associated systemic conditions have been described in the literature. Genetic predisposition secondary to hyperexpression of genes related to hormonal metabolism, particularly the estrogens, may play a role in the pathogenesis of this disease acting in association with behavioral and endogenous risk factors.

Methods:

202 female patients over the age of 40 were included in the study (N = 202). They were then divided into 2 different groups (n = 101): cases and controls. We defined as cases postmenopausal women with symptomatic PTTD, diagnosed by clinical and MRI examinations. Females with similar epidemiology, but clinically asymptomatic and with normal MRI evaluation for the posterior tibial tendon were defined as controls. Oral mucosa epithelial cells were collected from the patients and genomic DNA was extracted from the samples. The SNPs for the ER1 (XbaI and PvuII) and ER2 (AluI) genes were assessed by PCR-RFLP.

Results:

Patients with SNP Xbal genotype xx had 2.38 higher estimated risk (p = 0,029) in developing PTTD, when compared to patients with the other genotypes. No associations were found for the SNP PvuII and AluI.

Conclusion:

The present study demonstrates that patients with the Xbal single nucleotide polymorphism of estrogen receptor 1 gene have higher risk of developing posterior tibial tendon dysfunction.
Proximal Rotational Metatarsal Osteotomy for Hallux Valgus
Authors: Wagner Pablo , Wagner Emilio , de Solminihac Diego Zanolli , Ortiz Cristian , Díaz Andres Keller , Radkievich Ruben
Published: September 2017

Category:

Bunion, Midfoot/Forefoot

Introduction/Purpose:

Hallux valgus combines two deformities, the metatarsus varus and metatarsal internal rotation. The rotational deformity is seldom corrected during surgery, but is a known recurrence factor. Most techniques only correct the metatarsus varus (scarf, chevron, etc). We present a prospective case series using a novel metatarsal rotational osteotomy called PROMO (proximal rotational metatarsal osteotomy) which simultaneously corrects the metatarsal internal rotation and varus deformity by rotating the metatarsal through an oblique plane osteotomy. This is performed with no bone resection. Our objective was to report this new technique, preliminary results, its advantages and complications.

Methods:

20 consecutive patients (17 women) with Hallux Valgus, average age 45 (25-55), were operated using this technique. The average preoperative intermetatarsal angle (IMA) was 15 degrees with an average Hallux internal malrotation of 30 degrees and a sesamoid malposition of grade V or more in all cases. Postoperatively, sesamoids position, Hallux rotation, IMA and metatarsal length were registered. They were followed for 1 year (8-14 months). The surgical technique is described, with its potential benefits and drawbacks. The radiological outcome, postoperative LEFS score, recurrence rate (IMA increase >5 degrees) and complications were registered.

Results:

Well positioned sesamoids (grade IV or less) were obtained in all patients postoperatively, with a complete Hallux rotational correction. Postoperative IMA was 5 degrees. achieving a complete metatarsal varus correction. No metatarsal shortening was observed whatsoever. No recurrence has been observed until final follow up. Preoperative and postoperative LEFS scores were 58 and 73 respectively.

Conclusion:

The PROMO has the advantage over other osteotomies that it can reliable correct, both metatarsal malrotation and varus deformities, achieving a complete deformity correction and hopefully decreasing recurrence rate. The surgical technique has been studied and refined extensively, in order to simplify it and make it reliable. Although more patients and follow-up are needed, the authors believe it is a promising surgical technique which addresses a previously not considered hallux valgus deformity component.
Effectiveness of arthroscopically assisted surgery for ankle fractures
Authors: Ahmed Sonya , Lee Kyoung min , Park Moon Seok , Sung Ki Hyuk , Koo Seungbum , Lee Seung Yeol
Published: September 2017

Category:

Ankle, Arthroscopy, Trauma

Introduction/Purpose:

This meta-analysis was performed to determine whether the arthroscopically assisted open reduction and internal fixation (ORIF) for ankle fractures is more beneficial than the conventional ORIF.

Methods:

Articles in electronic medial databases were searched between March 1983 and August 2016, including Pubmed and SCOPUS. We included the studies with comparative design comparing the surgical outcomes between the arthroscopically assisted ORIF for ankle fractures and the conventional ORIF. Finally, two RCTs and two retrospective comparative studies were included for analysis. Mean and standard deviation (SD) of postoperative functional scores, number of subjects, and P-values were extracted from the studies. In addition, postoperative follow-up period, fracture type, and study quality were collected.

