bluuebunny/crossref_metadata_2025 huggingface dataset:
Prescribing Fewer Opioid Pills to Hallux Valgus Patients Undergoing Minimally Invasive Bunion Correction: A Prospective Comparative Study
Authors: Caolo Kristin C. , Marion Celia , Paugh Rebecca , Johnson A.
Published: January 2022

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

This study aims to compare opioid usage and patient satisfaction with postoperative pain management in similar hallux valgus (HV) patients who underwent minimally invasive distal chevron akin (MIS) correction with patients who underwent modified Lapidus and scarf corrections. We hypothesized that patients who underwent minimally invasive bunionectomy would consume fewer opioids and report similar satisfaction with pain management compared with modified lapidus and scarf patients.

Methods:

This study is a single center prospective study of 33 patients diagnosed with hallux valgus undergoing MIS bunion correction who received a novel opioid prescribing protocol used by the senior author. Preoperatively, patients undergoing MIS corrections were counseled on the expectations of pain after surgery, received a take home pamphlet, and were prescribed opioids for moderate surgery (5-15 pills). These patients were then compared to a cohort of 25 hallux valgus patients status post Lapidus or scarf bunionectomy who were prescribed 40-60 opioid pills without preoperative coaching or handouts. Patients were excluded if they used opioids or muscle relaxants preoperatively or had a known history of a substance use disorder. Patients completed surveys postoperatively for eight weeks reporting pain level, number of opioid pills consumed, refill requests, and satisfaction with their pain management plan.

Results:

There was a significant difference (p< 0.001) in mean pills consumed between MIS patients who averaged 2.5 opioid pills (5mg Oxycodone/pill) and modified Lapidus and scarf patients who averaged 25.2 opioid pills (5mg Oxycodone/pill) at all time points (Table 1). There was no significant difference between the ratio of pills taken to pills prescribed between both groups (p>0.05). Patients had comparable levels of pain at all time points (p>0.05). MIS patients did not request any refills, whereas Lapidus and scarf patients requested a total of 5 refills over the course of the study.

Conclusion:

HV patients who underwent MIS correction achieved equivalent analgesic effect when compared to similar HV patients who underwent Lapidus or scarf procedures. The Lapidus and scarf group received approximately four times the amount of opioids and consumed 11 times the amount of pills. This study demonstrates that HV patients undergoing MIS bunion correction require far fewer opioid pills to achieve the same level of postoperative pain control compared with Lapidus and scarf patients. This study also suggests that a novel postoperative prescribing protocol utilized by the senior surgeon may decrease the number of pills both prescribed and consumed by patients.
Feasibility of Arthroscopic Anterior Talofibular Ligament Repair and Comparison Between Arthroscopic and MR Findings for Anterior Talofibular Ligament Injuries
Authors: Cho Whi Je , Lee Young Koo
Published: January 2022

Category:

Arthroscopy; Ankle; Arthroscopy

Introduction/Purpose:

The Modified Broström Operation (MBO) has been frequently used to treat chronic lateral ankle instability. Recent studies of arthroscopic anterior talofibular ligament (ATFL) repair found that if the ligament is detached at the fibular attachment or there is sufficient remnant tissue, it can be directly repaired using suture anchors. In this study, ATFL injuries were classified and the feasibility of arthroscopic ATFL repair according to injury type was determined. The diagnostic validity of magnetic resonance imaging (MRI) of ATFL injuries was investigated by comparing MRI and arthroscopic findings.

Methods:

The 197 ankles (93 right, 104 left; 12 bilateral) of 185 patients (90 men and 107 women; mean age, 33.5 years, range: 15-68 years) were treated between September 2015 and October 2019. All patients underwent arthroscopic MBO after a diagnosis of chronic lateral ankle instability. ATFL injuries were classified according to their grade and arthroscopically determined location (type 2: partial rupture, type 3A: fibular detachment, type 3B: talar detachment, type 3C: midsubstance rupture, type 3D: absence of ATFL, type 3E: os subfibulare). Two musculoskeletal radiologists blinded to the surgical findings evaluated all of the ankle injuries and classified them as described above. An oblique-coronal MRI sequence was used to improve diagnostic accuracy.

Results:

The kappa value for interobserver reliability was 0.82 (95% confidence interval [CI], 0.76-0.88), indicating excellent interobserver reliability. The kappa value for the agreement between the arthroscopic findings and MRI findings was also high (0.85; 95% CI, 0.79-0.91). Among the 197 injured ankles, according to ankle arthroscopy, 67 were type 2 (34%), 28 were type 3A (14%), 13 were type 3B (7%), 29 were type 3C (15%), 26 were type 3D (13%), and 34 were type 3E (17%).

Conclusion:

In this study, arthroscopic ATFL repair was feasible in ~14% of ATFL injuries related to chronic lateral ankle instability. The ATFL classification system proposed herein could help surgeons to determine treatment options before surgery in patients with ATFL injuries, and even evaluate acute injury. Our results also supported the use of MRI for diagnosing ATFL injuries and showed that it is an informative tool during the preoperative period.
Comparison of Midterm Outcomes Between the Intramedullary Fibular Nail and the Locking Plate for the Treatment of Unstable Ankle Fractures in Active Young Patients
Authors: Choi Seung-myung , Cho Byung-Ki
Published: January 2022

Category:

Trauma; Ankle

Introduction/Purpose:

We aimed to compare the midterm radiological and clinical outcomes between closed reduction and internal fixation (CRIF) using the fibular intramedullary nail (IMN) and open reduction and internal fixation (ORIF) using plates for the treatment of unstable ankle fractures in active young patients.

