bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effect of Achilles Tendon Loading on Ankle Joint Contact Area and Peak Pressure
Authors: Latt L. Daniel , Ayala Alfonso , Kim Samuel , Lopez Jesus
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Increased tibiotalar peak pressure (PP) and decreased contact area (CA) following ankle fracture are associated with the development of post-traumatic osteoarthtritis. Lateral talar translation of just 1 mm has been shown to decrease CA by 42%. The impact of talar malalignment in other directions on ankle joint contact pressures (AJCP) are not well understood. The majority of research on AJCP has utilized cadaveric models in which body weight is simulated with an axial load applied through the tibia. This model does not account for Achilles tendon - which transmits the largest tendon force in the body during weight bearing. This study aimed to determine the effects of Achilles tendon loading on tibiotalar CA and PP in an axially loaded cadaver model at different ankle flexion angles.

Methods:

Ten fresh frozen cadaveric lower extremity specimens transected mid-tibia were dissected free of soft tissues surrounding the ankle, sparing the ligaments. The proximal tibia and fibula were potted in quick drying cement for rigid mounting on a MTS machine. A pressure sensing element (TekScan KScan model 5033) was inserted into the tibiotalar joint and used to measure CA (cm2) and PP (MPa). An axial load of 686 N was applied through the tibia and fibula, followed by a 350 N load via the Achilles tendon to simulate mid-stance conditions. Measurements were taken at neutral position, 15 degrees of dorsiflexion and 15 degrees of plantarflexion, with and without Achilles load. The effects of Achilles load and ankle flexion angle on CA and PP were analyzed using a 2x3 ANOVA. Bonferroni post-hoc adjustments were used for multiple comparisons. Level of statistical significance was set at p < 0.05.

Results:

ANOVA revealed significant main effects of ankle flexion on contact area and peak pressures (Table 1). Contact area was significantly lower for 15 degrees of plantarflexion than neutral and 15 degrees of dorsiflexion (p < 0.001). In addition, peak pressure was significantly higher for 15 degrees of plantarflexion than neutral and 15 degrees of dorsiflexion. ANOVA also indicated that contact area and peak pressure were significantly higher with Achilles load than without (p < 0.001). No interaction effects were found.

Conclusion:

The applied Achilles tendon load significantly altered tibiotalar PP in an axially loaded cadaver model. On the other hand, changes in CA with Achilles load were found to be minimal (~1.8%). We also found that the greatest PP and smallest CA occured during plantar flexion. This observation can be explained by a difference in width between the anterior and posterior talus. While the results of this study demonstrate the importance of Achilles tendon load on tibiotalar measurements, further studies investigating the effects of additional factors such as loading techniques are warranted to improve the physiological accuracy of cadaver models.
Open syndesmotic repair for open-book type syndesmotic injury
Authors: Lee Young Koo , Yoo Jungwoo
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Although there are several approaches to the treatment of syndesmosis injury, there is no gold standard technique. Syndesmotic screw fixation is one of commonly used treatment options but there remains debate topics such as implant breakage and the need for device removal. The purpose of this study was to evaluate the clinical, radiologic and arthroscopic outcomes of open syndesmotic repair for open-book type syndesmotic injury as a new treatment option.

Methods:

We reviewed the clinical, radiographic and arthroscopic results of 20 patients with traumatic injuries to the distal tibiofibular syndesmosis who were treated with open syndesmotic repair. Arthroscopic evaluations including cotton test were performed at the primary and second-look operation. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle–hindfoot score and visual analog scale (VAS) score were used to evaluate clinical outcomes. The measurement of the tibiofibular clear space and tibiofibular overlap were used to evaluate radiologic outcomes. Both Clinical and radiologic outcome evaluations were performed preoperatively, at 6 weeks and 6 months postoperatively, and at a final follow-up at a minimum 12 months postoperatively. The average follow-up period was 15.3 months.

Results:

The average AOFAS score improved from 45.4 (range 30-68) preoperatively to 94.12 (range 83-100) at the last follow-up (P < .001). The radiologic parameters of the syndesmosis returned to normal range since the first postoperative follow-up. At second-look arthroscopy, all the patients showed negative cotton test results and the gap of distal tibiofibular joint was remained less than 2 mm in all patients.

Conclusion:

We had excellent clinical, radiologic and arthroscopic results and there is no major complication. Open syndesmotic repair for open-book type syndesmotic injury is effective in healing and maintaining the injured joint. Therefore this procedure could be a reasonable alternative treatment for traumatic syndesmosis injury of the ankle.
The Plantar Support of the Navicular-Cunieform Joint
Authors: Mason Lyndon , Swanton Eric , Fisher Lauren , Fisher Andrew , Molloy Andrew
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Weight-bearing radiographic analysis of pes planus deformities shows, with varying degree of severity, a break in Meary’s line, uncovering of the talar head and an increase in talar-first metatarsal angle. Work by Alsousou (BOFAS 2016) has shown the break in Meary’s line to occur not only at the talonavicular joint (2/3rds of cases) but also at the navicular-cuneiform joint (1/3 rd of cases), distal to the spring ligament and reported posterior tibial tendon insertion. There are currently no anatomical studies analysing the medial longitudinal arch distal to the spring ligament insertion. We aimed to examine this area and assess the anatomy supporting the distal medial longitudinal arch.