Results:

The pooled effect size of the four studies 0.535 (95% CI, 0.247 to 0.823) in Hedges’s g, which favored the arthroscopically assisted ORIF over conventional ORIF. There was no evidence of publication bias in funnel plot and in Egger’s test (p=0.534).

Conclusion:

The arthroscopically assisted ORIF for ankle fractures were more beneficial than the conventional ORIF in the current evidences. However, since it needs more medical cost and longer operation time, possible additional complications and cost effectiveness are to be validated in future studies.
The influence of vitamin C on the outcome of ankle fractures. A protocol of double-blind RCT
Authors: Alhammoud Abduljabbar , Ahmed Ghalib
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Ankle fracture is one of the most common orthopedics injuries. Poor functional outcome, residual pain and discomfort is a major burden to the patients daily activities Complex regional pain syndrome (CRPS) is one of serious complication after orthopedics injuries .The incidence of CRPS is 0.3% after foot and ankle surgery. CRPS is well studied in wrist fracture. Vitamin C has been proposed to improve outcomes after a distal radius fracture by promotion of bone and soft-tissue healing and reducing the prevalence of complex regional pain syndrome (CRPS). We aim to detect the effect of vitamin C on the functional outcome, post op pain, incidence of CRPS, wound healing and fracture healing after an ankle fracture

Methods:

Prospective, Double blind, Randomized control study of 110 subjects (55 subjects in each group). Subjects in study group will receive 500 mg vitamin C for 50 days and standard of care, whereas control group will receive the stander of care alone. Subjects with age from 18-50 years old, with ankle fracture which treated surgically will be recruited, whereas open fracture, Peripheral vascular disease, Allergy to Vitamin C will be excluded. Subjects will be followed up in regular basis for one year. Primary end point will be diagnosis of CRPS and secondary end point will be failure of initial management

Results:

Although CRPS is more common in wrist injuries comparing to ankle injuries, subclinical of CRPS is more common after ankle fracture. Vitamin C showed promising results in decrease the incidence of CRPS in distal radius fracture. Literature lack of studies looking for CRPS and foot and ankle fracture without high evidence of effect of vitamin C on the functional outcome and post op pain after ankle fractures.

Conclusion:

We assume that vitamin C will improve functional outcome, decrease post op pain, decrease the incidence of CRPS and improve wound and fracture healing.
Mobile- vs. Fixed-Bearing Total Ankle Prostheses
Authors: Barg Alexej , Phisitkul Phinit , Saltzman Charles
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Total ankle replacement (TAR) is a well-accepted treatment option in patients with end-stage ankle osteoarthritis. In general, TAR designs can be classified based on their number of components: 2-components (fixed-bearing) vs. 3- components (mobile-bearing). In the U.S. the STAR prosthesis is the only one mobile-bearing TAR with FDA approval. It remains unclear whether 3-component TAR designs have superior clinical outcomes including prosthesis survivorship. Therefore we performed a systematic review and meta-analysis of the available TAR designs to determine prosthesis survivorship and whether there is a statistically significant difference between mobile- and fixed-bearing TAR designs.

Methods:

We reviewed literature using common data bases. All searches were unlimited. For the search we used the subject heading terms: “ankle”, “replacement”, “arthroplasty”, and “prosthesis”. For meta-analysis a checklist was used as described by Meta-analysis Of Observational Studies in Epidemiology (MOOSE) Group. The quality of included studies was assessed using Coleman’s Methodology Score. The following parameters were reviewed: type of study, inventor bias, number of patients/ankles, mean age with range, gender, etiology of underlying ankle osteoarthritis, average and maximum follow-up, number of TAR failures, and total exposure time. For each study, failure rate was estimated as the number of failures/total exposure years. N-year (here, 5 or 10 years) failure rate was calculated as 1-exp(-N*failure rate). The pooled estimate of failure rate was a weighted average across studies using the inverse variance weighting method. The test for heterogeneity was not significant so fixed effects models were used.

Results:

In total, 32 studies with 3968 ankles were included into the analysis. Nine studies included 844 fixed-bearing TARs and 23 studies included 3124 mobile-bearing TARs. Patient characteristics were comparable in both study groups. For fixed-bearing TAR, the 5-year and 10-year failure rate was 0.077 and 0.149 with an average annual failure rate of 0.016 (95%CI 0.008-0.025). For mobile-bearing TAR, the 5-year and 10-year failure rate was 0.074 and 0.142with an annual failure rate of 0.015 (95%CI 0.011- 0.020). Two studies with fixed-bearing TAR and six studies with mobile-bearing TAR had inventor bias. The average annual failure rate was comparable in both groups (P = 0.88), with and without inventor bias, 0.013 vs. 0.018 (P = 0.87).

