bluuebunny/crossref_metadata_2025 huggingface dataset:
How Has Opioid Prescribing in Total Ankle Arthroplasty Changed with Time and State Legislation? A National and State-Level Analysis
Authors: Cunningham Daniel J. , Wixted Colleen , Allen Nicholas B. , Hanselman Andrew , Adams Samuel B.
Published: January 2022

Category:

Ankle; Ankle Arthritis

Introduction/Purpose:

Total ankle arthroplasty (TAA) is an increasingly-utilized treatment for ankle arthritis, and opioids are commonly used as part of perioperative pain control. However, many states have enacted opioid-limiting legislation to reduce perioperative opioid prescribing. The aim of this study was to evaluate the impact of time and state legislation on perioperative opioid prescribing in TAA.

Methods:

This study is a retrospective, observational review of 90-day perioperative opioid prescribing in 1,829 patients undergoing TAA throughout the United States using a large insurance database. Initial and cumulative volumes and rates of opioid prescription filling were recorded along with baseline patient and operative characteristics. Dates of state legislation enactment were also recorded. Student t-tests, analysis of variance (ANOVA), and multivariable linear and logistic regression were utilized to analyze the impact of time and state legislation on opioid prescription filling.

Results:

In the 90-day perioperative time period, initial and cumulative opioid prescription filling in oxycodone 5-mg equivalents has decreased significantly from 2010 (63.8 initial and 163.3 cumulative oxycodone 5-mg equivalents filled) to 2019 (41.1 initial and 67.2 cumulative oxycodone 5-mg equivalents filled). States with opioid-limiting legislation saw larger and more significant reductions in initial and cumulative opioid prescription filling pre-act to post-act (63.3 to 50.6 oxycodone 5-mg equivalents filled with legislation vs 61.4 to 51.9 oxycodone 5-mg equivalents filled without legislation initial and 146.4 to 93.3 oxycodone 5-mg equivalents filled with legislation vs 125.1 to 108.6 oxycodone 5-mg equivalents filled without legislation cumulative).

Conclusion:

This study demonstrates that orthopaedic surgeons in states with opioid-limiting legislation have responded by significantly reducing 90-day perioperative opioid prescribing in TAA. These results encourage states without legislation to enact opioid-specific laws to reduce opioid prescribing.
Regional Anesthesia Decreases Early Perioperative Opioid Demand but Increases Late Opioid Demand in Ankle and Distal Tibia Fracture Surgery
Authors: Cunningham Daniel J. , Paniagua Ariana , DeLaura Isabel , Zhang Gloria X. , Kim Billy I. , Kim Jonathan , Lee Terry , LaRose Micaela , Adams Samuel B. , Gage Mark
Published: January 2022

Category:

Ankle; Trauma

Introduction/Purpose:

Regional anesthesia (RA) is commonly used in ankle and distal tibia surgery. However, the pragmatic effects of this treatment on inpatient and outpatient opioid demand are unclear. The hypothesis was that RA would decrease inpatient opioid consumption and have little effect on outpatient opioid demand in patients undergoing ankle and distal tibia fracture surgery.

Methods:

All patients ages 18 and older undergoing ankle and distal tibia fracture surgery at a single institution between 7/2013 and 7/2018 were included in this study (n=1,310). Inpatient opioid consumption (0-72 hours post-operative) and outpatient opioid prescribing (1-month pre-operative to 90-days post-operative) were recorded in oxycodone 5-mg equivalents (OE's). Adjusted models were used to evaluate the impact of RA on inpatient and outpatient opioid demand.

Results:

Adjusted models demonstrated decreased inpatient opioid consumption in patients with RA (12.1 estimated OE's without RA vs 8.8 OE's with RA from 0-24 hours post-op, p<0.001) but no significant difference after that time (9.7 vs 10.4 from 24-48 hours post-op, and 9.5 vs 8.5 from 48-72 hours post-op). Estimated cumulative outpatient opioid demand was significantly increased in patients receiving RA at all timepoints (112.5 OE's without RA vs 137.3 with RA from one-month pre-op to two- weeks, 125.6 vs 155.5 OE's to 6-weeks, and 134.6 vs 163.3 OE's to 90-days, all p-values for RA <0.001). Figure demonstrates a histogram of the inpatient opioid consumption in patients with and without RA.

Conclusion:

In ankle and distal tibia fracture surgery, RA was associated with decreased early inpatient opioid demand but significantly increased outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These findings provide information on the real-world impact of RA and temper enthusiasm for perioperative nerve blockade.
State Regulation Positively Impacts Opioid Prescribing Patterns in Ankle Fracture Surgery: A National and State-Level Analysis
Authors: Cunningham Daniel J. , Blatter Michael , Adams Samuel B. , Gage Mark
Published: January 2022

Category:

Ankle; Trauma

Introduction/Purpose:

The impact of time and state regulation on opioid prescribing in orthopaedic trauma is not well known. The purpose of this study is to evaluate the impact of time and state-level opioid legislation on 90-day perioperative opioid prescribing in ankle fracture surgery from 2010 - 2019.

Methods:

This is a retrospective, cohort study using a national insurance database including commercial insurance, Medicare, Medicaid, and cash pay patients to evaluate 90-day perioperative opioid prescription filling in 40,286 patients ages 18 and older undergoing Current Procedural Terminology codes 27766, 27769, 27792, 27814, 27822, and/or 27823 between 2010 and 2019 in all 50 United States. The primary study outcome was initial and cumulative 90-day perioperative opioid prescription filling and rates of filling and refills.