Methods:

We examined 11 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University, in a solution of formaldehyde. The lower limbs were carefully dissected to identify the plantar aspect of the medial longitudinal arch

Results:

In all specimens, the posterior tibial tendon inserted into the plantar medial aspect of the navicular with separate slips to the intermediate and lateral cuneiform. Following insertion, on the navicular, a tendon-like structure extended from this navicular insertion point to the medial cuneiform. This tendon-like structure is statically inserted between the navicular and medial cuneiform allowing the pull of tibialis posterior to act on the navicular and medial cuneiform in tandem. The average width of this ligament (15.2 mm) is much greater than that of the tibialis posterior tendon (9.5 mm). A separate smaller plantar ligament is also present between the navicular and medial cuneiform.

Conclusion:

The posterior tibialis tendon inserts into the navicular, and what is likely an anthropological remnant, extends onto the medial cuneiform as the navicular cuneiform ligament. This provides a static restraint between two bony insertions and increases the lever arm of the posterior tibial tendon. The major support of the distal aspect of the medial longitudinal arch (i.e. the navicular-cuneiform joint) is provided by the substantial navicular cuneiform ligament.
Incidence and Risk Factors for Complications of Exposed Kirschner Wires Following Elective Forefoot Surgery
Authors: McKenzie James , Rogero Ryan , McDonald Elizabeth , Nicholson Kristen , Shakked Rachel , Raikin Steven , Khawam Sultan
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Kirschner wires (K-wires) are commonly utilized for temporary metatarsal and phalangeal fixation following forefoot corrective osteotomies. K-wires can remain in place for up to 6 weeks postoperatively and are at risk for wound complications. Their exposure to the outside environment and direct osseous communication makes infection an important concern for the clinician. Early removal, prophylactic antibiotics, and re-operation are potential sequelae of infected K-wires and can affect outcomes. The purpose of this study is to evaluate the incidence of complications of exposed K-wires after forefoot surgery and identify patient or perioperative risk factors for these complications.

Methods:

A single surgeon retrospective chart review of forefoot surgeries over the past 10 years was undertaken. Inclusion criteria were any adult undergoing elective forefoot surgery with the use of exposed K-wires. Incidence of wound complication defined as cellulitis, pin site drainage, or migration/loosening of the pin requiring prophylactic antibiotics or early removal was noted. Patient demographic data such as age, BMI, comorbidities, and smoking status were recorded. Perioperative data such as tourniquet time, type of anesthesia, and perioperative antibiotics was also recorded. Univariate analysis was performed via Mann-Whitney test for continuous variables and Chi square test for categorical variables. Multivariate analysis was performed for statistically significant risk factors.

Results:

1,217 Patients (2,018 K-wires) were analyzed. There was a 10% complication rate requiring prophylactic antibiotics or early removal (N=123). 40 patients required early pin removal, 54 patients were given oral antibiotics, and 29 patients required both. Female gender (p<0.001), BMI over 28 (p<0.001), general anesthesia (p=0.025), increased tourniquet time (p=0.003) and history of rheumatoid arthritis (p=0.047) were significantly associated with complications. Both male gender [OR 2.62] and tourniquet time [OR 1.01] remained significant on multivariate regression analysis. There was no increased risk of complications with a history of smoking or diabetes.

Conclusion:

The K-wire is an important modality for providing temporary immobilization of the smaller bones of the forefoot following deformity correction. Male gender, elevated BMI, history of rheumatoid arthritis, general anesthesia, and longer tourniquet time are associated with increased risk of pin infection requiring early removal and/or antibiotics. Further study is needed to determine whether optimizing inflammatory disease, using efficient perioperative technique, and utilizing local anesthesia may limit the risk of wound complications with K-wires in forefoot surgery.
The Incidence and Clinical Utilization of the Calcific Spur in patients with Insertional Achilles Tendinopathy
Authors: Michelson James , Charlson Mark , Holleran Amanda
Published: September 2018

Category:

Hindfoot

Introduction/Purpose:

Retrospective review of 38 patients treated by two F&A surgeons from 2009 - 2017 for insertional calcific Achilles tendinopathy to determine the location of the calcific spur. We hypothesize that the spur is most commonly seen affecting the posterior fibers. Our secondary hypothesis was that three-dimensional imaging would allow patients to be identified with less than 50% involvement which would make them eligible for resection without the need for reattachment.

Methods:

Patients with calcific Achilles tendonitis were identified by ICD-10. Patients were included if they had both calcification identified on xrays and MRI imaging. Patients with prior surgery or trauma to the calcaneus or Achilles were excluded. The axial MRI section with the largest cross section of the calcification was used and a line was drawn sagittally and coronally to divide the tendon into four quadrants to identify laterality and anterior vs posterior involvement.

Results:

There was no significant difference in anatomic location or laterality of the spur between men and women. Seventy five percent of the patients had a spur that encompassed 50% or less of the insertion site. The predominant configuration was posterior in 89.5%, with half of those being lateral and the rest being central or medial. Eighty percent underwent operative management, with two thirds managed by one surgeon and the remaining by the other surgeon.

