bluuebunny/crossref_metadata_2025 huggingface dataset:
Establishing Maximal Subjective Outcome Improvement after Total Ankle Arthroplasty
Authors: Agarwalla Avinesh , Yao Kaisen , Gowd Anirudh , Cody Elizabeth , Nunley James A. , Amin Nirav , Liu Joseph
Published: November 2020

Category:

Ankle; Ankle Arthritis

Introduction/Purpose:

Total ankle arthroplasty is considered one of the most common treatments for end stage osteoarthritis of the ankle. This procedure results in significant long-term improvements in pain and function while preserving pre-operative range of motion. Patients also demonstrate improvements in patient reported outcome measures (PROMs) - a modality that quantifies patient’s subjective well-being. Understanding the time to maximal subjective medical improvement (MMI) following total ankle arthroplasty can help guide resource allocation and manage patient expectations. The purpose of this investigation is to establish when patients perceive MMI according to PROMs following total ankle arthroplasty.

Methods:

A systematic review was conducted on the PubMed database to identify studies on total ankle arthroplasty which reported consecutive PROMs for at least two years postoperatively. Pooled analysis was done at 3-months, 6-months, 12-months, and 24-months postoperatively. The minimal clinically important difference (MCID) was established by a distribution-based method, which is one-half of the standard deviation of outcome score change for a given instrument. Clinically significant improvement was determined between pairs of intervals that exceeded the MCID.

Results:

A total of 12 studies and 1514 patients met the inclusion criteria for this review. Clinically significant improvement was seen up to 6 months postoperatively in both the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score (AOFAS) and Visual Analog Scale (VAS) scoring systems but was not demonstrated at later intervals. The Short Musculoskeletal Function Assessment (SMFA) Function and Bother subsections were scored individually and both demonstrated clinically significant improvement until 1 year postoperatively.

Conclusion:

After total ankle arthroplasty, the maximal subjective medical improvement based on PROMs is seen until one year postoperatively, with clinically insignificant improvement beyond one year. The SMFA scoring system may offer greater sensitivity to subjective improvements compared to the AOFAS or VAS scales. This trajectory may help guide patients in managing their expectations in their functional outcomes during preoperative patient education.
Adverse Events Involving Hallux Metatarsophalangeal Joint Implants: Comprehensive Analysis of US Food and Drug Administration Data from 2010 to 2018
Authors: Akoh Craig C. , Kadakia Rishin J. , Chen Jie , Park Young-uk , Kim Hyong Nyun , Wang Juntao , Adams Samuel B.
Published: November 2020

Category:

Midfoot/Forefoot; Other

Introduction/Purpose:

The prevalence of osteoarthritis of the hallux metatarsophalangeal joint (MTPJ) is estimated to affect 1 in 40 people over the age of 50. Surgical treatment options for MTPJ arthritis include joint preservation, joint resurfacing, and salvage arthrodesis. Arthroplasty of the great toe MTPJ has evolved over the past several decades. The aims of this study were to examine the MAUDE database to determine reported adverse events for hallux MTPJ arthroplasty.

Methods:

The US Food and Drug Administration’s (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2010-2018 to determine reported adverse events for approved implants. We recorded and categorized the type of adverse event and excluded duplicate reports and those extracted from already published literature.

Results:

Among 64 unique hallux MTPJ implant adverse events, the most common modes of failure were component loosening (34%), component fracture (9.4%), inflammation (9.4%), infection (14.1%), and allergic reaction (7.8%). In regards to implant type, synthetic implants (Cartiva) had the highest percentage of adverse events (23.4%), followed by Arthrosurface ToeMotion (20.3%), Ascension MGT (12.5%), Arthrosurface HemiCAP (10.9%), Futura primus (9.4%), and Osteomed Reflexion (6.3%). The number of adverse events reported increased substantially after 2016.

Conclusion:

Our study of the MAUDE database demonstrated that component loosening and infection are the most common modes of adverse events for hallux MTPJ implants. Cartiva accounted for one-fourth of the implant-related adverse events during our study period, followed by ToeMotion and Ascension MGT implants. Given that the adverse events for hallux MTPJ implants are underreported, improved reporting mechanisms should be utilized to improve our understanding on long-term effects of various hallux MTPJ implants. [Table: see text]
Applying the Periprosthetic Joint Infection Consensus Definition to a Case Series of Revision Foot and Ankle Implant-Associated and Infection-Suspected Procedures to Assess Diagnosis
Authors: Baker Erin A. , Harley Jackson , Gehrke Corinn , Ciufo David J. , Fortin Paul T. , Vaupel Zachary M.
Published: November 2020

Category:

Other

Introduction/Purpose:

Periprosthetic joint infection (PJI) affects 2-3% of all total joint replacement cases. In 10-30% of these cases, the organism is unidentifiable, which may impact treatment planning and outcomes. In this study, suspected periprosthetic infections of foot and ankle procedures treated by four foot and ankle-trained orthopaedic surgeons were retrospectively reviewed to determine culture status and applicability of the 2018 International Consensus Meeting on Orthopaedic Infections (ICM) Revision classification system.

Methods:

Under an IRB-approved protocol, cases of suspected infection, based on ICD-9/10 codes, from cases performed at a Level 1, private, academic hospital from October 2014 to November 2019 were reviewed for demographic, surgical, and infection-related data.