Methods:

In this retrospective cohort study, 204 patients treated with CRIF using the fibular IMN (94 patients) or ORIF using the locking plate (110 patients) were included after at least 3 years of follow-up. The mean patient age was 41.4 years. Radiographic evaluation included the quality of reduction assessed by plain radiography and the three-dimensional (3D) reconstruction model using the CT scan images as well as the development of posttraumatic ankle osteoarthritis (PTOA) assessed by weightbearing plain radiography. Clinical evaluation included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Olerud and Molander score (OMAS), the Foot and Ankle Outcome Score (FAOS) and visual analog scale (VAS) pain score as well as complications.

Results:

In an assessment by both plain radiography and the 3D reconstruction model, the fair or poor reduction was more observed in the IMN group than in the ORIF group at final follow-up (P <.001). Poor reduction in the IMN group was significantly related to Weber type C, pronation type injury, and comminuted fibular and trimalleolar fractures (P <.001). PTOA was observed in 21.3% in the IMN group compared to 9.1% in the ORIF group (P =.024). There were no significant differences in clinical outcomes between the 2 groups. There were signiﬁcantly fewer postoperative complications in the IMN group than in the ORIF group (9.5% vs 39%, P <.001).

Conclusion:

Surgeons should consider ORIF for unstable ankle fractures in active young patients with Weber type C, pronation type injury, and comminuted fibular and trimalleolar fractures.
Risk Factors for Complications Associated with Minimally Invasive Medial Displacement Calcaneal Osteotomy
Authors: Coleman Michelle M. , Thompson John , Bean Bryan , Guyton Gregory P.
Published: January 2022

Category:

Hindfoot

Introduction/Purpose:

Several minimally invasive medial displacement calcaneal osteotomy (MIS MDCO) techniques have been described utilizing differing methods for creating the osteotomy. However, there are few clinical reports of the safety profile and outcomes after percutaneous MDCO procedures. The purpose of this study was to describe short-term outcomes and complications associated with MIS MDCO for the correction of hindfoot valgus deformities.

Methods:

A retrospective study was conducted of all patients who underwent consecutive minimally invasive MDCO for the treatment of a hindfoot valgus deformity by a single fellowship-trained foot and ankle orthopaedic surgeon from September 2013 to August 2018. Demographic data, treatment data, and complications were recorded from the electronic medical record for the duration of the patient's follow-up. Univariate statistics were used to determine the relationship between complications and demographic/treatment variables. A p<0.05 was considered significant.

Results:

Patients who underwent 189 MIS MDCO procedures were included in the study. Median follow-up was 12 months (interquartile range, 7 to 25 months). Osteotomy healing complications were present in 7% of cases. A 12-month cluster of osteotomy healing complications was observed. Healing complication rates were 28% during the cluster and 0.7% outside of the cluster. Osteotomy healing complications were significantly associated with higher American Society of Anesthesiologists (ASA) classification, female sex, current tobacco use, and higher body mass index (BMI). Healing complications were not associated with osteotomy technique (saw vs. burr) or fixation type. Other complications included wound dehiscence (3%), surgical site infection (2%), transient nerve symptoms (6%), and persistent nerve symptoms (2%). Nerve symptoms were significantly associated with an increased number of concomitant procedures.

Conclusion:

Patients with higher ASA classification, current tobacco use, and higher BMI were at higher risk for osteotomy healing complications after minimally invasive MDCO procedures. Patients were also more likely to develop nerve complications with more extensive surgical procedures. These findings may be useful for surgeons when counseling patients regarding their surgical risks and when optimizing their comorbidities preoperatively.
Talar Osteoperiostic Grafting from the Iliac Crest (TOPIC): Return to Sports Outcomes of A Novel Press-Fit Surgical Treatment for Large Talar Osteochondral Lesions
Authors: Dahmen Jari , Rikken Quinten , Stufkens Sjoerd A. , Kerkhoffs Gino
Published: January 2022

Category:

Ankle

Introduction/Purpose:

The purpose of this study was to evaluate the sports outcomes of a new press-fit OATS technique for large primary and secondary talar osteochondral lesions of the talus (OLTs), Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC).

Methods:

The study population included amateur and professional athletes with a talar osteochondral lesion size of at least 10 mm in diameter as measured anteroposteriorly or mediolaterally. The surgical intervention in question was the Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) procedure, which was performed in a press-fit way. Sports outcomes at a minimum of 24 months included return to sports rates, level (return to any level of sports, return to pre-injury levels of sports, and return to performance), including corresponding return to sports times of the aforementioned levels.

Results:

A total of 30 athletes, including 1 professional athlete, were assessed. All patients were available for the follow-up at 24 months post-operatively. The mean follow-up duration was 24 months (SD 4.5). The mean lesion size was 356 mm2. Return to any level of sports rate was 90% (95% CI 83 - 95) with an associated time of 8.4 months (SD 2.3). Return to pre-injury level of sports rate was 72% (95% CI 60 - 83) with an associated time of 9.5 months (SD 3.0). Return to performance was 30% (95% CI 20 - 40) with an associated return to performance time of 12 months (SD 4.6).