Results:

Mean first prescription volume has not changed dramatically from 2010 (37 oxycodone 5-mg pills) to 2019 (33.3 oxycodone 5-mg pills). However, cumulative prescriptions within the 90-day perioperative timeframe have decreased considerably from 2010 (128.5 oxycodone 5-mg pills) to 2019 (70.4 oxycodone 5-mg pills, p<0.001), and cumulative prescription filling in years 2018 and 2019 was significantly less than in 2010. Legislation targeting duration or duration and volume had the largest impacts on initial and cumulative opioid prescribing (approximately 14-22 fewer oxycodone 5-mg pills filled in states with legislation compared to states without legislation, p<0.001). The figure shows state-level pre-act and post-act cumulative 90-day opioid prescribing in ankle fracture surgery.

Conclusion:

In ankle fracture surgery, cumulative opioid prescribing has decreased dramatically over time. In addition, states with opioid prescribing legislation had larger reductions in perioperative opioid prescribing compared to states without opioid legislation. Legislation targeting duration or duration and volume had the largest impacts on opioid prescribing.
The Incidence of Osteochondral Lesions after Isolated Syndesmotic Injury: A Systematic Review and Meta-Analysis
Authors: Dahmen Jari , Stufkens Sjoerd A. , Kennedy John G. , Kerkhoffs Gino
Published: January 2022

Category:

Ankle

Introduction/Purpose:

To determine the incidence of osteochondral lesions of the ankle (as well as their location and size) incidence after isolated syndesmotic injuries.

Methods:

A literature search was performed to identify studies published using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the MINORS criteria. Available full-text studies published in English, Dutch and German were eligible for inclusion. OCL incidence as well as location after isolated syndesmotic injuries were extracted from the original articles and subsequently pooled. Whenever possible, OCL incidence per syndesmotic timing (Acute/subacute/chronic) was calculated, pooled and compared with a random effects model.

Results:

Nine articles were included with 694 syndesmotic injuries. Overall (O)CL incidence was 21.6% (95% CI 18.7 - 24.8%). This rate was 15.9% (95% CI 12.2 - 20.4), 11.4% (95% CI 5.9 - 21.0), and 54.2% (95% CI 44.2-63.8) for the acute, sub-acute, and chronic isolated syndesmotic group, respectively, thereby showing a significant difference in incidence rate between the acute and chronic syndesmotic injuries group (p<0.05). Concerning overall (O)CL incidence, 74.6% (95% CI 65.9 - 81.2) of the lesions were located on the talar dome and 16.7% (95% CI 10.9 - 24.6%) of the lesions were located on the distal tibia (p<0.05). (O)CL size was not reported in any of the studies. Concerning location difference between the acute and chronic group, the incidence of talar (O)CLs was higher in the acute group than in the chronic group (100% 95% CI 93.9 - 100% vs. 46.8% 95% CI 33.3 - 60.8%.) (p<0.05).

Conclusion:

This meta-analysis showed that (osteo)chondral lesions of the ankle are frequently associated with isolated syndesmotic injuries. (O)CL incidence was significantly higher in the chronic isolated syndesmotic injuries group compared to the acute group (54% versus 16%). The vast majority of (O)CLs were located on the talar dome.
Homolateral Lisfranc Fracture/Dislocation of 1st - 5th Metatarsals in a Collegiate Quarterback: A Case Study
Authors: Dayton Steven R. , Krautmann Kurt M. , Boctor Michael , Tjong Vehniah K. , Kadakia Anish R.
Published: January 2022

Category:

Sports; Midfoot/Forefoot

Introduction/Purpose:

Lisfranc injuries encompass a spectrum of injuries to the tarsometatarsal (TMT) joint complex from ligamentous sprains to fractures with dislocation. While studies have shown it is possible to return to sport (RTS) after low- energy injuries, no literature exists demonstrating RTS after homolateral fracture/dislocation of all 5 metatarsals. We present a novel surgical technique for repair of homolateral Lisfranc fracture/dislocation of the 1st-5th metatarsals. Fusion of the 2nd and 3rd TMT joints provides stability of the middle column. Internal bracing of the 1st TMT joint gives stability while preserving greater physiologic motion in a high-level athlete.

Methods:

A dorsal approach is used for fusion of the 2nd and 3rd TMT joints with medial approach for internal bracing of the 1st TMT joint. 2nd and 3rd metatarsals were denuded of cartilage, and the fusion site was fully prepared. Rigid fixation was applied to the fusion sites. Guidewire for the cannulated Internal Brace system is inserted into the base of the 1st metatarsal. Fluoroscopic imaging confirmed positioning and the 3.4mm drill is passed over the wire, followed by the cannulated tap. A 4.75mm Swivelock anchor with Fibertape suture is inserted into the metatarsal base. The guidewire is placed in a reciprocating position on the medial cuneiform. The 2.7 mm drill is passed over the wire, followed by the 3.5 mm tap. A 3.5 mm Swivelock is then loaded with the Fiberwire from the 1st metatarsal. Tensioning is performed, and the 3.5 mm Swivelock is inserted into the medial cuneiform.

Results:

The athlete was cleared to return to full competition 9 months following surgery with physical exam demonstrating stability in both dorsiflexion and abduction. Weight bearing x-rays showed no evidence of hardware failure and no instability in the 1st TMT joint. CT scan demonstrated solid fusion of 2nd and 3rd TMT joints and maintained anatomic reduction of the 1st TMT joint. At 1-year post-op, patient was having pain over the 4th TMT joint. He had a second surgery to remove an exostosis at the 4th TMT joint as well as remove the screw from the 3rd metatarsal to the middle cuneiform. His pain had resolved at most recent follow up. He returned to game action in the final game of his senior season.