Results:

Of the 210 revision cases coded for infection, 82 met the inclusion criteria of the study; cases included removal of an implant and were not wound infection-related only. Preoperatively and intraoperatively, 10 (12%) and 59 (72%) cases were culture-positive, respectively. In this series, 21 (26%) cases met the ICM Revision major criteria and 36 (44%) cases met the threshold for ICM Revision minor criteria; overall, 43 (52%) cases were defined as infected by the 2018 ICM Revision classification system.

Conclusion:

This study reviewed and identified culture status and infection by the 2018 ICM classification system. In this series of 82 cases, approximately half of the cases met the criteria for infection diagnosis, according to the most recently revised ICM classification system, although nearly three-quarters of the population had at least one positively-identified intraoperative culture. Further data analysis is ongoing to assess the correlation between ICM scoring with pre/postoperative treatment and outcomes. [Table: see text]
Comparative Evaluation of the Presence of Insertion Enthesophyte in the Achilles Tendon by X-Ray and Magnetic Resonance Imaging: Intra and Inter Observer Reliability
Authors: Baumfeld Tiago S. , Silva Thiago A. , Benevides Wilel A. , Silveira Dário M. , Baumfeld Daniel
Published: November 2020

Category:

Other; Sports

Introduction/Purpose:

To evaluate the intra and interobserver variation on the presence of enthesophyte in patients with Achilles insertional tendinopathy and the clinical radiological correlation of x-ray (X-ray) and magnetic resonance images (MRI).

Methods:

We selected Lateral X-ray images of the calcaneus and videos of ankle MRI in which we showed the entire thickness of the calcaneus in the coronal, sagittal and axial views, in both T1 and T2 weightings, of 20 patients with Achilles insertional tendinopathy. 5 foot and ankle surgeons and 5 musculoskeletal radiologists, with varied experience time, analysed the images. Intra and Interobserver correlations were studied with the kappa index.

Results:

The average Ƙ intraobserver of the results of the MRI analyzes was 0.49, and the average Ƙ interobserver of the results of the MRI analyzes was 0.47. The mean Ƙ intraobserver values of the results of the X-ray analyzes were 0.61, while the Ƙ interobserver had a value of 0.60. We also observed that the group of less experienced surgeons and radiologists showed a worse Ƙ intraobserver than the more experienced ones.

Conclusion:

The values are in agreement with previous studies, confirming moderate intraobserver and interobserver reproducibility in MRI exams and good or substantial interobserver and interobserver reliability in X-ray exams.
Evaluation of Ankle Mobility Loss in Patients Undergoing Subtalar Arthrodesis
Authors: Baumfeld Tiago S. , Pinto Roberto Zambelli de A. , Lopes Fernando Araujo S. , Baumfeld Daniel , Tavares Camilo
Published: November 2020

Category:

Hindfoot

Introduction/Purpose:

Objective: To evaluate and quantify the loss of ankle mobility in patients undergoing subtalar arthrodesis compared to the contralateral side, through physical examination.

Methods:

A total of 12 patients who had only the subtalar arthrodesis procedure from various causes in one foot were selected. The same foot and ankle surgeon performed all measurements of bilateral tibiotarsal range of motion, with loaded closed-chain and unloaded open-chain tests. Then, to assess whether there was a difference between the operated and the non-operated side, statistical analysis was performed with the Mann-Whitney test (Hollander and Wolfe 1999).

Results:

On the loaded closed-chain test, the operated side had a significantly lower range of motion than the contralateral side, with a mean difference of 5.4 degrees for dorsal flexion and 7.6 degrees for plantar flexion. The open-chain tests showed non- significant differences of 3 degrees for dorsal flexion and 5.3 degrees for plantar flexion.

Conclusion:

Subtalar joint arthrodesis was shown to cause a loss of mobility in the ipsilateral ankle, which is greater in plantar flexion movement.
Long Term Autograft Harvest Site Pain after Ankle and Hindfoot Arthrodesis
Authors: Baumhauer Judith F. , Glazebrook Mark A. , Younger Alastair S. , Fitch David , Quiton Jovelyn , Daniels Timothy R. , DiGiovanni Christopher W.
Published: November 2020

Category:

Ankle; Hindfoot; Other

Introduction/Purpose:

Autologous bone has traditionally been the gold standard for grafting material during foot or ankle arthrodesis. While autograft use has been effective, its harvest does present certain distinctive risks to the patient including persistent harvest site pain. Previous studies have examined harvest site pain, but most have focused on the iliac crest and none provide longer term follow-up. The purpose of this study was to examine long-term (7-10 year) donor site pain from four lower extremity harvest site locations in subjects undergoing autograft harvest for hindfoot or ankle arthrodesis.

Methods:

All subjects in the control arm of a previously conducted Level 1 clinical trial comparing autologous bone with a synthetic bone graft substitute for hindfoot or ankle arthrodesis were invited back for a single visit at a minimum of 5 years following their initial surgery. Autograft was harvested from either the proximal tibia (51.7%), iliac crest (17.2%), calcaneus (15.5%), distal tibia (6.8%), or other location (8.6%). Harvest site pain, fusion site pain, and weight-bearing pain were evaluated using a 100-point visual analog scale (VAS), with clinically significant pain considered as any score greater than 20 (Todd et al., 1996).