Conclusion:

Our study suggests that a TOPIC procedure can be considered a good option in the management of large osteochondral lesions of the talar dome in an active sports population, with adequate return to sports and work outcomes. Further research is required to optimize our surgical technique and show long-term outcomes.
The Routine Use and Cost Analysis of Acid-Fast Bacilli and Fungal Cultures in Foot and Ankle Surgery: A Retrospective Study
Authors: El-Zein Zein S. , Diamond Scott , Bohr Margaret , Baker Erin A. , Fleischer Mackenzie M. , Gehrke Corinn , Fortin Paul T. , Vaupel Zachary M.
Published: January 2022

Category:

Other; Diabetes

Introduction/Purpose:

Infections pertaining to orthopaedic surgery play a major role in patient morbidity and increased healthcare-associated expenses. In the setting of foot and ankle surgery for infection, it is common practice to send acid-fast bacilli (AFB) and fungal intraoperative cultures, although there is no standard protocol in place. In this study, the rate of positive AFB and fungal cultures and associated costs in a consecutive series of foot and ankle surgeries was retrospectively assessed.

Methods:

Under an IRB-approved protocol, CPT codes were used to identify 447 procedures in 320 patients, who underwent foot and ankle surgery for infection by fellowship-trained foot and ankle orthopaedic surgeons at a Level 1, private, academic hospital from 2014 to 2019. A medical records review was performed to collect microbiology and patient demographic data. Materials and labor cost data, which was provided by the institution, was used to quantify a total culture cost.

Results:

In this series, there were 185 male and 135 female patients with an average age of 57 years (range, 10-105) and average BMI of 31 kg/m2 (range, 13-56). No patients had positive AFB cultures and 20 patients (7.5%) had positive fungal cultures. There were 434 AFB and 525 fungal cultures performed during these procedures. Based on total cultures performed, there were 0% (0/434) AFB and 5% (26/525) fungal culture positivity rates. The total intra-institutional cost (i.e. labor and materials) for AFB cultures was $23,967. The total labor/materials cost for negative and positive fungal cultures was $12,428 and $2,371, respectively. The total labor/materials cost for all the cultures obtained over the time frame of our study was $38,767.

Conclusion:

This study highlighted low rates of positive AFB and fungal cultures in the orthopaedic foot and ankle surgery service in a 6-year retrospective review, as well as substantial institutional costs of routine use of intraoperative cultures. While this series included cases from three fellowship-trained foot and ankle orthopaedic surgeons, this study will be expanded to analyze AFB and fungal culturing practices and cost in other orthopaedic subspecialties. Creating and implementing a standardized protocol may achieve cost effectiveness of cultures without diminishing patient outcomes.
Sesamoidectomy Utilizing a Medial Approach with a Bur: Patient Outcomes and Early Complications
Authors: Engasser William M. , Coetzee J. Chris , Seybold Jeffrey D. , Den Hartog Bryan D. , Ebeling Patrick B. , Raduan Fernando C. , Seiffert Kayla
Published: January 2022

Category:

Midfoot/Forefoot; Sports

Introduction/Purpose:

Patients with pathology of the sesamoids can have significant pain and disability both with activities of daily living and high impact athletic movements. Sesamoidectomy is a widely used procedure for patients who fail conservative treatment measures. Traditional dorsal or plantar approaches for sesamoidectomy have shown to successfully alleviate pain but complications are noted, including hallux varus deformity, painful plantar incision, and clawing of the hallux. Additionally, the dorsal approach is technically difficult because of poor visualization, which can lead to unnecessary disruption of important plantar ligamentous structures. An alternative medial approach using a bur provides many advantages compared to traditional approaches.

Methods:

This was a retrospective chart review of patients undergoing sesamoidectomy using a bur with a medial approach to the sesamoid metatarsal articulation. Data collected included patient demographics, radiographic analysis, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), Visual Analog Scale (VAS), patient satisfaction, and complications.

Results:

In patients (10 feet) with an average age of 36.5 (range, 13-77) years were analyzed. Six patients underwent medial sesamoidectomy, three underwent lateral sesamoidectomy, and one patient underwent excision of both medial and lateral sesamoids using a bur. The average latest follow up was 11.9 months. Scores were improved from pre-operatively to most recent follow-up for VR-12 Physical (29.43 vs 53.86), FAAM ADL (48.8 vs 94.1 points), FAAM Sports (7.8 vs 87.4 points), and VAS (57.8 vs 8.6). Patient satisfaction with the treatment was 96.4%. There were zero complications or additional procedures performed.

Conclusion:

In this series, sesamoidectomy utilizing a medial approach with a bur provided excellent pain relief, zero complications, and significantly improved outcome scores at early follow up. The medial approach is familiar to orthopedic foot and ankle surgeons, provides adequate exposure, and eliminates the possibility of a painful plantar incision. Furthermore, this technique allows for maintenance of the plantar plate, flexor hallucis brevis (FHB) tendon, and all other ligamentous structures that attach to the sesamoids. Larger studies with longer term follow up are needed to further our knowledge on this surgical technique.
Extended Chevron Osteotomy in the Management of Mild-Severe Hallux Valgus: Clinical Results in a Long-Term Follow-Up
Authors: Espinosa-Uribe Abraham , Garza Jaime I. Ortiz , Terán Jorge Luis R. , Garza Fernando Alfredo F. , Carranza-Cantú Eduardo R. , Gutierrez Jorge A.
Published: January 2022

Category:

Bunion

Introduction/Purpose:

Hallux Valgus (HV) is a forefoot complex deformity. More than 200 surgical techniques for its treatment have been described, Chevron Osteotomy and its modifications represent a widely accepted highly reproducible option in the HV treatment. Since described in 1991 the Extended Chevron Osteotomy (ECO) represents a distal osteotomy with a plantar diaphyseal extension. Biomechanically the advantages it offers are even greater stability, early consolidation by increasing the contact surface and correcting the facet with a minimum shortening. It also offers lower morbidity and a lower rate of complications. However, there is controversy regarding long-term follow-up for most of these procedures. This study aims to demonstrate ECO for the correction of moderate to severe HV in a long-term follow-up.