Conclusion:

The literature demonstrates return to sport is possible for athletes with Lisfranc injuries though the data focuses on either purely ligamentous injuries or Myerson type B and C fractures. This case study demonstrates a novel surgical approach to homolateral fracture/dislocation. While return to sport in this athlete took longer than lower-energy injuries, it is possible for athletes with homolateral displacement to return to full competition.
Does BMI Effect Intermediate Outcomes of Open Brostrom-Gould Repair?
Authors: Dib Aseel G. , Andrews Nicholas A. , Torrez Timothy , Pate James , Ozimba Kalah , Jacob Roshan , Harrelson Whitt , Naranje Sameer , Shah Ashish
Published: January 2022

Category:

Ankle; Midfoot/Forefoot

Introduction/Purpose:

High BMI is a known risk factor for development of CAI and intraarticular pathology, but few studies have examined BMI's impact of the outcomes of lateral ligament reconstruction. The open Brostrom-Gould reconstruction, an anatomic repair, is the gold standard for repair of the lateral ligamentous complex. We aim to evaluation the impact of BMI on patient reported outcomes after open Brostrom-Gould repair.

Methods:

A total of 201 patients who underwent open Brostrom-Gould Repair were identified using CPT code. Patients undergoing repair for acute ligamentous injury were excluded. A completed telephonic survey was required for inclusion yielding 92 patients. The telephone survey included: PROMIS Physical Function (PF), Pain Interference (PI), and Depression domains(D) and the Foot and Ankle Ability Measure (FAAM). Medical records were examined for patient characteristics, operative variables, and complications. Patients were grouped by BMI <30 and BMI >30.

Results:

A total of 28 males (30%) and 61 females (69%) were including in this study. The average time at completion of survey was 4.1 years (standard deviation of 2.8). The median age was 44 with an interquartile range (IQR) of 20, while the median BMI was 31.5 with an IQR of 13.4. Obese patients had significantly worse PROMIS PF (Median 44.5 IQR 7.4 vs median 48 IQR 16.5) and FAAM Activity of Daily Living subscale scores (Median 61.6 IQR 30.0 vs. median 82.7 IQR.36). Patients' FAAM self-reported overall level of function was significantly lower in obese patients (Median 70.0 IQR 20.0 vs median 85 IQR 29). The BMI groups did not vary by other PROMIS domains or FAAM subscales.

Conclusion:

At intermediate term follow-up, Obese patients report significantly worse physical function after open Bostrom- Gould repair compared to non-obese patients. Surgeons should be aware of this when prognosticating the outcomes of anatomic ankle reconstruction.
Acute Achilles Tendon Rupture, A More Cost-Effective Surgical Technique Option: Dresden-Calcaneal Tunnel
Authors: Enríquez Gonzalo , Escudero Mario I. , Pellegrini Manuel J. , Nuñez Alfredo
Published: January 2022

Category:

Sports; Ankle

Introduction/Purpose:

Surgical treatment remains the standard of care for active patients with acute midsubstance Achilles tendon ruptures. Clinical decisions must be made, often under circumstances of limited resources. The objective of our study was to describe a reduced cost minimally invasive surgical technique. The use of suture anchor increases the tensile strength of the repair, allowing to prevent tendon lengthening and re-ruptures during early rehabilitation, but these present a high cost and are not exempt from complications such as pullout, local irritation and bone edema. A simple and low-cost alternative that allows us to replace the function of the anchors is to drill a bone tunnel in the calcaneus and pass a high-resistance suture through it.

Methods:

After obtaining IRB approval, a retrospective review of 12 patients with acute Achilles tendon rupture treated with the modified Dresden-Calcaneal Tunnel technique, between January 2019 and August 2020 and followed up for 6 months. Clinical outcome was assessed using the AOFAS, FAOS and SF-36 scores. Complications, and time to return to work and light sport activity were assessed.

Results:

The AOFAS score was 94 +/- 5, FAOS 95% +/- 2 and SF-36 92 +/- 4 at 6 months postoperatively. The recovery time of the patients was 10-18 weeks. The postoperative recovery time to exercise was 16-24 weeks. There was only 2 cases with discomfort in relation to the suture knot near to the calcaneal tunnel, but both case refers spontaneous relief at the second month postoperative.

Conclusion:

This new and minimally invasive technique could be a more cost-effective option in the management of acute Achilles tendon rupture with good functional outcomes. These strategy presents a low occurrence of complications, permit a strong fixation, avoid sural nerve entrapment and respect the biologic environment.
Retrospective Chart Review: Weight Bearing CT Scans and the Measurement of the Lisfranc Ligamentous Complex
Authors: Falcon Spencer , McCormack Thomas J. , Mackay Matthew , Tarakemeh Armin , Mullen Scott , Schroeppel Paul , Wolf Megan R. , Vopat Bryan G.
Published: January 2022

Category:

Midfoot/Forefoot

Introduction/Purpose:

Lisfranc Ligamentous Complex injuries are commonly misdiagnosed due to their unreliable projection on plain films. Many studies have striven to establish baseline measurements of the frequently injured articulations. While cadaver, MRI, ultrasound, and non-weight bearing computer tomography (CT) have been utilized, weight bearing CT (WBCT) scans are a relatively new imaging modality that has not yet been utilized to establish reproducible and widely-referenced baseline anatomic positions. The hyoptheses of this study are: 1. Standing, weight bearing CT scan will allow for evaluation and measurement of the Lisfranc joint complex. 2. There will be no side to side variation or sex-based differences in the Lisfranc joint complex.