Results:

Of the 130 subjects receiving autograft in the original trial, 58 returned for assessment at a mean follow-up of 9.0 years (Table 1). The mean harvest site VAS at final follow-up was 4.4 (range, 0.0-97.0) with 37.9% of subjects reporting some level of pain. The percentage of subjects who reported clinically significant pain was 35.7%, 21.4%, 18.2%, 10.5%, 8.9%, and 5.2% at 2, 6, 12, 24, 52 weeks, and final follow-up, respectively. Of those subjects reporting clinically significant pain at final follow-up, two had undergone harvest from the proximal tibial and one from the iliac crest. A significant correlation was found between harvest site pain and both weight-bearing and fusion site pain, but not between harvest site pain and the volume of graft harvested.

Conclusion:

This study is the first to examine persistence of long-term harvest site pain following autologous bone graft harvest during hindfoot or ankle arthrodesis. Over one-third of patients still reported persistent pain at an average follow-up of 9 years, with 5% experiencing clinically significant pain. The proximal tibia harvest site had the greatest incidence of reported pain. These data suggest that harvesting autologous bone does carry inherent risk of persistent, long-term pain. This factor should be considered when informing patients of procedural risks and when choosing between autograft or graft substitute during arthrodesis surgery. [Table: see text]
Long-term Outcomes of Immediate Weightbearing with Anchorless Achilles Debridement and Secondary Reconstruction for Insertional Achilles Tendonopathy
Authors: Bemenderfer Thomas B. , Boersma Jacob B. , Maskill John D. , Anderson John G. , Bohay Donald R.
Published: November 2020

Category:

Hindfoot; Sports

Introduction/Purpose:

Achilles debridement and secondary reconstruction is a widely accepted procedure for treatment of insertional Achilles tendonopathy with or without Haglund resection, calcaneus exostectomy, retrocalcaneal bursectomy, and possible flexor hallucis longus tendon transfer. When less than 50% of the tendon is pathologic and elevated from the calcaneus, primary reconstruction with or without bony fixation (bone tunnels or anchors) has been advocated. Postoperative protocols demonstrate wide variability in the orthopaedic literature. This study is the first to evaluate clinical and radiographic outcomes in patients with insertional Achilles tendonopathy who underwent soft tissue only Achilles debridement and secondary reconstruction with immediate plantigrade weightbearing in plantigrade foot ankle stabilizer (FAS) high walking boot.

Methods:

All patients with symptomatic insertional Achilles tendonopathy who failed conservative management underwent Achilles debridement and secondary reconstruction with or without Haglund resection, calcaneus exostectomy, and retrocalcaneal bursectomy by a single senior foot and ankle surgeon at a single tertiary center between January 2006 to December 2013 were included in our retrospective case series. Patients with greater than 50% involvement of the tendon requiring flexor hallucis longus transfer were excluded. Demographics, clinical outcomes, patient comorbidity information, and Coughlin satisfaction scores were collected. The primary outcome was change in visual analog scale (VAS) pain score. Secondary outcomes were reoperation, minor complications (local wound care, use of antibiotics, and skin dehiscence).

Results:

From 2006 to 2013, 66 patients (40.9% male, 59.1% female) at an average age of 53.6 years (range 19 to 78) underwent Achilles debridement and secondary reconstruction. At final average follow up of 4.3 years, average VAS score improved from 5.9 to 2.3 preoperatively to postoperatively. There were a total of 10 reoperations in 9.1% of patients (n=6). Minor complications were present in 12.1% of patients (n=8; 3 local wound care, 8 use of antibiotics, and 5 skin dehiscence). Physical therapy desensitization was utilized in 25.8% of patients (n=17).

Conclusion:

The present study demonstrates a significant improvement in VAS pain scores following Achilles debridement and secondary reconstruction for treatment of insertional Achilles tendonopathy with immediate plantigrade weightbearing in plantigrade FAS high walking boot. This technique appears to be safe and effective.
Subtalar Arthroereisis as an Adjunct Procedure Improves Forefoot Abduction in Stage IIb Adult- Acquired Flatfoot Deformity
Authors: Bernasconi Alessio , Argyropoulos Miltiadis , Patel Shelain , Ghani Yaser , Cullen Nicholas , Singh Dishan B. , Welck Matthew J.
Published: November 2020

Category:

Hindfoot; Midfoot/Forefoot

Introduction/Purpose:

Our aims were: (i) to determine whether subtalar arthroereisis (STA) as adjunct procedure improved radiographic correction of stage IIb adult acquired flexible flatfoot deformity (AAFD); (ii) to assess the STA-related complication rate.

Methods:

A retrospective analysis of 22 feet (21 patients) diagnosed with stage IIb AAFD treated by medialising calcaneal osteotomy (MCO), flexor digitorum longus (FDL) transfer, spring ligament (SL) repair with or without Cotton osteotomy and with or without STA in a single institution was carried out. Seven measurements were recorded on pre and postoperative (minimum 24 weeks) radiographs by two observers and repeated twice by one. Inter and intraobserver reliability was assessed. The association of demographic (gender, side, age, BMI) and surgical variables (Cotton, STA) with radiographic change was tested with univariate analysis followed by a multivariable regression model.