Methods:

We reviewed 25 feet (20 patients) with moderate to severe HV in which the Intermetatarsal Angle (IMA) greater than 16⁰. The mean age was 64 years and the patients were followed by a mean of 30 (14 to 59) months. Additionally, 8 patients (N=12 feet) were followed with a mean of 68 (50 to 86) months. The following scales were applied before and after surgery: the functional scale of the American Orthopaedic Foot & Ankle Society (AOFAS) for the forefoot and the Visual Analog Scale (VAS). In the same way, the radiographic measurements corresponding to HV were made pre and postoperative. This research study was approved by our institution and hospital research ethics committee. Additionally, all the patients were reviewed under the Mexican law NOM-004-SSA3-2012 regarding Clinical file and privacy rights.

Results:

In the AOFAS for forefoot and VAS scales an improvement of 51.28 (CI95% 46.34 to 56.21) -6.08 (CI 95%-6.65 to -5.50) points, respectively. Regarding the angular values, the correction was -9.08⁰ (CI 95% -10.29 to -7.86) for the IMA. There was one foot with post-surgical infection (4%) and two feet (8%) with transfer metatarsalgia. Additionally, we documented a mean AOFAS forefoot score of 90.16 (+- 5.27) and a mean of 0.8 (+- 0.4) VAS scale during a second follow-up period of 68 months (range from 50 to 86 months) in 8 patients (N=12 feet). Statistically significant differences (p <0.05) were documented by the means of these long-term follow-up periods in the AOFAS score and VAS scale regarding the pre-surgical scores.

Conclusion:

According to the results obtained, we consider that the ECO technique for the treatment of moderate to severe HV provides significant functional improvement and angular correction (p <0.05) and good clinical outcomes on both long-term follow-up periods. ECO technique represents a highly reproducible option when performing HV correction.
Long-Term Outcomes of Autograft Osteochondral Transplantation for Osteochondral Lesions of the Talus: Eight to Twelve Years Follow-Up
Authors: Gianakos Arianna L. , Mercer Nathaniel P. , Dankert John , Kennedy John G.
Published: January 2022

Category:

Ankle

Introduction/Purpose:

Autologous osteochondral transplantation (AOT) is a replacement strategy used to treat osteochondral lesions of the talus (OLT), typically reserved for the treatment of lesions of larger sizes, highly cystic lesions, or in patients who have failed previous treatment. The purpose of this study was to evaluate the long-term (>8 years) clinical and radiographic outcomes of AOT for the treatment of OLT in the form of a retrospective case series.

Methods:

Patients who underwent AOT between 2006 and 2008 were evaluated. Functional outcomes were assessed pre- and post-operatively using the Foot and Ankle Outcome Score (FAOS), and Short-Form-12 (SF-12) general health questionnaire. The most recent post-operative MRI was evaluated with the modified Magnetic resonance Observation of Cartilage Repair Tissue (MOCART) score.

Results:

Twenty-eight patients who underwent AOT were included and evaluated at a mean follow-up of 122.9 months. The mean FAOS pain subscale improved from 52.7 to 82.9 and the mean SF-12 improved from 30.3 to 58.3 at final follow-up (both, p < 0.01). The mean FAOS pain subscale then decreased to 77.6 at final follow-up, but this decrease was not statistically significant (p=0.293). At the final follow-up, the mean FAOS subscale scores of symptoms, pain, daily activities, sports activities, and quality of life were 66.6, 77.6, 86.0, 60.4, and 53.6, respectively. The mean VAS score was 2.2 at a final follow-up. The mean MOCART score was 83.8 with a mean MRI follow-up of 82.8 months. Ten patients (35.7%) had additional surgery, with the most common procedure being arthroscopic anterior ankle debridement. One patient failed AOT and developed osteoarthritis of the ankle requiring a total ankle replacement.

Conclusion:

AOT appears to be an effective treatment for OLT with good long-term clinical and radiographic outcomes. Secondary procedures were typically minor and the overall clinical failure rate was low.
Standardization of the Foot Sagittal Axis for Measurement of Hindfoot Alignment Using Weight- Bearing Computed Tomography (WBCT)
Authors: Godoy-Santos Alexandre L. , Pires Eduardo A. , Lobo Carlos , Netto Cesar de Cesar , Fonseca Fabio C. , Sposeto Rafael B.
Published: January 2022

Category:

Hindfoot; Other

Introduction/Purpose:

The radiographic measurement of hindfoot alignment (HA) suggested by Saltzman, worldwide accepted, uses the medial aspect of the foot as the sagittal axis. When defining the medial face of the foot as its axis, the adduction and abduction deformities of the forefoot are disregarded, making it necessary to rotate the ankle internally or externally to acquire the radiographic image according to Saltzman protocol. The emergence of weight-bearing computed tomography (WBCT) allowed immeasurable advancements for a better understanding of the joints relations of the foot and ankle under stress. Previous studies using this technology adopted several sagittal axes to measure HA. Our hypothesis is that the adduction observed in the forefoot of the cavovarus feet illusively accentuates the real deformity of the hindfoot.