Methods:

A retrospective chart review was conducted using the electronic medical record. Inclusion criteria was applied as follows: patients who have undergone weight bearing CT of the bilateral lower extremities from 2018 to 2020. One hundred twelve foot CT scans were acquired for measurements. Measurements were collected by two independent reviewers twice in order to achieve inter- and intra-reliability. The measurements were then analyzed in order to establish a baseline for normal anatomy, compare injured to non-injured side, and observe any sex-based differences.

Results:

Measurements of uninjured legs were utilized to define normal parameters for Lisfranc ligamentous complex (LLC) injuries. Averages were found for measurements of base 1 to 2 MT 2.7mm (SD=0.7mm), medial cuneiform to 2nd MT [M2-C1] 3.7mm (SD=0.7mm), intercuneiform distance 1.2mm (SD=0.3mm), sagittal descent 12.2mm (SD=5.4mm).Patient's with injury to LLC had a larger base of M1-M2, distance from base of first metatarsal to base of second metatarsal (Δ=.5903, p <.0001) and M2- C1 interval (Δ=1.8008, p<0.0001). Males had significantly higher M2-C1 (p=0.0031), intercuneiform distance (p=0.0039), and sagittal descent (p=0.0008) compared to female patients.No significant differences were found with regard to left vs right side in any of the measurements. Intercuneiform distance (p=0.0039) was found to significantly decrease as age increased, while sagittal descent significantly increased with increased age (p=0.0066).

Conclusion:

This study is one of the first investigations aims to assist in defining baseline anatomic measurements for Lisfranc ligamentous complex parameters on WBCT. The values and comparisons obtained were able to reinforce that weight bearing CT is valuable in identifying subtle injuries to the LLC while also demonstrating that there is male-to-female and age-related differences that should be kept in mind when radiographically evaluating imaging studies of injured patients.
Retrospective Chart Review: Weight Bearing CT Scans and the Measurement of the Tibiofibular Syndesmosis
Authors: Falcon Spencer , McCormack Thomas J. , Mackay Matthew , Tarakemeh Armin , Mullen Scott , Schroeppel Paul , Wolf Megan R. , Vopat Bryan G.
Published: January 2022

Category:

Ankle

Introduction/Purpose:

Tibiofibular Syndesmosis injuries are commonly misdiagnosed due to their unreliable projection on plain films. Many studies have striven to establish baseline measurements of the distal tibial and fibular articulation. While cadaver, MRI, ultrasound, and non-weight bearing computer tomography (CT) have been utilized, weight bearing CT (WBCT) scans are a relatively new imaging modality that has not yet been utilized to establish reproducible and widely-referenced baseline anatomic positions. The hypotheses of this study are: 1. Standing, weight bearing CT scan will allow for evaluation and measurement of the tibio-fibular syndesmosis. 2. There will be no side to side variation or sex-based differences in syndesmosis measurements.

Methods:

A retrospective chart review was conducted using the electronic medical record. Inclusion criteria was applied as follows: Patients who have undergone weight bearing CT of the bilateral lower extremities from 2018 to 2020. One hundred twenty ankle CT scans were acquired for measurements. Measurements were collected by two independent reviewers twice in order to achieve inter- and intra-reliability. The measurements were then analyzed in order to establish a baseline for normal anatomy, compare injured to non-injured side, and observe any sex-based differences.

Results:

Measurements of uninjured legs were utilized to define normal parameters for tibiofibular syndesmosis on weight bearing CT. Averages were found for measurements of anterior incisura 3.2mm (SD=1.1mm), middle incisura 3.9mm (SD=1.1mm), posterior incisura 5.6mm (SD=1.7mm), alpha angle 16.3° (SD=6.3°), medial clear space 2.2mm (SD=0.6mm).Patients with syndesmotic injuries had significantly larger measurements for anterior (p<0.0001), middle (p=0.0007), and posterior incisura (p=0.002) when compared to uninjured ankles. Males had significantly higher medial clear space widening (p=0.0012) compared to female patients. Anterior incisura (p <0.0001), posterior incisura (p=0.0005) were found to significantly decrease as age increased.

Conclusion:

This study aims to assist in defining baseline anatomic measurements for syndesmotic parameters. The values and comparisons obtained were able to reinforce that weight bearing CT is valuable in identifying subtle injuries to the TFS while also demonstrating that there is male-to-female and age-related differences that should be kept in mind when radiographically evaluating imaging studies of injured patients.
Divergent vs Parallel Screw Configurations for Subtalar Arthrodesis: Comparing Clinical Outcomes
Authors: Fernandes Carlton , Johnson Eric B. , Moritz Brandon W. , McDonald Matthew R. , Amin Amgad M. Haleem , Kammerlocher Paul A.
Published: January 2022

Category:

Ankle Arthritis; Hindfoot

Introduction/Purpose:

Subtalar arthrodesis is a frequently performed surgery used to treat several hindfoot pathologies. Rigid fixation is essential for successful fusion and percutaneous screws are most commonly used. Controversy still exists regarding the most optimal screw configuration. While cadaveric biomechanical studies have shown diverging screw configuration to be superior to parallel screws, this has never been proven in the clinical setting. The aim of this study was to compare fusion rates and clinical outcomes between patients treated with divergent versus parallel screw constructs for subtalar arthrodesis.

Methods:

We conducted a retrospective review of 58 patients that underwent subtalar arthrodesis during a four-year period at our institutions. Patients were divided into two groups based on screw construct; diverging versus parallel. Outcomes measured were radiographic and clinical evidence of fusion at 3 months, American Orthopaedic Foot & Ankle (AOFAS) ankle-hindfoot and Visual Analog Scale (VAS) scores at final follow up and post-operative complications.