Conclusion:

Three dimensional imaging may guide surgical management in treatment of these conditions by identifying those spurs that are predominantly posterior and can be removed without necessitating the need for formal reattachment. This allows for shorter recovery time for the patient and perhaps improved patient outcomes and satisfaction.
NEMISIS Minimally Invasive Surgical Correction for Midfoot Charcot Arthropathy
Authors: Miller Roslyn
Published: September 2018

Category:

Diabetes

Introduction/Purpose:

The most common cause of Charcot Neuroarthropathy is diabetes. The incidence of diabetes continues to rise globally, with a significant socio-economic burden to both patient and society. Despite good total contact casting techniques, deformity and subsequent ulceration still occurs in this patient group. This make shoe-fitting challenging and the risk of subsequent ulceration increases. This in-turn increases the patients risk of amputation and mortality at five years. Conservative treatment is often protracted, with multiple clinic visits. The has a significant impact on the patients ability to work and quality of life. Open surgery carries a significant risk of poor wound healing and infection again with risk of ulceration. NEMISIS for mid-foot Charcot provides surgeons with a surgical technique for osteotomy, that protects the soft tissues.

Methods:

The surgical technique utilises Minimally Invasive Shanon and Wedge burrs to perform a biplanar closing wedge osteotomy to achieve a triplanar correction. This takes the tension off the soft tissues which ensures that there is still good tissue cover, without compromising the blood supply to the skin, therefore in theory reducing the risk of infection. Stabilisation is achieved with screws, beams and bolts, +/-medial column plating. Patients are immobilised in a Bholer walker for a period of 3 months post-op. The short to medium term results (3months to 3 years) are presented. Patients are followed up to asses for re-ulceration at the same site, different site, failure of metalwork, return to surgery.

Results:

16 patients were followed-up. 14 were diabetics. 4 patients developed deep-seated infection, which required removal of the metal-work. 2 of these patients did not have recurrence of their deformity and progressed to orthotic foot-wear. 1 patient had recurrence of deformity with wound breakdown and is awaiting further surgery. 1 patient had removal of metalwork from midfoot and subsequently developed hind-foot deformity which was stabilised with a hind-foot fusion nail. 1 patient broke the medial beam and bolts and required revision surgery. 2 patients had recurrence of plantar exostosis which was managed with minimally invasive exostectomy. 1 patient had early stabilisation of mid-foot and had subsequent Charcot of the talus, managed conservatively. The remaining patients have not required revision surgery. There have been not amputations.

Conclusion:

NEMISIS Minimally Invasive Surgery for Mid-Foot Charcot is a promising surgical technique which may help to reduce infection rates and subsequent amputations. The technique is relatively straightforward to teach, but is currently limited by the size of the burrs. The technique however can be coupled with innovation in biologics to aid the surgeon further in trying to achieve a stable plantigrade foot that does not have recurrence of ulceration and deformity.
The risk factors of subsidence of the talar component in the 3 rd generation TNK ankle
Authors: Morita Shigeki , Taniguchi Akira , Tanaka Yasuhito , Takakura Yoshinori
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

One of the major reasons for revision surgeries after total ankle arthroplasty (TAA) was subsidence of the talar component. The purpose of this study was to evaluate mid-term outcomes after total ankle arthroplasty(TAA) using the 3 rd generation TNK ankle and investigate risk factors leading to subsidence of the talar component.

Methods:

Fifty consecutive patients who received the 3 rd generation TNK prosthesis between October 2007 and December 2014 were investigated in this study. Weight-bearing foot and ankle radiographies were taken and evaluated before and after surgery. At least 1 mm sinking of the talar component was defined as the subsidence. BMI, age at the surgery, complications were investigated as patient specific parameter and talar tilting angle(TTA) and inclination of the articular surface of the distal end of tibia were investigated as preoperative radiographic parameters. Position and angle of replaced implant were also investigated using postoperative radiography.

Results:

Preoperative TTA had positive correlation (p=0.049, Cox model), and the angle between the talar and the 1st metatarsal axis (Meary angle) had negative correlation with subsidence (p=0.042, Cox model).

Conclusion:

The larger TTA shows varus deformity of the ankle and indicates the potential instability of the ankle, that leads to frequent incidence of ankle sprain postoperatively. Repeated micro trauma causes the loosening and subsidence of the talar component. The smaller Meary angle shows the cavus deformity, that prevents the favorable load distribution to the navicular and calcaneus, and leads to higher pressure concentration to the implant. The larger TTA and smaller Meary angle were risk factors of subsidence of the talar component in the TAA.
Prevalence of AALTF and relevant associated MR findings in persons with and without sinus tarsi pain
Authors: Park Chul-Hyun
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Sinus tarsi pain is very common, however, etiology of this condition has not been well understood. The purpose of this study was to evaluate differences of MRI findings between persons with and without sinus tarsi pain and to investigate the relationships of sinus tarsi pain and accessory anterolateral talar facet (AALTF).