Methods:

Two evaluators calculated the HA of twenty-eight feet - 14 cavovarus and 14 neutral or slightly valgus (control group) - in three different sagittal axes (second metatarsal axis, calcaneus - second metatarsal axis and talar dome axis). Measurements were compared by Student's t-test after normality test by Shapiro-Wilk method. Observers' agreement was evaluated by intraclass correlation coefficient (ICC). P-values <.05 were considered significant.

Results:

We found excellent intra-observer (0.93) and inter-observer (0.9) agreements following the measuring assessment. The average Foot and Ankle Offset (FAO) of the cavovarus feet group was -3.35 (-0.64 - -7.01), while the control group was 2.01 (-1.3 - 6.4). The mean difference in HA when comparing the axis of the talar dome with the axis of the second metatarsal was 9.88 ° (3.1 ° - 17 °), while in the control group the mean difference was 3.16 (0.2 ° - 7.5 °). All of these data showed statistical significance.

Conclusion:

As a great variability was observed in the measurements of hindfoot alignment in the cavovarus foot group in the sagittal axes analyzed, this article suggests standardizing the measurement of hindfoot alignment using the talar dome axis. In addition, it becomes possible to quantify adaptations of the hindfoot secondary to modifications of the forefoot in an isolated manner.
Epidemiology of Ankle Sprain in the Military: A Systematic Review of Literature
Authors: Goodrich Ezra , Morris Brandon L. , Hermanns Christina , Herda Ashley A. , Tarakemeh Armin , Vopat Bryan G.
Published: January 2022

Category:

Ankle; Sports

Introduction/Purpose:

Ankle sprains occur frequently within the general population, however, the extent to which this injury impacts the military population remains unknown. The purpose of this study was to systematically review the literature describing ankle sprains in the military population.

Methods:

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, articles were retrieved from PubMed, Embase, and Cochrane Library using the search terms 'military,' 'epidemiology,' 'incidence,' 'prevalence,' 'ankle sprain,' and 'ankle instability.' Inclusion criteria consisted of active military duty status, English language, and levels of evidence I-IV.

Results:

Nineteen articles were included, representing 1,671,763 study participants from six countries and four branches of the military. Among the ten studies that reported ankle sprain incidence in terms of overall injury incidence, seven studies reported ankle sprain as the most common injury, with an incidence ranging from 2.20% to nearly one third of all injuries in the paratrooper population. Ankle sprain was also reported as the most common injury among lower extremity injuries in two studies, with incidences of 35% and 38.7%, respectively. Ankle sprain incidence rate per 1,000 person-years was reported in four studies, with values ranging from 15.3 to 58.4. Incidence rate was also reported for males and females separately in three of these studies, ranging from 33.89 to 52.7 for males, and 41.17 to 96.4 for females. The number of days lost to ankle sprain ranged from one to eight days per servicemember.

Conclusion:

Ankle sprains are among the most prevalent injuries within the military population, with a reported incidence that is higher for females than males. This injury results in time away from active duty, which impacts overall readiness within the military system.
Prevalence of Asymptomatic Bone Marrow Edema in the Talus in Professional Ballet Dancers: Preliminary Data from 2-Year Prospective Study
Authors: Harlow Ethan R. , Khambete Pranav , Ina Jason , Miskovsky Shana N.
Published: January 2022

Category:

Ankle; Sports

Introduction/Purpose:

Bone marrow edema (BME) appears as increased interstitial fluid accumulation within the bone marrow on magnetic resonance images (MRI). Asymptomatic BME has been found incidentally and described in competitive athletes, long- distance runners, and patients with altered biomechanics where the true etiology remains unclear. The natural history and clinical implications of asymptomatic BME in the elite and actively-competing athlete is not well characterized. Moreover, there is debate on how to manage and counsel patients on these findings in a high-risk bone such as the talus. This study presents early data from a prospective enrollment study of professional ballet dancers characterizing the prevalence of asymptomatic BME in the talus.

Methods:

Fourteen (14) professional ballet dancers enrolled in the 2-year prospective, IRB-approved study after informed consent was obtained. Exclusion criteria included: subjects reporting foot and ankle pain or disability on initial preseason evaluation, foot and ankle surgery or injury within the last year prior to evaluation, and any contraindications for MRI. Subjects underwent a physical examination and completed Foot and Ankle Ability Measure (FAAM) and Foot and Ankle Disability Index scores (FADI). Bilateral foot and ankle MRIs without contrast were completed upon study enrollment and interpreted by a blinded, fellowship-trained musculoskeletal radiologist.

Results:

Of 14 professional ballet dancers enrolled in the study, 6 were female, 8 were male, and the mean age was 24.4 years. All dancers reported no pain or disability in their feet and ankles at the time of evaluation and had physical exam findings unremarkable for performance-limiting pathology. Of the 14 dancers, 64% (9) had MRI evidence of talar BME. 6 subjects had bilateral talar BME and 3 had unilateral findings. 53% (8) had BME localized to the posterior process of the talus, 13% (2) localized in the talar body, 13% (2) localized to the talar head and neck, and 20% (3) subjects had pan-talar BME. All subjects had BME seen only on T2 sequences with one patient demonstrating bilateral pan-talar BME on both T1 and T2 sequences. There was no significant correlation using Welch’s unequal variances t-test (α = 0.05) between talar BME and either FADI or FAAM scores.