Results:

Thirty patients underwent subtalar fusion with a divergent screw construct and twenty-four with parallel screws. The mean age was 58.5+-13.9 years and mean follow up period was 44.5+-20.8 months. The overall fusion rate at 3 months was 94.8%. The fusion rate for the divergent screw group was 93.3% versus 96.4% for the parallel screw group, showing no statistical significance (p=0.60). Overall, the mean AOFAS and VAS scores improved post-operatively by 28.1+-5.49 and 4.27+-1.45 points respectively (p<.0001). In the divergent group, mean improvement in AOFAS and VAS scores was 28.5+- 4.99 and 4.39+-1.42 versus 27.7+-6.05 and 4.14+-1.48 in the parallel screw group, showing no statistical significance (p=0.59 and p=0.44). The overall complication rate was 5.2% with no statistically significant difference between the two groups (6.7% versus 3.6%, p=0.60).

Conclusion:

When used for fixation during subtalar arthrodesis, divergent and parallel screw constructs have similar radiological union rates and clinical outcomes when it comes to fusion rates at 3 months, post-operative improvement in AOFAS scores and complication rates. Screw configuration should be determined by surgeon experience and comfort level.
Proximal Fifth Metatarsal Fracture Treated with Plantar Plating: Retrospective Multi-Surgeon Case Series
Authors: Gardner Stephanie S. , Klavas Derek M. , Cosculluela Pedro E. , Hanson Travis W. , Heier Keith A. , Varner Kevin E.
Published: January 2022

Category:

Midfoot/Forefoot; Sports; Trauma

Introduction/Purpose:

Proximal fifth metatarsal fractures are a common foot injury. Previous surgical treatments have consisted of intramedullary screw fixation and a newer technique of plantar plating due to non-union and refractures seen with screw fixation. Purpose of this multi-surgeon case series study is to evaluate clinical and radiographic outcomes and complication rates after fifth metatarsal plating for proximal fifth metatarsal fractures in recreational and elite athletes.

Methods:

Retrospective multiple surgeon case series involving patients who underwent fifth metatarsal plantar plating for proximal fifth metatarsal fractures with a mean follow-up of 33.1 months (range, 12-52). Elite and recreational athletes were included. Demographic data, radiographic evaluation, and clinical notes were analyzed. Patient phone conversations were made to document complications outside of our electronic medical record.

Results:

Forty-four patients (45 fractures) were treated with plantar plating technique with a mean age of 37.3 years (range 14- 80). Five patients sustained refractures (11.1% of patients), 2 at previous fracture site, 1 through a screw hole, 1 proximal to plate, and 1 distal to plate. All refractures were treated non-operatively. No wound complications were seen. No secondary revision surgery was needed and union rate was 100% at final follow up.

Conclusion:

With a one year minimum follow up, plantar plating of proximal fifth metatarsal fractures is a viable option for treatment of both acute and chronic fractures as well as after failed intramedullary screw fixation with low refracture rates and without non-unions. Plantar plating allows the surgeon to have direct visualization of fracture reduction and ease of access for bone grafting. Both elite and recreational athletes can benefit from the plating technique.
Outcomes Following Arthroscopy for Anterior Impingement in the Ankle Joint in the General and Athletic Populations: Does Gender Play a Role?
Authors: Gianakos Arianna L. , Ivander Axel , DiGiovanni Christopher W. , Kennedy John G.
Published: January 2022

Category:

Ankle; Arthroscopy; Sports

Introduction/Purpose:

To provide an overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement and to determine if gender affects outcomes.

Methods:

A systematic literature search of the Medline, Embase, and Cochrane databases was performed during June of 2019. The combination of search terms utilized included the following: 'ankle', 'impingement', 'talus', 'osteophyte', 'arthroscopy', 'surgery', 'procedures', and 'treatment'. Two reviewers independently performed data extraction consisting of demographic data, intraoperative arthroscopic data, functional outcome scores, patient satisfaction, complications, return to play, and gender differences.

Results:

Twenty-eight articles evaluating a total of 1,506 patients were included in this systematic review. Sixty percent (17 of 28) and 14% (4 of 28) of studies assessed anterolateral and anteromedial impingement, respectively. Overall, good to excellent results were reported following arthroscopic treatment in patients with anterior ankle impingement with an average success rate of 81.04%. Eleven studies reported return to sport with an average return to sport of 8 weeks. The most common concomitant pathology found during arthroscopic evaluation included synovitis, osteophytes, meniscoid lesions, and AITFL injury. Four studies (15%) failed to report gender as a demographic variable. Only 7 (25%) studies reported gender analysis with four (57%) studies demonstrating differences when comparing gender outcomes. Female patients have higher rates of traumatic ankle sprains, chondral injury, and chronic ankle instability associated with anterior ankle impingement when compared with male patients.

Conclusion:

Our systematic review demonstrates that arthroscopic treatment for anterior ankle impingement provides good to excellent functional outcomes, and good return to sports rates in the athletic population. This study underscores that lack of statistical analysis evaluating outcomes comparing male and female populations. Our study does demonstrate that female patients have higher rates of traumatic ankle sprains, chondral injury, and chronic ankle instability associated with anterior ankle impingement when compared with male patients. Therefore, women may benefit from both AMI/ALI resection as well as lateral ankle ligament repair or reconstruction in order to address both impingement and chronic lateral ankle instability.
Sex-Specific Differences Following Lateral Ankle Ligament Repair
Authors: Goodrich Ezra , Vopat Matthew , Baker Jordan , Tarakemeh Armin , Templeton Kim , Mulcahey Mary K. , Schroeppel Paul , Mullen Scott , Vopat Bryan G.
Published: January 2022

Category:

Ankle; Sports

Introduction/Purpose:

Chronic ankle instability is a common condition that can be treated with lateral ankle ligament repair. These procedures have a reported success rate greater than 85% in the literature, but little has been reported about the differences in postoperative outcomes between males and females. The purpose of this study was to evaluate sex-specific outcomes following lateral ankle ligament repair.