Results:

Excellent inter and intraobserver reliability was demonstrated for all measurements (ICC range, 0.75-0.99). Multivariable regression showed that STA was the only predictor of change in talo-navicular coverage angle (TNCA) (R2=0.31; p=0.03) and in calcaneo-fifth metatarsal angle (CFMA) (R2=0.40; p=0.02) on dorsoplantar view. STA was associated to a greater change in TNCA by 10.1 degrees and in CFMA by 5 degrees. Four patients out of 12 STA complained of sinus tarsi pain after STA, and removal of the implant resolved symptoms in 3 of them.

Conclusion:

In this series, STA as an adjunct procedure to MCO, FDL transfer, SL repair in the treatment of stage IIb AAFD led to improvement in correction of forefoot abduction. STA-related complication and removal rates were 33%.
Use of Intramedullary Locking Nail for Displaced Intraarticular Fractures of the Calcaneus: What is the Evidence?
Authors: Bernasconi Alessio , Iorio Paolino , Ghani Yaser , Argyropoulos Miltiadis , Patel Shelain , Welck Matthew J.
Published: November 2020

Category:

Trauma

Introduction/Purpose:

There is increasing interest on how to best manage displaced intraarticular calcaneal fractures (DIACF). Intramedullary locking devices (ILDs) have recently been advocated since the technique adopts a minimally invasive approach which may minimise complications and therefore improve outcomes. We reviewed the literature of commercially available devices to identify their characteristics, efficacy and safety.

Methods:

Medline, Scopus and EMBASE databases were searched to identify studies reporting use of ILDs for treating DIACF. A PRISMA checklist was used to sort eligible studies. Technical notes and biomechanical studies were first reviewed. Cohort studies were then reviewed for demographics, surgical technique, postoperative protocol, clinical and radiographic scores, complications and reoperations. The modified Coleman Methodology Score (CMS) was used to assess the quality of studies.

Results:

Thirteen studies investigated two devices (Calcanail; C-Nail). Four technical notes described how to use these devices and three biomechanical studies proved they offered adequate primary stability, stiffness, interfragmentary motion and load to failure. Seven clinical studies (302 feet, 289 patients) demonstrated satisfactory clinical (AOFAS, VAS) and radiographic (Bohler’s angle, Gissane angle, Goldzak index, posterior facet step-off) outcome at 16-months average follow-up. Metalware irritation (up to 20%) and temporary nerve entrapment symptoms (up to 30%) were the most common complications; soft tissue issues were reported in 3-5% of cases. Conversion to subtalar fusion was necessary in 4-6% of cases. Four (57%) studies were authored by implant designers and in 5 (71%) relevant conflict of interest were disclosed. Mean CMS was 61 (moderate quality).

Conclusion:

Treating DIAFCs with ILDs leads to satisfactory clinical outcomes at short term follow-up, enabling restoration of calcaneal height and improved subtalar joint congruency. Metalware irritation and temporary nerve entrapment symptoms are common complications although wound complications including infection and wound breakdown are less frequent than after open lateral approaches. The quality of evidence provided so far is only moderate and biased by potential conflict of interest, raising concerns about the generalisability of results.
Diagnosing the Impact of the Syndesmotic Injury on Lateral Ankle Stability using Dynamic Ultrasound
Authors: Bhimani Rohan , Saengsin Jirawat , Sato Go , Hagemeijer Noortje , Lubberts Bart , Guss Daniel , Waryasz Gregory R. , DiGiovanni Christopher W.
Published: November 2020

Category:

Ankle; Basic Sciences/Biologics; Sports; Trauma

Introduction/Purpose:

There is a high prevalence of coexisting lateral ankle ligament injuries and syndesmotic ligamentous injuries. However, it is unclear whether syndesmotic ligaments directly contribute toward the stability of the lateral ankle. Dynamic ultrasonography (US) is an imaging modality increasingly used for the care of orthopaedic foot and ankle patients because it allows dynamic evaluation of structures at the point of care with little risk to the patient and at low-cost. The aim of this study is to assess the effect of syndesmotic injury as well as combined syndesmotic and lateral ankle injury on the stability of the lateral ankle.

Methods:

Sixteen fresh frozen above-knee amputated cadaveric specimens, divided into two groups, underwent ultrasound evaluation for lateral ankle stability. In both the groups, the assessment was first done with all ligaments intact and later with sequential transection of anterior inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), posterior inferior tibiofibular ligament (PITFL), anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). In all scenarios, two loading conditions were considered: (1) Anterior drawer test: 50N and 80N and (2) Lateral clear space (LCS): 1.7Nm torque. The talar translation and LCS to the fixed tibial plafond were measured using Image J. Wilcoxon rank-sum test was used to compare the findings of each ligamentous transection state to the intact state. A p-value <0.05 was considered statistically significant.

Results:

In group 1 after transection of the all syndesmotic ligament and ATFL, an increase in the anterior drawer and lateral clear space values were found as compared to the intact state. Similarly, in group 2 the anterior drawer and lateral clear space values significantly increased after transection of the AITFL and ATFL as compared to the intact state (p-values = 0.01).