Conclusion:

We have shown that TAR has an overall failure rate of 0.149 and 0.142 at 10 years in patients with fixed-bearing and mobile-bearing TAR design, respectively. No superiority of one implant design over another can be supported by the available data.
Leicester Achilles Management Programme (LAMP)
Authors: Bhatia Maneesh , Patel Mohammed , Aujla Randeep , Jones Annette
Published: September 2017

Category:

Trauma

Introduction/Purpose:

Conservative treatment of acute AT ruptures with functional rehabilitation has demonstrated superior results to surgery with equal reported re-rupture rates without the added complications of surgical treatment. The variation in patient selection for functional rehabilitation as well as the duration and type of rehabilitation regime utilised adds to the confusion of this clinically proven method of treatment. Since 2011, all patients presenting to our department with an acute AT rupture have been treated with a standardised functional rehabilitation regime in a Vacoped boot for 8 weeks with immediate weight bearing (the LAMP regime). The aim of this paper is to present ATRS scores and objective measures at 12 months follow up of patients treated with the LAMP regime.

Methods:

A prospective study of all AT ruptures treated conservatively with the LAMP regime between February 2011 and September 2015 was performed. The LAMP regime consists of the use of a Vacoped boot locked in 30° plantar flexion for the 1st 4 weeks. The boot is then dynamised allowing movement between 15-30° over the following 2 weeks, and finally completely dynamised allowing movement from 0-30° over the final 2 weeks. After a total of 8 weeks treatment, the boot is removed. During treatment, patients are allowed to remove the boot once a day to enable them to shower without putting any weight on the affected leg. Patients who had 12 months follow up data of ATRS scores were included. Subsequent evolution of the service has resulted in objective measures including the calf girth, heel raise height and heel raise repetitions being recorded. Complications of treatment were noted.

Results:

442 patients were treated conservatively with the LAMP functional rehabilitation regime. Ultrasound imaging was only performed in 10% of cases where clinical assessment was equivocal. The incidence of a venous thromboembolic event was 5.9% with a re-rupture rate of 2%. 200 patients had 12 months ATRS scores available and 46 patients had ATRS scores as well as objective measures of calf girth, heel raise height and repetitions at 12 months. The average ATRS score was 75.3 at an average follow up of 25 months post injury. Men had significantly better outcomes compared to women. There were statistically significant differences in the muscle girth and heel raise height when compared with the uninjured side but these did not correlate with the ATRS score.

Conclusion:

This is the largest series of acute AT ruptures treated conservatively with the use of a standardised functional rehabilitation regime demonstrates satisfactory patient reported outcome measures at 12 months follow up. Objective measures demonstrate inferior results when compared to the uninjured side but this does not correlate with the ATRS score
Macrodystrophia Lipomatosa of the foot. Extensile dorsal approach for Reductive Surgery. Report of 4 cases
Authors: Briceño Jorge , Nussbaum Jorge Filippi , Villa Andres , Ponce Pablo Mery , Palma Joaquin , Abarca Mario
Published: September 2017

Category:

Lesser Toes, Midfoot/Forefoot

Introduction/Purpose:

Macrodystrophia lipomatosa (ML) is a rare cause of local gigantism affecting hands or feet of congenital non-hereditary origin and unknown etiology. The main characteristic of this disease is the overgrowth of the mesenchymal structures as bone, tendons, vessels, nerves and, predominantly, the fibroadipose tissue. The low frequency of this pathology implies a difficulty to establish management guidelines. The most recommended treatment for this condition is the reductive surgery as an alternative to amputation of the affected segment. Our objective is to report the clinical results of the reductive surgery in four patients with ML in the forefoot.

Methods:

Four cases of ML surgically treated in our center between 2008 and 2016 were retrospectively analyzed after approval from our institutional review board. For each case, clinical history at admission, pre and post-operative radiographs and pre and post-operative clinical images were obtained.