Methods:

In this systematic review and meta-analysis, we utilized Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) criteria to search for articles on electronic databases. Inclusion criteria consisted of English-language, in-vivo clinical studies, mean follow-up of at least one year, sex-specific evaluation of outcomes, and study participants who underwent primary lateral ligament repair. Functional postoperative outcomes for males and females were recorded and statistically analyzed.

Results:

Out of 2,768 studies, eight (0.29%) met inclusion criteria and were analyzed in this review. These studies included 631 patients (409 males [65%] and 222 females [35%]) who underwent primary lateral ligament repair for ankle instability. There was no statistically significant difference between males and females in terms of Karlsson scores (93.5 +- 1.6 for males, 92.7+- 2.3 for females, P =.1582) or American Orthopaedic Foot & Ankle Society (AOFAS) scores (90.44 +- 4.82 for males, 90.19 +- 3.54 for females, P =.1586). Postoperative success was defined as a 'good' or 'excellent' Karlsson score (>81), and success rate analysis revealed no statistically significant difference between males and females (86% +- 7.1% for males, 87% +- 3.5% for females, P =.9374).

Conclusion:

There was no difference in postoperative mean Karlsson scores, AOFAS scores, or success rates between males and females who underwent primary lateral ankle ligament repair. This surgical procedure appears to have comparable outcomes in both sexes; however, more research is warranted to further assess the impact of patient sex on postoperative outcomes.
Biomechanical Comparison of Cannulated Screws vs Nitinol Staple for Tarsometatarsal Fusion in A Cadaveric Model
Authors: Herrin Alexander S. , Koroneos Zachary , Elakkari Sherif T. , Lewis Gregory , Adebayo Temitope , Aydogan Umur
Published: January 2022

Category:

Diabetes; Midfoot/Forefoot

Introduction/Purpose:

Patients with hallux abducto-valgus typically require first-tarsometatarsal arthrodesis procedures for which the method of fixation is controversial. Nitinol staples have increased in popularity due to their pseudoelastic, and fatigue resistant properties that allow for shape memory. The objective of this study was to evaluate the performance of a Nitinol staple and crossed-screws through three-dimensional diastasis measurements for the first-tarsometatarsal joint in a 4-point bending isolated cadaveric joint model. We tested the hypothesis that a medially applied Nitinol staple would provide the same dynamic stability as crossed-screws while allowing for more physiologic motion.

Methods:

Seven matched-pairs of lower limb cadaveric specimens were thawed and dissected to isolate the first-tarsometatarsal joint including the first-metatarsal, medial cuneiform, and joint capsule. One specimen from each donor was fixed with a Nitinol staple placed on the medial side of the joint while the other specimen was fixed with two cannulated crossed-screws. Specimens were potted and tested in an MTS test frame (MTS FlexTest 40 MTS, Eden-Prarie, MN) in a 4-point bending setup (Figure 1A) while maintaining a temperature of 37°C. The diastasis between the first-metatarsal and medial cuneiform was measured at two points on the plantar aspect of each bone near the joint (Figure 1B). Specimens were pre-loaded to 10 N, then stepwise increases in cyclic loading performed at 1 Hz and 50 cycles, at 5 N force intervals until failure (complete separation) at the joint occurred. Diastasis measurements were recorded after every 25 N (250 cycles).

Results:

3 of 7 matched pairs of specimens have been tested to date. All specimens were able to endure loading up to a peak load of 225 N (2000 cycles) (Figure 1C). At this peak-load, specimens fixed with the Nitinol staple had an average diastasis of 0.79 mm +/- 0.70 mm (average +/- std deviation) versus 0.39 mm +/- 0.16 mm in specimens fixed with screws. Specimens fixed with the staple construct failed at 277 N +/- 51 N whereas those fixed with screws failed 315 N +/- 48 N. Results for 4 additional matched pairs are pending.

Conclusion:

There has been debate as to whether the rigid fixation of crossed-screws or the compressive shape memory properties of Nitinol staples are advantageous for tarsometatarsal arthrodesis. No previous study has compared the two methods of fixation in a cadaveric model. In this study no significant differences between the two methods have been detected to date. However, other benefits of the staple construct may include decreased procedural time, decreased time under anesthesia, and possible permittance of earlier post-operative weightbearing.
Vascular Evaluation of Diabetic Patients Presenting with Radiographic Calcified Vessels of the Foot and Ankle
Authors: Herscovici Dolfi J. , Scaduto Julia M.
Published: January 2022

Category:

Diabetes

Introduction/Purpose:

Calcification of the vessels is a common finding in patients with peripheral arterial disease (PAD) and can indicate a compromised extremity. The incidence of PAD disease has been reported in approximately 29% of diabetics and calcification may also indicate a foot or ankle at risk. The purpose of this study was to evaluate toe pressures (TP) in patients who presented with radiographic calcification of vessels in the foot and ankle and determine if adequate flow existed despite the calcification.

Methods:

Using a Diabetic Registry from January, 2011 through February, 2021, a retrospective review was used to identify patients who presented with x-ray calcifications of the foot and ankle and was compared to patients who had undergone TP. For the purpose of this study, the findings of Vitti et al., who demonstrated that no surgical failures occurred in patients with TP >68 mm Hg, were used to stratify patients as having adequate (68 mm Hg) or a compromised (<68 mm Hg) blood flow to the foot. The patients' age, body mass index (BMI), hemoglobin A1C, smoking history, use of insulin, whether they could adequately detect a 5.07 monofilament and whether they had adequate TP were all recorded.