Methods:

We reviewed MR images of 120 ankles with sinus tarsi pain in 115 consecutively registered patients. And age- and sex-matched MR images of 120 ankles without pain were also reviewed. We compared the presence of AALTF, calcaneal cyst (CC), bone marrow edema (BME), sinus tarsi fat obliteration (STFO) at the Gissane angle, and coalition between persons with and without sinus tarsi pain. We also compared Gissane angle, talar infero-lateral surface angle (TILSA), and calcaneal cortical thickness (CCT). Of persons with sinus tarsi pain, we compared these parameters between persons with and without AALTF.

Results:

AALTF was present in 61 ankles (50.8%) with sinus tarsi pain and 34 ankles (28.3%) without sinus tarsi pain (P<0.001). BME (P=0.001) and STFO (P=0.009) were significantly more frequent in persons with sinus tarsi pain. Presences of CC (P=0.108) and coalition (P=0.605) were not different. The Gissane angle was significantly smaller in persons with sinus tarsi pain than in persons without sinus tarsi pain (P<0.001) and TILSA (P=0.032), and CCT (P<0.001) were significantly larger in persons without sinus tarsi pain (Table 1). Of persons with sinus tarsi pain, BME was significantly more frequent in persons with AALTF and TILSA (P=0.032) and CCT were significantly larger in persons with AALTF (Table 2).

Conclusion:

The MRI findings of patients with sinus tarsi pain showed higher prevalence of AALTF, BME, and STFO. The AALTF may be associated with the MRI findings of talar and calcaneal BME.
Molybdenum Rhenium (MoRe®) as a Biologically Superior Alloy for Foot and Ankle Implants
Authors: Pedowitz David , Parekh Selene , Adams Samuel , Nunley James , Easley Mark , Hyer Christopher , Brigido Stephen
Published: September 2018

Category:

Other

Introduction/Purpose:

The most common complications in orthopaedic surgery of the foot and ankle documented in the literature are postoperative infections with a frequency between 1 and 8%. The development of an implant-associated infection can be a potentially devastating complication following foot and ankle surgery. This leads to a high number of revision surgeries after initial fracture stabilization and potential loss of function of the joint and quality of life in the long-term follow-up. Titanium, the most commonly used alloy for foot and ankle implants, has limited strength and is notch-sensitive so repetitive stress leads to fatigue failure of implants and limits design options. Better materials with both optimized mechanical and biological properties could result in the development of superior foot and ankle implants.

Methods:

Several studies were performed to evaluate the biological properties of MoRe®: A study was conducted to characterize the hydrophilic properties by contact angle comparisons of the MoRe alloy compared to Titanium. A cell growth study was conducted to look at the influence of MoRe alloy on osteoblast growth and differentiation as compared to Titanium. A bone implantation study was conducted based on ISO 10993: Biological Evaluation of Medical Devices, Part 6: Tests for Local Effects after Implantation to evaluate the local tissue and bone response of MoRe® alloy test coupon compared to Titanium controls, when implanted in the mid-shaft femoral bone of rabbits for 4, 13 and 26 weeks. Biofilm formation study was conducted to quantify attachment and biofilm development of S. aureus bacteria upon MoRe® alloy in comparison to CoCr alloy in a well-controlled, reproducible, ex vivo laboratory experiment.

Results:

MoRe®, composed purely (99.99%) of molybdenum and rhenium, is a cofactor to the enzymes xanthine and sulfite oxidase, which are essential to bone metabolism. Rhenium is an inert metal with no biological affect. MoRe® has superior hydrophilicity (CA 37°±3°) compared to Titanium (CA 58°±3°), a key factor in cell adhesion, migration and replication. Pre-osteoblast cell seeding was found to be equivalent between MoRe° and Titanium alloy (10,000 cells/cm2). The bone implantation study demonstrated continued bone maturation over time for both MoRe® and Titanium implant sites with similar osteoconduction and bone remodeling histology of the cortical and medullary bone at 4, 13 and 26 weeks. The biofilm study found that S. aureus better colonized cobalt chrome alloy in comparison to MoRe® (p = 0.009).

Conclusion:

The MoRe® alloy, with its advantageous biological properties and hydrophilicity, offers great promise for the design of a new generation of bio-friendly foot and ankle implants with superior cell growth, osseointegration and biofilm resistance resulting in better outcomes for patients.
Arthroscopically Assisted Treatment of Complex Ankle Fractures
Authors: Polzer Hans , Baumbach Sebastian , Braunstein Mareen
Published: September 2018

Category:

Arthroscopy

Introduction/Purpose:

Especially after complex ankle fractures, patients suffer from residual pain, swelling and stiffness. Evidence suggests that this poor outcome might be related to occult intraarticular injuries. Recent studies documented chondral lesions in up to 89%. Therefore, many authors emphasize the value of ankle arthroscopy in acute fracture treatment (AORIF). Only few studies reported on the findings of AORIF, even less documented the subjective and objective outcome thereafter. Aim of this study was to evaluate the intraarticular lesions and the results following AORIF for complex ankle fractures after 1-year of follow-up.

Methods:

Patients presenting with closed, complex ankle fractures were included. AORIF was performed following a standardized protocol. Primary outcome was the AOFAS Score. Secondary outcome parameters were the Olerud and Molander Score, Tegner activity scale, arthroscopic findings, functional assessment and complications. Statistical analysis was performed using SSPS 22.0 (IBM).