Results:

Patients were adults between 28 and 38 years old and followed between 1 and 4 years. The toes involved were: 1 hallux, 2 second toes and 1 fourth toe. All had failed conservative treatment prior to surgery. SURGICAL TECHNIQUE: An extensile dorsal approach preserving the neurovascular bundles was performed. Bone was resected until a harmonic appearance of the toe related to the rest of the foot was obtained. In one case, removal of the distal phalanx was necessary to achieve adequate reduction. The remnant soft tissue was resected from dorsal and distal. Skin was closed using non-absorbable sutures. Wound dehiscence was observed in 2 patients and managed conservatively. No major complications were observed. All the patients were satisfied and able to wear regular shoes postoperatively.

Conclusion:

The reductive surgery for adults with symptomatic ML of the foot offers good functional results. The extensile dorsal approach allows an excellent surgical exposure, preservation of neurovascular supply and adequate tissue resection. Based on our clinical results and the high satisfaction observed in our 4 patients, we suggest reductive surgery as a good alternative to amputation in selected patients with ML.
The Role of Arthroscopic Debridement after Ankle Fractures Treated with ORIF
Authors: Ceccarini Paolo , Rinonapoli Giuseppe , Teodori Julien , Caraffa Auro
Published: September 2017

Category:

Ankle, Ankle Arthritis, Arthroscopy

Introduction/Purpose:

The role of ankle arthroscopy in managing the consequences of ankle fractures is yet to be fully estab- lished. This study aims to assess this procedure in terms of the accuracy of preoperative diagnosis, re-operation rate and patient- reported outcomes.

Methods:

We compared two homogeneous groups of 16 patients (32 in total, average age 40.6 years) operated for a fracture of the distal tibia and/or fibula treated with ORIF. For all fractures the AO classification was used. The baseline was 6 months after surgery. Inclusion criteria were: patients aged between 19 and 50 a pre-trauma Tegner score >3, FAOS score <75 at the baseline, R.O.M. <20° vs contralateral; we included patients with well-aligned osteosynthesis and with radiographic union. Patients with open fractures, with osteochondral lesions and with previous were excluded. In the first group we planned an arthroscopy of the ankle from 6 to 12 months after trauma, in the second group, we continued with conservative rehabilitation treatment. All patients were then re-evaluated at 3,6 and 12 months with questionnaires (Tegner activity level, and FAOS). The mean follow-up was 18.2 months. For all data statistical analysis was performed.

Results:

The results of our case-series showed excellent patient satisfaction (12/14) with a FAOS Score and an improved R.O.M. statistically significant (p <.001) in patients treated with ankle arthroscopy. Eighty percent was able to return to previous activity. The average time until return to sport was 5.3 ± 2.4 months. Seventy percent of the athletes still had occasional pain with sport.

Conclusion:

The literature on arthroscopic treatment after fracture is still poor but results obtained, even with a limited number of cases, and with a short follow-up, are positive, especially in those patients where the functional demand is highest.
Patient Reported Outcomes in Athletes following ORIF of Jones Fracture
Authors: Chambers Monique , Hogan MaCalus , LaBaze Dukens , Abebe Ermias , Kromka Joseph
Published: September 2017

Category:

Lesser Toes, Midfoot/Forefoot, Sports

Introduction/Purpose:

Treatment of fractures to the 5th metatarsal metaphyseal-diaphyseal junction, known as Jones’ fractures, can present challenges in the elite athlete significantly prolonging return to play. Non-operative treatments in elite athletes result in a high incidence of nonunion and secondary fracture. Primary screw fixation remains the standard of care for athletes. However, delayed union and nonunion are still very common despite surgical fixation due to the fracture occurring in a watershed area with decreased healing potential. Bone marrow aspirate concentrate (BMAC) is an autologous source of hematopoeitic and mesenchymal stem cells that has been used in the treatment of poor healing fractures. We hypothesize that open reduction internal fixation (ORIF) augmented with BMAC will improve patient-reported outcome measures following Jones’ fractures in athletes.

Methods:

This study was a retrospective review of elite athletes that underwent intramedullary screw fixation augmented with BMAC for Jones’ fractures at an academic medical institution. All patients were assessed preoperatively and postoperatively to determine their pain outcomes based on their visual analog score (VAS). Student’s t test was used in statistical comparison of the preoperative and postoperative outcome scores. P < 0.05 was considered significant.

Results:

A total of 16 elite athletes were treated with ORIF with BMAC for a Jones fracture with a mean age of 22.2 years (range 19–26). There were 9 males and 7 females included in the study. Type of athlete ranged across various sport activities, with all patients functioning at a collegiate and/or professional level of elite athletics. The mean visual analog score for pain decreased from 6.2 preoperatively (range 3-8) to 2.75 postoperatively (range 1-6 p = 0.06). All patients have returned to elite competitive sport activity with reports of minimal to no pain.