Conclusion:

These findings demonstrate a high prevalence (64%) of talar bone marrow edema in asymptomatic professional ballet dancers with benign physical exams and normal functional scores. Yet, the long-term clinical significance of these findings are unknown.
Increased Complication Rate Associated with Podiatric Surgery
Authors: Hoch Caroline P. , Scott Daniel J. , Brinton Daniel L. , Maldonado Lizmarie , Gross Christopher E.
Published: January 2022

Category:

Other; Ankle; Bunion; Diabetes; Hindfoot; Midfoot/Forefoot

Introduction/Purpose:

Nationally, there has been an increase in the scope of practice between orthopaedic surgeons and podiatrists. However, there is a paucity of studies in the literature comparing outcomes between orthopaedic and podiatric surgeons in different areas of foot and ankle surgery.

Methods:

A retrospective analysis was conducted using 2016-2017 5% US national sample of the Medicare limited dataset (LDS). This included a total of 527 patients undergoing one of 14 CPT foot and ankle specific codes. Basic demographics, medical comorbidities, and 1-year post-surgical complications were reviewed. One-hundred and eighteen patients were operated on by a podiatrist versus 409 who were operated on by a physician. Mean age was 69. Common procedures included gastrocnemius recession (n=168), ankle fracture open reduction internal fixation (168), and Achilles tendon repair (72). Continuous variables were compared using Wilcoxon-Mann Whitney test and categorical variables with chi-squared test. In addition, a multivariable regression was performed, evaluating the impact of various factors on odds of complication.

Results:

Between cohorts, there were no statistically significant differences in demographics, Charlson Score, COPD, hypothyroidism, hypertension, or obesity. There was a higher rate of peripheral vascular disease in patients treated by a podiatrist versus a physician (8.5% vs. 2.4%; P=.0025). Univariate analysis showed complication rates were higher among podiatrist compared to physicians (29.7% vs. 18.8%; P=.0113). Specifically, there were high rates of complications for bunion correction (4.2% vs. 1.0%; P=.0160), diabetic wound infection (11.0% vs. 1.5%; P<0.0001), and plantar fascia release (7.6% vs. 0.1%; P=.0001). Multivariable logistic regression showed patients operated on by a podiatrist had 84.1% greater odds of suffering a complication than those operated on by a physician (OR: 1.84, 95% CI: 1.15-2.96).

Conclusion:

Surgical treatment of multiple types of foot and ankle conditions by orthopaedic surgeons was associated with lower complication rates when compared with podiatrists. The reasons for these differences are likely multifactorial, but warrants further investigation. Our findings have important implications for policymakers, as well as for large healthcare systems and patients when selecting a treating provider for surgical problems.
Vancomycin Powder Associated with Decreased Surgical Site Infections in Lower Extremity Trauma
Authors: Hoch Caroline P. , Robinson Christopher L. , Robinson Christopher L. , Rovner Alex , Waggett Raines M. , Horn Ryan , Scott Daniel J. , Gross Christopher E.
Published: January 2022

Category:

Ankle; Ankle Arthritis; Arthroscopy; Bunion; Hindfoot; Midfoot/Forefoot; Sports; Trauma

Introduction/Purpose:

The use of intraoperative topical vancomycin powder has recently increased in popularity as a method of theoretically decreasing post-operative surgical site infections; however, there is limited research in orthopaedic trauma to support its use. This study evaluates the use of topical vancomycin powder to decrease post-operative infections following lower extremity trauma. We also investigated socio-demographic factors and medical comorbidities that were associated with post- operative surgical site infections.

Methods:

We conducted a review of 226 patients at a single Level 1 Trauma Center following surgery between the years 2015 and 2020. These patients were treated predominantly by a single fellowship trained foot and ankle orthopaedic surgeon. Demographic factors, medical comorbidities, postoperative infections, and use of vancomycin powder were reviewed. Analysis of 4 groups (no infection, superficial infection, deep infection, or both) was performed using Fischer's exact test and Student t-test. A logistic regression model was utilized to identify independent demographic factors and medical comorbidities that were associated with surgical site infection.

Results:

The final cohort included 221 patients, of which 26 received intraoperative vancomycin powder. There were 23 total post-operative surgical site infections. Of those, 14 infections were superficial, 3 were deep, and 6 were both superficial and deep. All but one of these infections were in patients without vancomycin powder applied. Patients who received intraoperative vancomycin powder were statistically significantly less likely to acquire post-operative surgical site infections than those who did not (1 vs. 22, p=0.031). The one postsurgical site infection with vancomycin use was a deep infection in a patient with chronic kidney disease that had previously undergone three irrigation and debridement surgeries for a gunshot wound. Male sex was the only demographic or comorbidity factor associated with postoperative surgical site infection (p=0.009, OR=4.006).

Conclusion:

We found an association between topical vancomycin use and lower likelihood of developing postsurgical wound infections in lower extremity trauma. This is consistent with similar studies in spinal surgery. In contrast to previous studies, we did not find a significant association between medical comorbidities or demographic factors other than male sex and surgical site infection. Future studies should aim to identify which patients would have the greatest reduction of risk for postsurgical wound infections with the use of intraoperative topical vancomycin powder.
Clinical and Radiological Outcomes of Modified Lapidus Procedures Using 2 Compression Cannulated Screws in Hallux Valgus Deformity
Authors: Im Jemin , Jung Hong-Geun , Lim Jung-Won
Published: January 2022

Category:

Midfoot/Forefoot; Bunion

Introduction/Purpose:

Hallux valgus is common disease. Surgical correction is usually required because, conservative treatment can not correct deformity and lacks evidence for prevention of progression of deformity. Among the various methods for the correction of hallux valgus deformity, the modified Lapidus procedure is known to be performed in less than 10%. The purpose of this study is to investigate the clinical and radiological outcomes of patients who underwent the modified Lapidus method.