Results:

Between 05/13-12/14, 32 patients were enrolled (56% female, 45±16 years). Three patients were lost to follow-up. 16% suffered from uni-, 22% from bi- and 62% from trimalleolar fractures. Chondral lesions were observed in 91% (ICRS 2.9±0.9). In 34% micro fracturing was performed. Full thickness lesions were observed exclusively in in bi- and trimalleolar fractures. Three patients suffered from minor complications. After 1 year, the mean AOFAS was 93±6 and the mean OMAS was 88±8. Linear regression revealed no significant variables affecting the outcome.

Conclusion:

Intra-articular injuries are common in complex ankle fractures requiring chondral therapy in 34%. AORIF leads to good-excellent results in all but one patient, including those with bi- and trimalleolar fractures without increasing the risk for complications.
The Incidence of Nonunion of the Hallux Interphalangeal Joint Arthrodesis
Authors: Prissel Mark , So Eric , Chu Anson , Wilson Matthew
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Hallux interphalangeal joint (HIPJ) arthrodesis is an effective procedure to treat pain and provide stability, which is often performed for intrinsic pain to the HIPJ. Additionally, this procedure is typically employed in concert with the Jones tenosuspension. Despite that this is an accepted technique, the available literature is scant and questions remain regarding nonunion rates and contributory factors to poor healing. A systematic review of the literature was undertaken to determine the rate of nonunion for HIPJ arthrodesis.

Methods:

To acquire the highest quality and most relevant studies available, publications were eligible for inclusion only if they involved patients undergoing HIPJ arthrodesis. Studies additionally required mean follow-up of at least six weeks and inclusion of appropriate detail regarding complications, nonunion rates, and patient demographics. Ultimately, 7 studies involving 313 HIPJ arthrodeses met inclusion criteria.

Results:

A total of 291 patients with a weighted mean age of 48.9 were included. The nonunion rate was 28.3% at a weighted mean follow-up of 8.4 months. The overall complication rate was 33.0%.

Conclusion:

Considering the increased rate of complications and nonunions for this commonly employed procedure, additional prospective comparative analyses are needed to identify important patient demographics and to determine superior fixation constructs.
Does Hallux valgus severity change after medial capsulotomy? Intraoperative Analysis
Authors: Radkievich Ruben , Caicedo Nathaly , Díaz Andres Keller , Calvo Rafael , Wagner Pablo , Wagner Emilio
Published: September 2018

Category:

Bunion

Introduction/Purpose:

Most treatment algorithms for hallux valgus surgery consider the intermetatarsal angle (IMA) and the metatarsophalangeal (MTP) angle to help decide which technique to choose. Some guidelines are more stringent, and some use different absolute values to decide between one technique and another. Every open approach includes a medial metatarsophalangeal capsulotomy to gain access to the joint and perform some type of osteotomy. No study is available which measures hallux valgus deformity after an intraoperative metatarsophalangeal capsulotomy, which may change our surgical technique depending on the algorithm in use. Our hypothesis was that when performing a medial capsulotomy, the hallux valgus deformity would increase.

Methods:

We analyzed 20 feet in 14 hallux valgus patients operated between April to June 2017, average age 57 years, 13 women and 1 men. Patients with previous hallux valgus surgery, arthritic changes, knee or hip comorbidities were excluded. Fluoroscopic images were taken in a standardized manner, simulating weight bearing images, with knee and hip in flexion, stabilizing the foot over the mini C arm in maximal ankle dorsiflexion. All the images were taken by the same observer. Digital images were analyzed, and the IMA and MTP angles were measured by two independent observers. The average preoperative IMA was 13.6 degrees, and the average MTP angle was 23.4 degrees. Statistical analysis was performed using SPSS software, p<0.05.

Results:

After opening the medial capsule, we observed a significant increase in the IMA (mean 2.78 degrees, 2.4 - 3.1 degrees 95% confidence interval) and in the MTP angle (mean 4.4 degrees, 3.6 - 5.2 degrees 95% confidence interval). No correlation was found between the severity of the deformity and the relative increase in angular measurements. There was no significant variability between the two observers.

Conclusion:

When using algorithms for treatment decision making in hallux valgus surgery, it is important to clearly define the severity of the deformity to choose appropriately the technique to be used. When choosing a technique near its correction limit, if we consider that the deformity will increase after opening the medial capsule, it may be possible to underestimate the deformity and therefore use an underpowered technique, leading to a suboptimal result. We recommend therefore to add 3 and 5 degrees to the IMA and MTP angle measurement respectively, and then choose the appropriate technique.
Time to surgery for ankle fractures
Authors: Rai Paul , Mangwani Jitendra
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Ankle fractures constitute 9% of all fractures and surgical fixation is often required when they are unstable. The bony anatomy has little soft tissue coverage overlying the malleoli. The surgical site is therefore at risk of infection and wound breakdown. BOAST guidelines advise operative fixation on the first or second day after injury. Often in practice this window is missed and fixation is undertaken many days after the injury. We aimed to prospectively review the incidence of early wound complications and infection in 300 patients treated early or late with plate osteosynthesis for Weber B or C ankle fractures. This was conducted at a UK Trauma Unit.