Conclusion:

Intramedullary screw fixation of Jones’ fractures with BMAC results in optimal surgical outcomes in the elite athlete. A higher powered and long-term study with validated patient-reported outcomes is needed to confirm our observations.
Treatment of End-Stage Hallux Rigidus and Impact of Arthrodesis versus Arthroplasty on Patient Reported Outcomes
Authors: Chambers Monique , Hogan MaCalus , LaBaze Dukens
Published: September 2017

Category:

Bunion, Midfoot/Forefoot

Introduction/Purpose:

Hallux rigidus is a degenerative disease of the first metatarsophalangeal joint. Severe, end-stage hallux rigidus can become debilitating with surgical intervention becoming necessary once conservative measures and shoe modifications have failed. Joint salvage procedures include metatarsal phalangeal (MTP) arthrodesis and MTP arthroplasty. The purpose of this study was to assess for differences in patient reported outcomes in two cohorts who underwent fusion or joint reconstruction.

Methods:

This study was a retrospective review of prospectively collected data of 385 patients from an academic medical institution. Patients who underwent surgical intervention from July 2015 to November 2016 were identified based on CPT codes for MTP arthrodesis (28750) and arthroplasty (28293). We extracted outcome scores including SF12-M, SF12-P, FAAM, and VAS scores. Exclusion criteria included poly-trauma, revision procedures, and lack of pre and post-operative outcome scores. Mann- Whitney t-test was performed using GraphPad Prism version 7.0b for Mac to compare procedure groups, with significance define by a p-value of 0.05.

Results:

A total of eighteen patients met the inclusion criteria, with 6 who underwent arthroplasty and 12 arthrodesis. The average age was 63.7 amongst the cohort, with a total of 16 female and 2 males. Patients who underwent arthrodesis had better outcomes across all parameters. When comparing preoperative and postoperative scores, arthrodesis patients showed greater improvement of SF12-M (arthrodesis 9 vs arthroplasty -2, p=0.05), and SF12-P (9 vs -16, respectively p=0.05) scores. Arthroplasty patients were more likely to have a decrease in their SF-12 scores. VAS scores and FAAM scores showed no statistical difference between the two cohorts. Postoperative VAS scores were worse in 33% of arthroplasty patients despite surgical intervention, compared to 10% of arthrodesis patients.

Conclusion:

Our results suggests that both procedures provide a statistically significant difference in pain with several patients having a Global Rate of Change that is “very much better”. However, fusion of the metatarsophalangeal joint results in improved pain and functional outcomes for patients with severe hallux rigidus. These findings are consistent with current reports in the literature, which are mostly case series reports. Larger studies are needed to provide appropriate power and better support the findings of this study.
Normal Ultrasonographic Parameters of the Posterior Tibial, Peroneal, and Achilles Tendons
Authors: Chu Christopher , Jackson J. Benjamin , Williams Kevin
Published: September 2017

Category:

Ankle, Hindfoot, Imaging- Ultrasound

Introduction/Purpose:

Tendinopathy of the foot and ankle is common and can progress to become incapacitating. The most frequently affected tendons in the foot and ankle are the posterior tibial, peroneal, and Achilles. Studies have found a lifetime incidence of 5.9% in sedentary people and as high as 52% in athletes for Achilles tendinopathy. Previous studies demonstrated that ultrasound (US) of the soft tissues of the foot and ankle is a highly effective tool that can evaluate nearly every anatomical structure. Its lack of ionizing radiation, low cost, and painless nature make it a viable tool for foot and ankle evaluation. We sought to utilize US to determine normal values for the Achilles, peroneal, and posterior tibial tendons in patients presenting to the foot and ankle clinic.

Methods:

Patients were evaluated prospectively via a standardized US examination protocol from 2015-2016. Subjects who agreed to participate received a bilateral lower extremity ultrasound performed by a musculoskeletal ultrasonographer of the posterior tibial, peroneus longus, peroneus brevis, and Achilles tendons. Images were obtained in both the transverse and longitudinal axes above and below the malleoli and saved for analysis and measurement calculations. When indicated, color flow Doppler was utilized to assess for hyperemia and recorded. The imaging for each tendon was acquired with the patients in standardized positions on the examining table.