Methods:

From January 2010 to December 2019, 34 cases of patients who underwent the modified Lapidus procedure and followed up for at least 6 months were included in the study. For clinical evaluation, VAS score, AOFAS score, and patient satisfaction (very satisfied, satisfied, dissatisfied, very dissatisfied) were used. For radiological evaluation, hallux angle and 1-2 metatarsal angle on anterior and posterior foot x-ray of the weight-bearing were used. Furthermore, rate of bone union and the period until bone union were also evaluated.

Results:

The mean follow-up period was 21.0 (6~108) months. The indications for surgery were: Severe hallux valgus in 30 cases, metatarsus adductus in 17 cases, recurrent hallux valgus in 4 cases, and hypermobility of the first tarso-metatarsal joint in 10 cases. In terms of VAS score, between pre-operation and the last follow-up was significantly improved from 5.8+-2.1 to 1.1+-1.4 (p<0.05), and the AOFAS score from 52.8+-15.0 to 92.3+-9.8 (p<0.05). In terms of patient satisfaction, 33 patients (97.1%) showed overall satisfaction (very satisfied and satisfied). Complications were nonunion in 3 cases (8.8%), incomplete union in 1 case, delayed union in 1 case, and hallux varus in 1 case. There was no additional surgery for these complications. At preoperative and last follow-up, the hallux angle improved from 46.0°+-10.7° to 5.9°+-11.7°, and the 1-2 IMA improved from 18.2°+-5.1° to 5.5°+-4.5°. In the cases excluding complications, the average period to bone union was 3.9(3-8) months.

Conclusion:

In our study, the modified Lapidus method using 2 compression cannulated screws was showed satisfactory clinical, radiological outcomes and relatively satisfactory bone union (91.2%) in a short follow-up. The modified Lapidus method using 2 compression cannulated screws is a considerable option for severe hallux valgus deformity.
Soft Tissue Thickness as a Predictor of Wound Complications after Total Ankle Arthroplasty: A Retrospective Study
Authors: Kalma Jeremy J. , El-Zein Zein S. , Koueiter Denise , Fortin Paul T.
Published: January 2022

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

Periprosthetic joint infection following total ankle arthroplasty (TAA) is a serious complication often related to the surrounding soft tissue envelope which can lead to poor patient outcomes. The purpose of this study was to determine the relationship between wound complications following TAA and the overlying soft tissue envelope thickness using standardized radiographic soft tissue measurements. We hypothesized that a smaller soft tissue thickness would correlate with an increase in complications.

Methods:

197 patients who underwent primary TAA between October 2014 and December 2018 at a single institution with preoperative radiographs and 6 months of follow up were analyzed. We measured the horizontal distance from the posterior tibia to the overlying anterior skin surface and tibial width 2 cm above the tibiotalar joint on lateral ankle films. The ratio of the soft tissue thickness to the tibial width was calculated and named the ankle soft tissue thickness ratio (ASTR). The patients were divided into 2 groups based upon their ASTR. There were 102 patients in the low ASTR group (ASTR <1.38) and 95 patients in the high ASTR group (ASTR >1.38). Minor complications involved office-based treatment and/or oral antibiotics. Major complications involved surgical intervention. A chi-squared test determined complication incidence variance amongst patients in each ASTR group and an independent t-test determined mean ASTR difference.

Results:

Twenty-nine wound complications (14.7%) were identified among 197 patients, 24 (82.8%) minor and 5 (17.2%) major. There were 19 wound complications in the low ASTR group (17 minor and 2 major) and 10 wound complications in the high ASTR group (7 minor and 3 major). Complications were more frequent in the low ASTR group compared to high ASTR group, though not statistically significant (18.6% vs. 10.5%, P=0.158). There was no difference in the mean ASTR measurement between patients with and without wound complications (1.36 vs. 1.40, P=0.093).

Conclusion:

This study does not demonstrate a statistically significant difference in post-operative TAA wound complications based on standardized radiographic soft tissue thickness measurements. Though not statistically significant, complications were more frequent in patients with a lower ASTR. Lower surgical site soft tissue thickness may be a predictor of increased risk for wound complications following TAA however further research including studies with larger patient populations is needed to make this determination.
Calcaneal Bone Morphology in Association with Bone Mineral Density Status: A Cadaveric Study
Authors: Keeratiruangrong Jakkrit , Vaseenon Tanawat , Namwongprom Sirianong , Saengsin Jirawat
Published: January 2022

Category:

Basic Sciences/Biologics; Ankle; Other

Introduction/Purpose:

Displaced intra-articular calcaneal fractures are mostly treated by reduction and internal fixation. The calcaneal cortical thickness and regional bone density play an important role in the stability of the fixation construct. This study aims to assess the relationship between calcaneal bone morphology and bone mineral density (BMD) status.

Methods:

Seventeen fresh cadaveric specimens underwent a BMD scan at the femoral neck and were later classified according to WHO criteria into three groups, including normal five specimens, osteopenic six specimens, and osteoporotic groups six specimens. The calcaneus bone of each specimen was then dissected and evaluated for the bone morphology. The sustentaculum tali of the calcaneus was divided into anterior, middle, and posterior segment. The superior, inferior, and posterior cortices of the calcaneus were equally divided from medial to lateral into five segments and from anterior to posterior into three segments (Figure 1). The cortical thickness (mm) was measured at the center of each divided fragment. The calcaneal bone density (g/cm3) was quantified at three regions of interest (ROI), including superior, inferior, and posterior ROI (Figure 2).