Methods:

Between November 2013 and November 2016 consecutive patients with closed, isolated ankle fractures were included. Consent was obtained for entry into the study pre-operatively and they were followed up at 2 weeks post operation. Patients were categorised by time to surgery into the following subsets: < 24 hours, < 48 hours and > 48 hours. The 2 week consultation letters were reviewed retrospectively and reported wound complications recorded. The hospital microbiology database was used to identify any positive superficial or deep wound culture results. Comorbidity data and demographics were collected.

Results:

208 out of 300 patients had a complete dataset. The mean age was 46 (range 16-95). The superficial infection rate at < 24 hours, < 48 hours and > 48 hours was 4%, 0% and 3% respectively. There were no suspected deep infections at 2 weeks. There were 7 (3%) positive deep wound cultures. The mean BMI was 28 and venous thromboembolism prophylaxis was instituted for all patients as per local guidelines. 3% had diabetes and 23% were smokers.

Conclusion:

This study has shown that timing of surgery has not shown any significant influence on early infection rates. Surgery may be safely delayed until soft tissue swelling has reduced. However, there may be other benefits of early surgery such as reduced venous thromboembolism and improved patient reported outcome measures.
Syndesmotic Fixation With Suture Button. Neurovascular Structures at Risk. A Cadaver Study
Authors: Shah Ashish , Patel Harshadkumar , Pinto Martim , Dahlgren Nicholas , Abyar Eildar , Stibolt Robert , ehtonen Eva , Johnson Michael , Naranje Sameer
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Damage to distal tibiofibular syndesmosis occurs in 25% of operative ankle fractures. Syndesmotic stabilization is crucial to prevent significant pain, instability and degeneration of the joint. One operative method is insertion of suture buttons. Though effective, this method can result in entrapment and damage of the saphenous neurovasculature of the medial tibia. The purpose of this study was to describe the anatomic risk of direct injury to the saphenous nerve and greater saphenous vein during syndesmotic suture button fixation.

Methods:

This study was performed on 10 below knee cadaveric leg specimens. Under fluoroscopic guidance, syndesmotic suture buttons were placed from lateral to medial at 1cm, 2cm, and 3cm above the tibial plafond at an anterior angle of 30 degrees to the coronal plane. Dissection was performed through medial tibial incision to record the distance and position of each button from the greater saphenous vein and saphenous nerve. Statistical measurement and analysis was performed with SPSS.

Results:

The mean age of cadavers was 78.2 ± 6.9 years and mean BMI was 21.6 ± 2.2. The mean distance of the saphenous nerve to the suture buttons at 1cm, 2cm, and 3cm were 7.1 ± 5.6mm, 6.5 ± 4.6mm, and 6.1 ± 4.2mm, respectively. The saphenous nerve was compressed in 2 cadavers (20%) at 1cm, 2 cadavers (20%) at 2cm and 1 cadaver (10%) at 3cm by suture buttons. Mean distance of the greater saphenous vein from the suture buttons at 1cm, 2cm and 3cm were 8.6 ± 7.1, 9.1 ± 5.3, and 7.9 ± 4.9mm respectively. The great saphenous vein was compressed in 2 cadavers (20%) at 1cm, 1 cadaver (10%) at 2cm and 1 cadaver (10%) at 3cm by suture buttons.

Conclusion:

There was at least one case of injury to both the saphenous vein and nerve at every level of button insertion at a rate of 10-20%. The close proximity of the suture button to neurovasculature combined with significant anatomic variation in saphenous nerve anatomy suggest that neurovascular injury may be best avoided by direct visualization prior to suture button placement. Great care should be taken to avoid injury to saphenous neurovascular structures during suture button insertion. Keeping an eye on close proximity of neurovasculatures, we recommend medial incision for during syndesmotic suture button fixation.
Can Jones fracture be treated conservatively?
Authors: Shah Rajiv
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Operative management is the treatment of choice for Jones fracture. Situations are fought where operative management may not be possible or may not be accepted. Such situations being more common in developing countries, clinicians are forced to undertake conservative management. Pertain to this, many questions are still unanswered. Can conservative management succeed? If so, what should be the protocol? What all could be the possible complications? And how to overcome them? To answer all these questions, we undertook a study to evaluate results of conservative management of Jones fracture. The purpose of this study was also to suggest conservative management guidelines.

Methods:

Retrospective analysis of 32 conservatively treated Jones fracture cases over period of two years was done with average follow up of nine months. Only cases included were those between the ages of 20 to 50 years, not willing for operative management. Cases in the same age group, willing for surgery and cases lost to follow up were excluded. Conservative management comprised of full length below knee non weight bearing plaster cast in eversion and dorsiflexion for four weeks followed by short length below knee weight bearing plaster cast in neutral position of ankle and subtalar joint. Radiological evaluations were done at the end of 4, 8, 14, 20 and 26 weeks. Results of serial clinical and radiological assessments were analysed.

Results:

Thirty out of 32 cases went on to sound clinical as well as radiological union. With respect to average time to union, two major group of cases could be segregated. First group (20 cases) had a proximal fracture line nearer to zone 1 and took 11 weeks to unite. Second group (12 cases) had a distal fracture line nearer to zone 3 and took 18 weeks to unite. Both the nonunion cases were from this group. Clinical union preceded radiological union by average of 2 to 3 weeks.