Results:

A total of 200 patients with 400 extremities were identified, consented, and participated in the study. Measurements for each patient were recorded above and below the malleoli for each tendon. Most tendons demonstrated a normal distribution as illustrated in the representative Figure 1 of the peroneus brevis above the lateral malleolus. Values and distributions curves were similarly calculated for each tendon at each point of measurement. Patients with suspected tendinopathy frequently had an increase of two standard deviations above the mean.

Conclusion:

This is the largest studies to characterize the measurements of the posterior tibial tendon, Achilles, and peroneal tendons in patients that present to a foot and ankle clinic. This baseline data can assist clinicians in their diagnostic ability with US. Given its low cost, lack of ionizing radiation and dynamic ability along with an improved understanding of normative data it will likely become an increasingly utilized diagnostic modality.
Akin osteotomy as an adjunct to hallux MTPJ fusion
Authors: Damany Devendra , Dalwai Ramesh
Published: September 2017

Category:

Midfoot/Forefoot, Hallux MTP fusion

Introduction/Purpose:

It is not uncommon to note residual valgus at the hallux interphalangeal joint when performing a hallux MTPJ fusion. On occasion, despite optimum positioning of hallux MTPJ for fusion, we found that in some cases the hallux was still abutting the second toe. We noted that these cases had either a high hallux interphalangeus valgus angle or the proximal phalanx had a shorter, concave lateral border due to eccentric wear. These two variables were difficult to correct despite optimum positioning of the hallux MTPJ. Consequently the hallux abuts the second toe causing irritation. We have used Akin osteotomy as an adjunct to hallux MTPJ fusion to address this intraoperative problem

Methods:

Between 2013 to 2016 this technique was utilised in 16 patients in whom residual hallux valgus interphalangeus was noted once the hallux MTPJ was stabilised in the appropriate position. We used two 4.0 mm AO cannulated partially threaded screws inserted in a crossed configuration for MTPJ fusion and a 8 mm x 90 degree varisation staple for the Akin osteotomy. The Akin osteotomy was performed in the mid to distal diaphyseal region of the proximal phalanx to avoid the screw position. Postoperatively, patients were given a toe spica plaster cast and were advised to walk in a heel weight bearing wedge shoe for six weeks.

Results:

Despite the osteotomy not being in the metaphyseal region, we have not encountered any immediate post-operative complications. We accept that this technique may not be suitable when using plates and screws for fusion but would be suitable for use with screws or staples. We have not encountered any postoperative complications. All hallux MTPJ joints have fused and Akin osteotomies have healed uneventfully

Conclusion:

This technique has not been reported before. Akin osteotomy is commonly used as an adjunct to corrective hallux valgus surgery. It is a relatively quick and reproducible technique with minimal incidence of complications. We suggest that this technique be considered when carrying out a hallux MTPJ fusion, although may not be required in all cases.
Relationship Between Symptomatic Osteochondral Lesions of the Talus and Quality of Life, Body Mass Index, Age, Size and Anatomic Location
Authors: D’Ambrosi Riccardo , Maccario Camilla , Usuelli Federico Giuseppe
Published: September 2017

Category:

Ankle

Introduction/Purpose:

The aim of the study was to assess the relationship between symptomatic osteochondral lesions of the talus (OLTs) and age, Body Mass Index (BMI), quality of life (QOL), size and anatomic location.

Methods:

Fifty-two patients with chronic OLTs were analyzed including BMI, Visual Analgoue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS), Short-Form Healt Survey (SF-12 divided into Mental (MCS) and Physical (PCS) score) and the 12-Item General Health Questionnaire (GHQ-12). Every patient underwent magnetic resonance imaging (MRI) and computed tomography (CT) examinations. We carried out a sub-analysis by dividing the talus into 6 areas, 3 vertical (medial, central and lateral group) and 3 horizontal (anterior, middle and posterior group).

Results:

There were 31 (60%) male and 21 (40%) female patients. Mean MCS and PCS resulted respectively 43.9 and 35.2. OLTs were located as follows: medial 20 (38.50%); central 13 (24.0%); and lateral 19 (36.50%); anterior 24 (46.15%); middle 16 (30.77%); and posterior 12 (23.08%). No significant differences were found among different groups with the exception of the anterior and posterior group for MCS (p=0.021). In central group we identified a negative correlation (R=-0.672) between aging and AOFAS and a positive correlation between BMI and lesion size. We found a positive correlation between CT and MRI in each group.

Conclusion:

OLTs impact patients quality of life particularly in the physical component. Additionally, in patients with central lesions we found a positive linear correlation between lesion size and BMI and a worsening of the ankle with increasing age.