Conclusion:

Ultrasound can be used to evaluate the impact of the syndesmotic injury on lateral ankle stability while performing dynamic stress maneuvers. Lateral ankle instability appears after injury to all syndesmotic ligaments and ATFL, or after one syndesmotic ligament rupture (AITFL) with a concomitant anterior talofibular ligament rupture (ATFL). These findings suggest that surgeons should lower their threshold for stabilizing the syndesmosis if there is a concomitant lateral ankle ligament injury. [Table: see text]
Using Area and Volume Measurements on Weightbearing CT to Detect Isolated Lisfranc Instability
Authors: Bhimani Rohan , Sornsakrin Pongpanot , Ashkani-Esfahani Soheil , Lubberts Bart , Waryasz Gregory R. , Guss Daniel , DiGiovanni Christopher W.
Published: November 2020

Category:

Midfoot/Forefoot; Sports; Trauma

Introduction/Purpose:

Early detection of Lisfranc instability is critical for optimizing clinical outcomes. Injuries causing a more subtle instability, however, can be difficult to diagnose. The aim of this study was to compare the injured Lisfranc joint to the healthy contralateral side using weightbearing computed tomography (CT) in patients with known Lisfranc instability. We also aimed to define the range of normal measurement variation by comparing the Lisfranc joint measurements between the left and right foot in individuals without foot injury who underwent similar imaging. Our hypothesis was that compared to the healthy contralateral side, weightbearing CT area and volume measurements were increased in patients diagnosed with subtle Lisfranc instability.

Methods:

Patients with unilateral Lisfranc instability requiring operative fixation (n = 14) underwent preoperative bilateral foot and ankle weightbearing CT. A separate group of patients without foot injury who also underwent similar imaging were included as comparative controls (n = 36). For each weightbearing CT, 2 dimensional axial and coronal plane Lisfranc joint parameters, Lisfranc area, intercuneiform area, C1-M2 distance, C1-C2 distance, M1-M2 distance, first and second tarsometatarsal (TMT 1 and 2) alignment; and first and second tarsometatarsal (TMT 1and 2) dorsal step off were measured to evaluate the Lisfranc anatomy at a level 10 mm below the dorsal surface of medial cuneiform (Figures I and II). In addition, the volume of the Lisfranc joint was also evaluated. Values were recorded by two independent observers to assess interobserver reliability.

Results:

Among those with unilateral Lisfranc instability, values differed largely between the injured and the healthy contralateral side for all measurements performed (p-value range, 0.008 - <0.001). In the control population without foot injury, no differences were identified between any of the bilateral measurements (p-value range, 0.121 - 0.984).

Conclusion:

Weightbearing CT can effectively differentiate Lisfranc instability from those without instability. The Lisfranc volume and area had the largest difference between the injured and the uninjured feet among surgically treated patients with substantial interrater agreement making them the most relevant parameters for detecting Lisfranc instability. However, prospective studies are needed to validate the role of weightbearing CT in the diagnosis of subtle Lisfranc instability.
Achilles Injury and Access to Care in South Florida
Authors: Boden Allison , Geller Joseph S. , Granger Caroline , Summers Spencer H. , Kaplan Jonathan R. , Aiyer Amiethab A.
Published: November 2020

Category:

Hindfoot; Ankle

Introduction/Purpose:

Achilles Tendon (AT) rupture is the most common tendon rupture in the lower extremity with an incidence of 2.1 AT ruptures per 100,000 person years. Due to the non-emergent nature of this injury, a delay in presentation may occur leading to delays in diagnosis and treatment; which may alter both nonoperative and operative management. Health insurance status may directly impact time to presentation for many patients. To our knowledge, no study has evaluated the effect of insurance status on delay in diagnosis and treatment of AT rupture.

Methods:

From December 2013 to December 2018, 89 patients with AT ruptures who underwent surgical management were identified by CPT code in a dual-institution retrospective chart analysis. Demographic and injury-specific data were obtained with attention to the date of injury, date of diagnosis, location of initial presentation (clinic vs. emergency room), and number of medical visits. A univariate two tail t test was used to compare various groups. Statistical significance was set at p < 0.05 to determine the effects of insurance type on the time to diagnosis and treatment of acute AT ruptures.

Results:

When compared to adequately insured patients (private and Medicare), underinsured patients (uninsured and Medicaid) experienced a significantly greater time from the date of: injury to first clinic visit (14.5 days versus 5.2 days, p < 0.001), first clinic visit to surgery (34.6 days versus 4.8 days, p < 0.002), injury to surgery date (48.9 days versus 9.8 days, p < 0.001), initial presentation to when magnetic resonance imaging (MRI) was obtained (48.1 days versus 1.9 days, p < 0.002), and initial presentation to diagnosis (22.8 days versus 1.71 days, p < 0.029).