Results:

A total of 43 patients were identified with radiographic calcification of the foot and ankle. Within this population the average age was 68.1 years (45-89), the average BMI was 30. 8 (18.4-51.1), with an average A1C of 7.7 (5.5-14.2). Three patients (7%) were smokers. Eighteen patients (42%) could adequately detect a 5.07 monofilament and only 20 patients (47%) were on insulin. A TP evaluation was performed on a total of 53 patients. A total of 13 patients who had calcification of the vessels and who had TP evaluations were identified. Within this group, 11 patients demonstrated TP values > 68 mm Hg with only 2 patients demonstrating compromised TP.

Conclusion:

Calcification of vessels in the foot and ankle has been stated to suggest vascular compromise and indicate a foot and ankle at risk. These patients are obese, older individuals with poor glycemic control who, for the most part, are neuropathic. However, in this small study group, patients who had calcification of their vessels and had TP, demonstrated that despite the calcifications, adequate blood flow was achieved into the foot. This may indicate that combined with improved glycemic control, patients can undergo elective or semi-elective surgical procedures with adequate healing rates expected.
Comparison of Clinical Results Between Locking Plate Fixation and Screw Fixation for Intra-Articular Calcaneal Fractures
Authors: Hio Naohiro , Taki Masanori
Published: January 2022

Category:

Trauma; Hindfoot

Introduction/Purpose:

The purpose of this study is to compare the results of the two fixation groups for intra-articular calcaneal fractures based on the hypothesis that the locking plate group (P-group) can have a less corrective loss but smaller range of motion due to soft tissue contracture than the screw alone group (S-group).

Methods:

P-group included ten feet, five feet of which were categorized as Sanders classification type 2, four as type 3, one as type 4. S-group included 11 feet, nine as type 2, two as type 3. In both groups, small incisions such as sinus tarsi approach were used, and P-group was fixed with a locking plate, and canulated cancellous screws if necessary, while S-group was fixed with canulated cancellous screws only. We assessed range of motion of the ankle joint and subtalar joint, Creighton-Nebraska scale (CN scale) and pre- and postoperative width and height of the calcaneal body and step of subtalar joint surface.

Results:

The mean postoperative range of motion in the P-group / S-group was 15°/46.2° / 13.2°/45.9° for ankle dorsiflexion/plantarflexion, and 5°/13° / 5.5°/16° for subtalar joint eversion/inversion, respectively. The mean postoperative clinical score was 89.8+-9.5 points / 93.9+-8.0 points on the CN scale, and the mean pre- and postoperative imaging evaluation showed improvements in the mean width from 120.7+-8.9% to 107+-6.7% / 122.6+-13.4% to 112.9+-10.7%, in the mean height from 88.7+-4.6% to 97.8+-3.3% / 88.3+-5.8% to 99.4+-5.3%, and in the mean step of subtalar joint surface from 6.2+-5.3 mm to 0.7+-1.1 mm / 10.5+-7.6 mm to 1.5+-2.5 mm. As complications, peroneal tendinopathy and transient peroneal neuropathy were observed in one case each in the both groups.

Conclusion:

There was no significant difference between the two groups in the corrective loss and postoperative range of motion.
Effect of Preoperative Ulceration on Outcomes of Tibiotalocalcaneal Arthrodesis
Authors: Hoch Caroline P. , Newton William , Newton William , Gross Christopher E. , Scott Daniel J.
Published: January 2022

Category:

Hindfoot; Diabetes

Introduction/Purpose:

Tibiotalocalcaneal (TTC) arthrodesis is commonly performed for complex deformity, arthritis, or unstable Charcot about the hindfoot. In patients with neuropathy, hindfoot deformity, and preoperative hindfoot ulceration, management options can be limited and very challenging. Previously, some authors have advocated for fine wire circular frames and avoidance of internal fixation in an effort to decrease the risk of infection in patients with preoperative ulceration, however, there is very limited data on the outcomes of TTC arthrodesis with internal fixation in this patient population. We hypothesized that internal fixation of TTC arthrodesis in patients with preoperative ulceration would lead to higher infection rates compared to patients without ulceration.

Methods:

A retrospective review was conducted on the TTC fusions performed from 2016-2020 by a single fellowship trained foot and ankle surgeon at an academic medical center. Preoperative diagnosis and indications, fixation method, clinical success, and complications were obtained from the patients' charts. Patients were excluded if their clinical or radiographic data were unavailable for review, or if they had less than 3 months of follow-up. 34 patients (34 ankles) underwent TTC arthrodesis Mean age was 60.7 years and mean follow-up was 1.3 years. Statistical analysis was performed using t-Student and Chi-squared tests with a p-value of 0.05 defining significance. Midline tibiotalar angle (MTA) was measured before and after surgery to assess position of fusion. Nine patients had preoperative ulcers at the time of surgery.

Results:

Common surgical indications included Charcot neuropathy (n=17), post-traumatic (n=14), and cavovarus (n=3). All patients with preoperative ulcers underwent TTC fusion with an intermedullary rod. Of the patients without ulceration, 18 underwent intermedullary nailing, 5 underwent plating, and 1 had an external fixator placed. There was no difference in deep wound infection rates between patients with (2/9, 22.2%) and without (2/25, 8.0%; p=.386) preoperative ulceration; nor was there a difference in rate of fusion, wound healing, or radiographic alignment. One patient without preoperative ulceration underwent a below knee amputation due to infection.