Results:

The calcaneal cortical thickness and calcaneal bone density of each fragment or each ROI were demonstrated as the median and interquartile range (IQR) (Table 1-5, Figure 3). The overall cortical thickness and calcaneal bone density values were significantly lower in the osteopenic or osteoporotic group when compared with the normal BMD group. Notably, the cortical thickness of the normal group at the lateral one-fifth and/or lateral two-fifth fragment of the superior, posterior, and inferior cortices of the calcaneus were not significantly different when compared with the osteopenic or osteoporotic group. When focusing at the sustenaculum tali, the posterior cortical thickness was significantly different only when compared between the normal and osteoporotic groups. Inter and intra-rater reliability of the outcome measurements were all excellent (>0.80).

Conclusion:

The cortical thickness of the posterior aspect of the sustenaculum tali, as well as the cortical thickness of the lateral one-fifth and lateral two-fifth of the calcaneus, were less likely effected by the decrease in BMD status. However, the anterior part of sustenaculum tali, anteromedial area of superior and inferior cortex and inferomedial area of posterior cortex are thicker than others.
A Historical Analysis of Randomized Controlled Trials in Pediatric Orthopaedic Foot and Ankle Surgery
Authors: Khurshed Abdulaziz , Abuhantash Monther , Kay Jeffrey , Habib Anthony S. , Kishta Waleed , de SA Darren
Published: January 2022

Category:

Ankle; Bunion; Lesser Toes; Midfoot/Forefoot; Trauma

Introduction/Purpose:

The primary objective of this systematic review was to comprehensively assess the quality of reporting of randomized controlled trials (RCTs) relating to pediatric orthopaedic foot and ankle conditions. Additionally, this current study looked at factors related to the quality of the RCTs and trends in the quality of reporting over time

Methods:

This systemic review was performed according to an agreed predefined protocol and conducted according to Preferred Reporting Items for Systemic Reviews and Meta-analyses (PRISMA) statement standards. PubMed, Ovid (MEDLINE) and Embase were searched for all RCTs on foot and/or ankle surgery from the database inception until March 31, 2020. The quality of reporting was evaluated using the Detsky quality index and the Consolidated Standards of Reporting Trials (CONSORT) checklist for reporting trials of nonpharmacologic treatments. A multivariate regression analysis was used to assess predictors of quality reporting.

Results:

The online search yielded 3,697 articles, 22 of which met the inclusion criteria and were assessed for quality of reporting. The earliest identified RCT was published in 1991. Close to 70% of all RCTs have been produced over the past 10 years (since 2010), and over 90% have been published in the past 20 years (since 2000). There has been a significant increase in the number of RCTs published over time (p=0.042). The mean (SD) Detsky score across all included studies was 69.2% (13.8%). Nine (41%) of the studies were considered 'high-quality' with a standardized Detsky score greater than or equal to 75%. The strongest predictor of quality reporting was the inclusion of a CONSORT flow diagram (β-coefficient: 18.4, p=0.0013).

Conclusion:

Despite an increase in the quantity of pediatric F&A RCTs over time, the quality has not significantly improved. The use of a CONSORT flow diagram is a strong predictor of high-quality reporting. We encourage investigators to devote more efforts in conducting high-quality RCTs in pediatric orthopaedic foot and ankle, as these are scarce in the literature.
Radiographic Evaluation of the Normal Distal Tibiofibular Syndesmosis in Neutral to Dorsiflexion on Weight-Bearing
Authors: Kim Ki Chun , Lee Kyung-tai , Young Kiwon
Published: January 2022

Category:

Ankle; Sports

Introduction/Purpose:

Reliable landmarks of ankle syndesmosis change in various position is important for managing ankle injury. The purpose of our study was to investigate and compare radiographic landmarks of normal ankle in various positions.

Methods:

The study involved both ankle radiographs of 30 subjects (15 males, 15 females) without clinical or radiographic abnormality. Tibiofibular clear space (TFCS) and tibiofibular overlap (TFO) were measured on anteroposterior (AP) and mortise radiographs in non-standing (NS) and standing (S) neutral and dorsiflexion 10 (DF10) and 20 degrees (DF20). The radiographic measurements were used to calculate means, standard deviations, and intra- and interobserver reliabilities, and compare TFCS and TFO in various positions and genders.

Results:

On the AP view, the mean TFCS in NS, S, DF10, and DF20 positions were 4.00+-0.97, 4.00+-0.83, 4.35+-0.95, and 4.45+-0.89 and the mean TFO on the same positions were 6.58+-2.27, 4.27+-1.90, 3.44+-1.96, and 2.38+-1.91. On the mortise view, the mean TFCS in NS, DF10, and DF20 positions were 3.62+-0.88, 4.08+-0.86, and 3.88+-0.97 and the mean TFO on the same positions were 3.57+-2.13, 2.31+-1.77, and 3.57+-2.14. The reliabilities in all positions except TFCS on some positions were excellent. No measurement was significantly different between females and males except TFO in NS on mortise view (p=0.006) and DF10 on AP view (p=0.032).

Conclusion:

Increase of TFCS and decrease of TFO on AP view reflects syndesmosis change from non-standing to DF20 on standing. Clinically, Effect of weight-bearing and reliability of TFO should be considered.