Conclusion:

Disparities in access to care are intimately related to insurance status. Uninsured and medicaid patients are subject to institutional delays and decreased access to care when compared to patients with private insurance. Under and uninsured patients are significantly more likely to present to the emergency department for their initial visit, potentially resulting in increased healthcare costs. Emergency department visits as well as difficulty in obtaining an appointment with an orthopedic surgeon may directly contribute to delay in diagnosis.
Quantitative Analysis of Talar Dome Morphology
Authors: Borchard Justine , Stevens Wilshaw , Siebert Matthew , Shivers Claire , Zide Jacob R. , Riccio Anthony , Francis Kirsten Tulchin-
Published: November 2020

Category:

Ankle; Other

Introduction/Purpose:

A flat-top talar dome deformity can alter ankle mechanics and impact daily activities. Radiographic determination of flatness is difficult using traditional measures. The purpose of this study is to describe a new method to quantify the talar dome morphology using lateral radiographs and a custom-written image processing algorithm.

Methods:

Skeletally mature patients previously treated for idiopathic clubfeet were identified from our institution’s clubfoot registry. All patients had weight-bearing lateral foot radiographs. Measurements included radius of curvature (ROC) of the talar dome and tibial plafond, talar length and height, and alpha angle. The ratio of the radii of the talar dome and tibial plafond (TD/TP Ratio) was determined. Custom-written, image processing MATLAB code was used to identify the talus from the lateral radiograph. Following manual identification of the articular surface, the average slope of the anterior, central, and posterior regions of the talar dome were calculated. Talar dome flatness was determined as the slope variance across all three regions. Higher variance indicated a rounder talar dome morphology, lower variance indicated a flatter dome. Inter-rater reliability of radiographic measures and the MATLAB based talar dome flatness were determined. Spearman’s rho was used to determine correlations between radiographic and MATLAB flatness measures.

Results:

For radiographic measures, the Inter-rater reliability (IRR) was determined for 52 feet. IRR was near perfect for the ROC of the talar dome (ICC=.985), talar length (ICC=.952), and alpha angle (ICC=.928). Measurement of the radius of the tibial plafond (ICC=.827) and talar height (ICC=.893) were reproduced with excellent reliability. The IRR of the TD/TP ratio was moderate (ICC=.608). Preliminary IRR for the MATLAB-based talar dome flatness (15 feet) was excellent (ICC=0.895). Flatness was strongly correlated with ROC of the talar dome (r=.621, p=.013), alpha angle (r=.557, p=.031) and TD/TP Ratio (r=-.589, p=.021).

Conclusion:

Flatness of the talar dome can be difficult to describe, as there lacks a single measure to accurately define its morphology. The method developed in this study was quick to apply (less than 5 to 10 minutes per foot) and had high inter-rater reliability.
A Retrospective Chart Review to Examine Intra-Compartment Pressures and Post-Operative Outcomes of Chronic Exertional Compartment Syndrome
Authors: Brower Jacob , Shuster David M. , Cheney Nicholas A. , Clark Brian C.
Published: November 2020

Category:

Other

Introduction/Purpose:

Chronic exertional compartment syndrome (CECS) is defined as reversible, insufficient blood supply to a fascial compartment’s contents. Patients with this condition have abnormally elevated pressures within specific fascial compartments, causing decreased blood flow to that area. This temporary loss of blood supply produces a feeling of tightness in the affected muscles, pain, and possibly local paresthesia. Surgical treatment involves a fasciotomy, which releases the implicated compartment’s fascia. This procedure creates additional space for muscle expansion and more adequate blood supply to the appropriate tissues.The purpose of this study is to review the surgical outcomes of patients diagnosed with lower extremity CECS whom received a fasciotomy, assessing correlations between resting intramuscular compartment pressures and surgical outcomes.

Methods:

A retrospective chart analysis was performed of the senior author’s patients between January 1st, 2013 and June 30th, 2019. Patients included in this study presented with symptoms consistent with lower extremity CECS and had the diagnosis confirmed, either unilaterally or bilaterally, via the resting intramuscular pressure cutoff (>=15 mmHg) outlined by the Pedowitz criteria. These patients subsequently received fasciotomies for the syndrome.

Results:

Out of the 37 patients included in this study, 30 (81.1%) reported improvement in their post-operative pain scores. There was a trend (P > 0.1523) between resting intra-compartment pressures and post-operative pain improvement.

Conclusion:

Our study suggests a positive trend between higher resting intra-compartment pressures and post-operative pain improvement. Due to the limited number of study participants, no correlations could be determined. However, this data is significant because it demonstrates the importance of the Pedowitz diagnostic criteria, as it is the first study showing a relationship between the resting pressure criteria and surgical outcomes. Further research is necessary to determine if there is a correlation between higher intramuscular pressures and positive surgical outcomes.
Osteochondral Lesions of the Tibial Plafond: A Systematic Review
Authors: Butler James J. , Rosas Kevin , Hurley Eoghan T. , Kennedy John G.
Published: November 2020

Category:

Ankle; Sports; Trauma

Introduction/Purpose:

Osteochondral lesions of the talus (OLTs) account for the majority of osteochondral lesions (OCLs) of the tibiotalar joint, with osteochondral lesions of the tibial plafond (OLTP) being less commonly reported. The purpose of this systematic review was to evaluate the topographical characteristics of OLTPs, and outcomes following surgical intervention.

Methods:

A systematic review of the MEDLINE, EMBASE and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting clinical data for OLTPs were included. The level and quality of evidence of the included studies was evaluated using the Modified Coleman Methodology Score.