Conclusion:

TTC arthrodesis with internal fixation appears to be a reasonable consideration in patients with a preoperative hindfoot ulcer. There was no statistical difference in infection rate in patients undergoing TTC fusion with and without preoperative ulceration. Further, the rate of infection in those with an ulcer and internal fixation was acceptable, and internal fixation can be considered in these patients.
Radiographic Characterization of Midfoot and Transverse Tarsal Joint Osteoarthritis
Authors: Hoch Caroline P. , Caughman Alexander , Baxley David E. , McGurk Katherine M. , Scott Daniel J. , Gross Christopher E.
Published: January 2022

Category:

Ankle Arthritis; Midfoot/Forefoot

Introduction/Purpose:

Midfoot osteoarthritis affects over 16% of adults over the age of 50, interfering with activities of daily living and leisure. Non-operative management includes anti-inflammatory, carbon fiber shank/custom orthotics, and cortico-steroid injections. To improve accuracy, these injections are often done under fluoroscopic guidance. Operative intervention with midfoot fusions is sometimes performed, though non-union rates and continued pain after surgery can be challenging. Sometimes, there can be difficulty in determining exactly which midfoot joints are most arthritic/symptomatic based on radiographs. This study aims to quantify how well surgeons are able to diagnose midfoot and transverse tarsal joint arthritis on standing radiographs versus advanced imaging.

Methods:

We reviewed the records of 113 patients (144 feet) with midfoot arthritis, who were treated from 2015 to 2019 at an academic medical center by a single fellowship trained foot and ankle surgeon. The mean age was 63.0 years, the average BMI was 31.5, and 7 patients eventually underwent surgery. Each patient underwent both plain radiographs, according to a standardized protocol, and either a CT or MRI scan. Radiographs and advanced images were graded separately for the presence of joint space narrowing, subchondral cysts, and other signs of arthritis in the following joints: 1st tarsometatarsal (TMT), 2nd TMT, 3rd TMT, 4th TMT, 5th TMT, naviculocuneiforms (NC), talonavicular (TN), calcaneocuboid (CC), subtalar (ST), and 1st metatarsophalangeal (MTP). The sensitivity, specificity, precision, negative predictive value, and overall accuracy of radiographs compared to CT scans was calculated for each joint. Statistical significance was assessed using a paired t-test.

Results:

The most common joints affected by arthritis were the 2nd TMT (radiograph=75.7%, CT=79.9%) and 3rd TMT (radiograph=65.5%, CT=70.4%). Advanced imaging showed a significantly higher rate of arthritis in the 1st TMT (P<0.01), 4th TMT (P<0.01), and 5th TMT (P<0.01), as compared to radiograph. Only 16.9% of patients' radiographs had a direct correlation with the results of their CT scan. A CT scan showed one or two additional affected joints by 19.7% and 13.0 %, respectively; and rarely showed one or two less joints affected by arthritis (8.1% and 3.2%, respectively). We found radiographic sensitivity and specificity to be highly variable (1st TMT=61.3% & 92.3%, 3rd TMT=79.5% & 69.3%).

Conclusion:

Radiographs vary drastically in their sensitivities and specificities in diagnosing arthritic joints in the midfoot and transverse tarsal joints. When treating midfoot osteoarthritis surgically, we recommend obtaining advanced imaging preoperatively, rather than relying on plain radiographs alone to determine which joints may need to be managed surgically.
Coronal Plane Deformity and Total Ankle Replacement: When to Stage with Cement Spacer Ankle Arthroplasty for Deformity Correction
Authors: Hyer Christopher F. , Malloy McCoy Antonio M. , Thompson John M. , Thompson Mitchell , Consul Devon
Published: January 2022

Category:

Ankle Arthritis

Introduction/Purpose:

Degenerative ankle joint disease is a debilitating condition that causes significant pain, adversely affects function and quality of life. Though primary arthritis of the ankle can occur without deformity, frequently soft tissue imbalances or joint deformities complicate the clinical picture. Often, additional procedures are required to balance the foot and ankle during the index total ankle replacement procedure. When large deformities exist a staged approach to first, align the ankle joint to neutral as stage one and then implantation of the TAR as stage two can be deployed. This paper will further popularize the cement spacer staged TAR technique in correction of coronal deformities, share a clinical algorithm on approach, and depict a case series demonstrating its application.

Methods:

A case series was performed of 7 patients and 8 ankles, who underwent staged primary TAR utilizing a cement spacer to assist with deformity correction, between the years 2016-2019.

Results:

Patients' mean age 58.5 yrs., preoperative varus coronal plane deformity mean 19.1 degrees, preoperative valgus coronal plane mean 10.25 degrees. Mean time from stage 1 till 2 was 163.5, +-140.2 days. Stage 1 soft tissue procedures: Chrisman-Snook procedure with synthetic ligament graft, Brostrum-Gould with synthetic graft, Brostrum-Gould without graft, FDL transfer, and isolated medial release/peel. Osteotomies performed during stage one: Dwyer, MDCO, Cotton, and MDCO with medial malleolus osteotomy. Fusions performed during stage one consisted: Subtalar joint, talonavicular joint (TNJ), and STJ with 1st Metatarsophalangeal joint (MTPJ). Seven ankles were replaced with Cadence Total Ankle System (Integra), and one with INBONE II (Wright Medical Technology). Average follow-up time for included patients was 290.75 days (9.7 months). One revision was performed following index TAR procedure.

Conclusion:

This paper describes a cement wedge spacer staged total ankle arthroplasty technique for correction and stabilization of deforming forces at the ankle joint. While not all ankle deformities necessitate a staged approach, the complexity of the malalignment and the extent of tissue disruption needed to achieve a neutral ankle should be considered when correcting a given deformity with a staged or non-staged approach.