Conclusion:

Jones fracture could be successfully treated conservatively even in young and active population provided specific protocol is followed. Initial full length below knee plaster in dorsiflexion and eversion neutralized deforming forces of peronei and plantar fascia while next short below knee walking plaster cast helped to regain muscle tone, increased perfusion and simulated walking leading to union. Fractures nearer the tuberosity had a faster union in comparison to distal fractures nearer the shaft. In view of short follow up with small numbers of present study, a multicentric prospective study comparing results of surgical versus conservative treatment is deemed.
Treatment of Pilon fracture malunion with distal tibiaI osteotomy and reconstruction
Authors: Shi Zhongmin
Published: September 2018

Category:

Ankle

Introduction/Purpose:

To evaluate the clinical outcomes of distal tibial osteotomy and alignment reconstruction for pilon fracture malunion.

Methods:

Between January 2010 and May 2012. 15 cases of pilon fracture malunion were treated with super-malleolar extra-articular osteotomy and alignment reconstruction. They were 12 males and 3 females with an average age of 30.8 years(from 24 to 39 years). The pre-operative X-ray and CT scan showed varus deformity in 9 cases anti valgus in 2 cases. There were 4 cases of anterior impact of the distal tibia and 4 cases of tibiotalar subluxation. All the patients complained about ankle pain, deformity, limited range of motion(ROM)and walking difficulty. X-ray was taken routinely to confirm the bone healing during post-operative follow-up. Scores of visual analogue scale(VAS), American Orthopaedic Foot & Ankle Society(AOFAS)and The Short Form-36(SF-36), ankle ROM and complications were also recorded.

Results:

13 cases obtained all average follow-up of 23. 8 months (from 19 to 48 months)and 2 were lost to the follow-up. Bony union was achieved after an average of 3.8 months(from 3 to 7 months). The average VAS score declined significantly from 5.1±3.2 preoperatively to 1.4±0.8 postoperatively (P<0.05). A complete pain relief was achieved in 8 cases. The AOFAS ankle and hindfoot score, SF-36 score, ankle ROM at the last follow-up were improved significantly compared with the preoperative ones (P<0.05). No implant failure, soft tissue complications or occurred during the follow-up.

Conclusion:

Distal tibial osteotomy and alignment reconstruction is an effective treatment of Pilon fracture malunion, as this strategy can restore the lower limb alignment, relieve pain and decrease the rate of long-term post-traumatic arthritis.
Sesamoidectomy for the Hallux Sesamoid Disorders
Authors: Shimozono Yoshiharu , Hurley Eoghan , Kennedy John
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Studies have shown that sesamoidectomy provides good clinical outcomes and quick return to sporting activities, however, there is concern regarding the complications following resection of one or both sesamoid bones. The purpose of the current systematic review was to evaluate the current evidence on sesamoidectomy for the treatment of the hallux sesamoid disorders.

Methods:

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

Results:

Ten studies with total 196 feet were included. The weighted mean age was 36.6 ± 11.0 with a mean follow-up of 45.1 ± 19.3 months. The mean Visual Analogue Scale score improved from a mean score of 6.5 ± 0.3 to 1.2 ± 0.5. The mean postoperative AOFAS score was 92.7 ± 2.7. Six studies demonstrated that 94.4% of patients returned to sport, with 90.0% returning to previous level, at a mean of 11.8 ± 1.8 weeks. The mean hallux valgus angle increased from 13.1 ± 2.1 preoperatively to 14.8 ± 3.7 postoperatively (p=0.470), and the mean intermetatarsal angle increased from 8.7 ± 0.8 to 9.7 ± 0.8 (p=0.180) following medial sesamoidectomy. The overall complication rate was 22.5%, and further surgeries were required in 3.0%(Table).

Conclusion:

The current systematic review demonstrated that sesamoidectomy for the hallux sesamoids disorders yields good clinical outcomes and a high rate of return to sports activity in the short-term. It is important to note however the high complications rate after sesamoidectomy, with a 22.5% complication rate in the short-term follow-up.
Does Hallux Rigidus produce worse functional disability than Hallux Valgus?
Authors: Siddique Malik , Ramaskandhan Jayasree , Qasim Sultan
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

There is paucity of literature comparing foot and general health status including quality of life between patients presenting with Hallux Valgus and Hallux Rigidus. We aimed to compare foot specific patient reported disability and general health status including higher functional activities and quality of life reported between patients presenting with Hallux Valgus and Hallux Rigidus.

Methods:

All patients who presented at our hospital foot and ankle clinics (between June 2016 and December 2017) with a diagnosis of primary Hallux Valgus or Hallux Rigidus were included in this prospective study. Patients with associated foot problems, bilateral presentations, h/o previous reconstructive surgeries, and underlying neurological conditions were excluded. These patients were grouped based on diagnosis into Group A (Hallux Valgus) and Group B (Hallux Rigidus). In these patients, differences were studied between groups for scores of MOX-FQ Manchester-Oxford foot questionnaire (Domains: Pain, Walking/Standing, Social activities), EQ-5D EuroQol (UK) and Foot and Ankle outcomes scores (FAOS) (Domains: Pain, symptoms, ADL, Recreation, Quality of Life). Statistical tests between groups included tests for normality, student t’tests and chi square tabulation tests using SPSS software.