Results:

Nineteen studies with 395 OLTPs were included. Overall, 75.9% of OLTPs were associated with a traumatic history and/or previous ankle sprain. OLTPs were most commonly located in the centromedial region of the tibial plafond (30.4%), with the fewest number of OLTPs found in the anterolateral region of the tibial plafond (3.9%). In total, 46.9% of OLTPs were associated with co-existing osteochondral lesions of the talus. Microfracture was the most frequently utilised surgical technique amongst the included studies, and reported good clinical outcomes at mid-term follow up. Four studies were level of evidence II and 15 studies were level of evidence IV.

Conclusion:

This systematic review has found that osteochondral lesions of the tibial plafond are not a rare clinical finding in the setting of ankle trauma and are often associated with co-existing osteochondral lesions of the talus. Clinical outcomes following arthroscopic intervention appear to produce good results in the mid-term, but the low level of evidence, poor quality of evidence, marked heterogeneity and underreporting of the data confounds any recommendation based on this systematic review.
Impact of COVID-19 Pandemic on Patients Perceptions of Safety and Need for Elective Foot and Ankle Surgery in the United States
Authors: Chan Jimmy , Chen Kevin K. , Choi Peter , Rojas Edward , Schipper Oliver N. , Aiyer Amiethab A. , de Cesar Netto Cesar , Amin Amgad M. Haleem , Kadakia Anish R. , Vulcano Ettore
Published: November 2020

Category:

Ankle; Ankle Arthritis; Arthroscopy; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports

Introduction/Purpose:

With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the U.S. to divert healthcare resources and limit exposure. Little is known about the impact of COVID-19 on patient’s willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision.

Methods:

Patients across six U.S. Orthopedic Institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient’s decisions.

Results:

A total of 150 patients participated in this study. N=21 (14%) opted not to proceed with surgery once restrictions were lifted. 43% (N=9) listed concern for COVID infection as the reason, however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs. 14%) and lower increase in pain medication used (5% vs. 12%).

Conclusion:

COVID-19 has made a significant impact on the healthcare. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic.
Minimally Invasive Correction for Symptomatic, Fixed Curly Toe Deformity
Authors: Choi Jun Young , Suh Jin Soo
Published: November 2020

Category:

Lesser Toes

Introduction/Purpose:

Curly toe deformity is a relatively common deformity that generally occurs at the 4th and 5th proximal and/or middle phalanges but rarely presents with symptoms. Although numerous open operative techniques have been introduced, there is no established treatment yet. We report the results of minimally invasive correction for symptomatic, fixed curly toe deformity.

Methods:

Between 2016 and 2018, 25 consecutive percutaneous dorsolateral closing wedge-shaped osteotomies with Shannon burrs at the proximal and/or middle phalanx were performed. We assessed the postoperative clinical and radiological changes at a mean of 22.51 months of follow-up.

Results:

The locations of osteotomy were at the middle phalanx in 10 cases, proximal phalanx in 13 cases, and both in one case. The mean amount of corrections of varus inclination and shortening were 16.54° and 2.24 mm, respectively. The Foot and Ankle Ability Measure Activities of Daily Living scores significantly improved from 59.09 preoperatively to 74.55 at the last follow-up. There was one case of pin site infection and one case of incision site numbness due to digital nerve injury.

Conclusion:

Minimally invasive dorsolateral closing wedge-shape osteotomy is a simple, safe, and effective correction for symptomatic, fixed curly toe deformity.
Is Immediate Weight Bearing Safe for Lateral Malleolus Fracture after Surgery?
Authors: Choi Young Rak , Lee Sang-June , Lee Jaehyung , Park Seung-Hwan
Published: November 2020

Category:

Trauma; Ankle

Introduction/Purpose:

Isolated lateral malleolus fracture is one of the most common fractures. However, there is controversy regarding the rehabilitation protocols used after surgery. In particular, the initiation point for the weight bearing has not been standardized. In the present study, we investigated the prognostic difference between the immediate and delayed weight bearing on isolated lateral malleolus fractures.

Methods:

Retrospectively, the medical records of matched 50 and 41patients in the immediate and delayed weight-bearing groups were reviewed. All patients were treated with open reduction and internal fixation using an anatomical locking compression plate. In the immediate weight-bearing group (IWB), tolerable weight bearing (i.e., that can be endured immediately after surgery with crutches) was permitted. In the delayed weight-bearing group (DWB), weight bearing was completely restricted for 4 weeks after surgery. Ankle motion exercise were permitted in both groups since postoperative day. Radiographic assessment data and the clinical outcomes were reviewed.

Results:

There were no significant differences noted in the radiographic assessments and complications between the two groups. Significant differences of shortening the return to work and hospital stays of IWB rehabilitation protocol were confirmed(5.7 vs. 8.0 days, 6.0 vs. 8.0 days in the IBW and DWB groups, respectively). In FAOS, there was a significant difference in the sport factor evaluated at postoperative 3 months(75.5 vs 68.5, respectively).

Conclusion:

There were no significant differences between the two groups in the postoperative radiological outcome and complications. And benefits of shortening the return to work and hospital stays of IWB rehabilitation protocol were confirmed. Conclusively, immediate weight bearing is recommended in patients with isolated lateral malleolus fracture, following anatomical reduction and firm fixation through surgery.
Patient Outcomes Following Polyvinyl Alcohol Hydrogel Implant of the Lesser Metatarsals
Authors: Chrea Bopha , Day Jonathan , Eble Stephanie K. , Elliott Andrew J. , O’Malley Martin J. , Deland Jonathan T. , Drakos Mark C.
Published: November 2020

Category:

Lesser Toes; Other

Introduction/Purpose:

Lesser toe metatarsal phalangeal (MTP) joint pathology presents a challenge for surgical treatment. Recently, synthetic cartilage implants have been shown to be safe and efficacious in treating hallux ridigus, offering pain relief while preserving motion at the MTP joint. At our institution, metatarsophalangeal joint arthroplasty using a polyvinyl alcohol (PVA) hydrogel implant has been utilized in the 2nd and 3rd MTP joints for advanced arthritis, failed management of Freiberg’s infraction, and osteochondral defects. We present a case series describing the clinical outcomes of 12 patients following PVA implantation of the 2nd or 3rd MTP.

Methods:

We retrospectively identified 12 consecutive patients (13 joints) who underwent PVA hydrogel implantation of the 2nd (n=12) or 3rd (n=1) metatarsal head between 2017 and 2019. PVA implant was indicated for advanced arthritis in 6 patients (7 joints), Freiberg’s infraction in 4 patients, and osteochondral defect in 2 patients. Average age was 51 years (range, 20-67), with 100% females. Patient-reported outcomes measurement information system (PROMIS) scores were collected preoperatively and at latest follow-up, with an average follow-up of 20.4 months (range, 8.3 to 29.2). Retrospective chart review was performed to evaluate postoperative complications, including need for revision, implant removal, and persistent pain.

Results:

Overall, patients demonstrated mean improvement in all PROMIS domains, with a significant improvement in Pain Intensity of 11.9 points (p=0.03) postoperatively. A total of 4 postoperative complications occurred in the 12 patients: one case of AVN at 2 years postoperatively, one revision with removal of the implant and bone grafting of the second metatarsal head at 1 year postoperatively, one periprosthetic fracture at 9 months postoperatively, and one recurrence of pain requiring ultrasound- guided injection at 7 months postoperatively. Three additional patients reported persistent pain postoperatively.

Conclusion:

This study represents the largest case series to date evaluating the use of PVA hydrogel implant in the surgical correction of lesser toe MTP joint pathology. While the PVA implant presents a viable option in the setting of advanced arthritis, Freiberg’s infraction, and certain osteochondral defects, it is not without complications. The specific indications for use of the PVA implant should be carefully considered before implantation.
Tibial Torsion May Predict Morphology of the Talus
Authors: Ciufo David J. , Baker Erin A. , Fortin Paul T.
Published: November 2020

Category:

Ankle Arthritis; Ankle; Hindfoot

Introduction/Purpose:

The role of implant positioning in total ankle arthroplasty (TAA) has garnered increasing attention, particularly in defining coronal and sagittal plane alignment. With the ongoing developments in patient specific instrumentation, advanced imaging is becoming a more common tool in preoperative planning. Despite this, there is limited information available on axial rotation of the ankle or variations in anatomy of the talus and foot. We aim to evaluate the rotational profile of the distal tibia and its relationship to morphology of the talus, as well as assess tibiotalar tilt, in a cohort of end-stage arthritic ankles.

Methods:

Computed tomography (CT) scans and plain radiographs were reviewed in 59 patients with end-stage ankle arthritis. Patients with previous tibial or ankle trauma were excluded. Scans were obtained prior to total ankle arthroplasty surgery as part of standard preoperative planning protocol. Demographic data was recorded. Measurements were obtained at the posterior condyles of the tibial plateau and transmalleolar axis to calculate tibial torsion, as well as along the talar neck and body to evaluate talar angle. Tibiotalar tilt angle was measured on weightbearing mortise view radiographs. Linear regression was performed to evaluate statistical associations between tibial torsion and other measured parameters.

Results:

The mean tibial torsion was 29.5±9.2 degrees external (range 13.6-50.8 degrees), no internal torsion was found. Mean talar neck-body angle was 38.2±8.8 degrees medial (range 24.1-59.5 degrees). Tibiotalar angle ranged from 26.5 degrees varus to 23.5 degree valgus. There was a statistically significant relationship between increasing tibial torsion and decreasing talar neck-body angle (r=-0.49, p<0.001), demonstrating more angulation of the talar neck corresponding to the least tibial torsion as seen in Figure 1. No relationship was found between tibial rotation and tibiotalar angle when assessing varus/valgus tilt on a spectrum (p=.89) or when evaluating absolute angulation from neutral (p=.43). Our cohort had a mean age of 63.1±8.2 years, and 54% were male.

Conclusion:

Our cohort displayed wide variation in axial anatomy of the ankle. Our analysis identifies a statistically significant correlation between tibial torsion and morphology of the talus. This is a previously unreported association that could help understand development of foot and ankle deformity and pathology. While there was no clear correlation to degree of tibiotalar angulation, these axial deformities surely play a role in altered foot and ankle mechanics and the development of end-stage ankle arthrosis. In patients undergoing ankle arthroplasty, these are important parameters for the surgeon to consider in conjunction with other aspects of the hindfoot deformity.