Results:

MOX-FQ differences: -  Both groups reported similar level of pain (59.6 ± 22.6 vs. 58.2 ± 23.3); p=0.776; Difficulty with walking/ standing (61.6 vs. 61.4 ); p= 0.960; and restriction with social activity because of foot symptoms (61.6 vs. 59.7 ); p=0.683 EQ-5D: -  For mobility, both groups reported no (21.7% vs. 26.8); slight (28.2% vs. 29.2%) or moderate (34.7% vs. 31.7%) problems; p=0.931. For self-care, pain/discomfort, anxiety/ depression levels, there was no differences between groups; p>0.05. Mean overall general health scores was (71.3 ± 22.8) and (69.5 ± 20.8); p=0.663 FAOS: -  There was no difference in mean pain score (59.6 vs. 58.2; p=0.776), symptoms (70.3 vs. 63.8; p=0.104), ADL score (p=0.587), difficulty with sport/ recreation (p=0.907) or Quality of Life (p=0.662) between groups

Conclusion:

-  There is no difference in foot related quality of life, general health status and higher functional disability levels between patients presenting with Hallux Valgus vs. Hallux Rigidus. -  The impact of these conditions on disability levels remain the same, amidst the difference in pathology
Stress Tests for Ligamentous Lisfranc Instability
Authors: Smith George , Loizou Constantine
Published: September 2018

Category:

Trauma

Introduction/Purpose:

The diagnosis of Lisfranc ligament disruption is notoriously difficult. Radiographs and MRI scans are often ambiguous therefore a ‘stress-test’ under anaesthesia is commonly utilised. Two midfoot stress-tests are in current practice, namely the varus first ray stress-test and the pronation abduction test. The optimal type of stress-test is not however evaluated in the literature. We hypothesised that after the loss of the main plantar stabiliser (the Lisfranc ligament) the patient would demonstrate dorsal instability, not the classic 1st/2nd metatarsal diastasis commonly described. We therefore devised a push-up test (placement of a force under the 2nd metatarsal to elevate the base on the lateral radiograph). We aimed to initially test our hypothesis and the previously described stress tests on a cadaveric model.

Methods:

Twelve fresh frozen cadaveric specimens without previous foot injury were used. The 2nd tarsometatarsal joint was exposed and the Lisfranc ligament and dorsal capsule were incised. An image intensifier was positioned and standard anteroposterior (AP) and lateral views were obtained. Two previously reported AP stress-tests (varus first ray stress test, pronation abduction test) and the novel test under investigation (‘Lisfranc Push-Up’ test) were duly performed. A positive test was taken as 2mm of dorsal or lateral displacement.

Results:

All twelve of the Lisfranc Push-Up tests showed dorsal subluxation of the 2nd metatarsal on the middle cuneiform of greater than 2mm on the lateral radiograph. No diastasis (greater than 2mm) of the 1st/2nd metatarsals was seen in any of the specimens on the AP radiographs for either of the other two stress-tests.

Conclusion:

The authors have described a novel way of demonstrating the dorsal instability associated with the ligamentous Lisfranc injury. Our results support the Lisfranc Push-Up test as a reproducible and sensitive method for assessing ligamentous Lisfranc injuries. In our cadaveric model the previously described stress-tests do not work.
Supramalleolar osteotomy and AMIC cartilage reconstruction in severe cartilage lesion
Authors: Thermann Hajo
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Severve cartilage lesion is defined by the author as: Cartilage substantial deterioration of the subchondral bone Kissing lesion, tibial and talar lesion. Gross cystic lesion Cartilage damage greater than 1/3 of the talar dome or the tibial platform Slerotic changes of the subchondral bone plate in arthritic cases in severe hindfoot varus or valgus alignment. This paper shows in a case series, exceptional cartilage lesions with the above mentioned pathological changes. The indications, strategies for osteotomies and the treatment strategies in malaligned bipolar, cystic and gross cartilage lesions is explained.

Methods:

35 patients with severe circumscript varus / valgus arthritis have been operated by supramalleolar osteotomy (SMOT), 11 of them with (tibial & talar “kissing”) lesions. 70 patients presented bipolar (tibial & talar “kissing”) lesions with correct hindfoot axis. 18 patients had a gross cystic lesion and were additionally treated with filling of the cysts. 2 of them had a “kissing lesion”.

Results:

All patients received an AMIC procedure (hyaluronic matrix, Hyalofast©) for cartilage reconstruction. The biological healing support was in all cases bone marrow aspirate and ACP© growth factors. The subchondral bone plate was treated aggressively was a power raps or burr according to L. Johnson technique The importance of a supramalleolar and calcaneous osteotomy in a hindfoot malalignment (varus / valgus) as a treatment key aspect for load transfer is elaborated. Planned early implant removal with revision und biological boosting of the cartilage regeneration is a further cornerstone of the treatment. Followup were evaluated by FAOS score

Conclusion:

This cases series have shown the possibilities for a successfull managing of this severe lesions and offers also its limit in the over all results.