bluuebunny/crossref_metadata_2025 huggingface dataset:
Nottingham Experience with The Fixed Bearing Infinity Total Ankle Replacement
Authors: Salem-Saqer Hatem , Raglan Martin , Dhar Sunil
Published: November 2020

Category:

Ankle; Ankle Arthritis

Introduction/Purpose:

Total ankle arthroplasty (TAA) is increasingly used for treatment of end stage arthritis of the ankle; improvements continue to evolve in implant design and instrumentation. We present our experience of the Infinity Total Ankle Arthroplasty (Wright Medical), a fixed bearing 4th generation implant with improved instrumentation

Methods:

This is a retrospective review of prospectively collected data. From October 2016 to July 2019, we identified 92 (52M/40F) who had the infinity Total Ankle Replacement. This review is of 70 patients with a minimum of 1 year follow up (33M,37F). The mean age was 67.5 years (33-87); 32 right side and 38 left no bilaterals. The indication for surgery was end stage Osteoarthritis in 52, post traumatic arthritis 12, inflammatory arthritis 4, conversion of fusion to TAR 2. The preoperative deformity was graded according to the COFAS classification. All patients had follow up at 6 weeks, 3,6 and 12 months and then annually, with MOXFQ questionnaire and weight bearing radiographs.

Results:

TAA was performed with the use of fluoroscopy. 77% (54/70) had concomitant procedures as listed in Table.5% (4/70) had complications consisting of, 1 DVT, 1 intra operative medial malleolus fracture, 1 EHL tendon laceration and 1 wound break down. There were no deep or superficial infections. Improvement in clinical outcome and PROMS data was noted on follow up. The MOXFQ for Pain improved from 72 pre-op to 25 at 1year (p<0.001). The outcome for Walking improved from 83 pre-op to 30 at one year (p<0.001). Radiological alignment was maintained asymptomatic posterior heterotopic ossification was noted in 23(16%) patients, lucent lines under the tibial implant were noted in 4 ankles and 1 fibula erosion. 2 TAA (3%) needed to be revised due to malpositioning.

Conclusion:

Our results show significant improvement in patient outcomes, a short recovery time and marked improvement in mobility post operatively with a very low complication rate, we had no deep infection to date. Two implants were revised which we attribute to the learning curve at the start of practice. This implant is fluoroscopically navigated allowing precise implantation with dedicated instrumentation and we feel this attributed to the low complication rate and good results in our short-term study [Table: see text]
Fixation of Hammertoes with a Permanent Intramedullary K-Wire: A Low-Cost Alternative for a Common Procedure
Authors: Sammarco V. James , Sammarco Josika A. , Delman Allegra L.
Published: November 2020

Category:

Lesser Toes; Midfoot/Forefoot

Introduction/Purpose:

Traditional K-Wire fixation of the proximal interphalangeal joint during correction of hammertoes is associated with various complications including loss of fixation, recurrence of deformity, pin tract infection and patient dissatisfaction due to the pin. At least 20 devices designed expressly for the purpose of fusing the interphalangeal joint of the lesser toes exist. Cost of the implants can range from $450 to $2000 per implant (when disposable instruments are included in the cost.) We hypothesized that a permanent intraosseous K-Wire bridging the proximal and middle phalanx would perform in an equivalent manner to many commercially available implants with a large potential for cost savings.

Methods:

A modified DuVries hammertoe correction procedure through a dorsal approach including resection of both joint surfaces. A 2mm or 1.6mm K-wire is then cut and placed into the intramedullary canals of the phalanges bridging the PIP joint (IP). A snug extensor mechanism repair affords compression and rotational control. External pins (EP) were used if the diaphyseal canal was less than 1.6mm. A retrospective review of medical records and radiographs of all patients undergoing hammertoe correction over three years by a single surgeon. 50 patients (28 Women, 12 Men) and 53 feet (2 bilateral) with mean age 66 (range 34 – 84) who had a minimum 6-month follow-up were available for study. 112 toes were corrected. Osseous union or stable fibrous union were the desired results with non-union, deformity recurrence and/or the need for revision being noted as failure. Average follow-up was 21.7 months (6 – 54).

Results:

Results: Of the 93 IP fixations, there were 68 fusions, 22 stable fibrous unions, and 3 non-unions. Of the 19 External pins there were, 11 fusions, 3 stable fibrous unions and 5 non-unions. 5 Patients required revision which was done by bone grafting and compression with an intramedullary screw. Success was noted in 96% of IP fixation and 74% of external pin fixations.

Conclusion:

Permanent internal K-Wire fixation for hammertoe correction is a viable option for fixation of hammertoe deformity outperforming traditional temporary K-wire fixation and resulting in good clinical results comparable to other commercially available implants. Given the negligible cost of this implant, the potential cost savings to the medical system is great. K-Wires are readily available worldwide and this technique may useful in countries where resources do not allow use of expensive implants.
What is the Effect of Lateral Ankle Ligament Injury on Syndesmotic Stability? Arthroscopic evaluation
Authors: Sato Go , Saengsin Jirawat , Bhimani Rohan , Hagemeijer Noortje , Lubberts Bart , Guss Daniel , Waryasz Gregory R. , DiGiovanni Christopher W.
Published: November 2020

Category:

Ankle; Arthroscopy; Sports; Trauma

Introduction/Purpose:

Numerous studies have shown a high incidence of associated lateral ankle and syndesmotic ligamentous injuries. It is unclear, however, if there is a direct contribution of the lateral ligaments towards stabilizing the syndesmosis. Using arthroscopy, we assessed to what extent lateral ankle ligaments contribute to syndesmotic stability in the coronal and sagittal plane. Our hypothesis was that lateral ankle ligament injury has effect on syndesmosis instability.

Methods:

Sixteen fresh frozen above-knee amputated cadaveric specimens were divided into two groups that underwent arthroscopic evaluation for syndesmotic stability. In both the groups, the assessment was done with all syndesmotic and ankle ligaments intact and later with sequential transection of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), the posterior talofibular ligament (PTFL), anterior inferior tibiofibular ligament (AITFL), the interosseous ligament (IOL) and the posterior inferior tibiofibular ligament (PITFL). In all scenarios, coronal and sagittal loading conditions were considered under 100N of direct force to fibula. The measurements of the distal tibiofibular coronal plane space at the anterior and posterior third of syndesmosis were performed using arthroscopic probes with increment of 0.2mm diameter. Further the sagittal translation were measured by arthroscopic scaled probe. Dunnett test was used to compare the findings of each ligamentous transection state to the intact state. A p-value < 0.05 was considered significantly defferent.

Results:

Compared with the intact ligamentous state, there was no difference in coronal and sagittal stability when the lateral ankle ligaments (ATFL, CFL, PTFL) and AITFL were transected (Table1 and 2, Group1). However, after subsequent transection of the IOL, or after transection of the lateral ankle ligaments (ATFL, CFL or and PTFL) alongside the AITFL and IOL, both coronal space and sagittal translation increased as compared with the intact state (p-values p<0.001 respectively) (Table1 and 2, Group2).

Conclusion:

Our findings suggest that lateral ankle ligaments do not directly contribute to syndesmotic stability in the coronal and sagittal plane. In concomitant acute syndesmotic and lateral ligament injury, surgeons should pay attention to whether there is combined IOL injury to determine the fixation of syndesmosis. [Table: see text][Table: see text]
Anatomical Study of Lapidus Arthrodesis using two Different Plantarplate Systems
Authors: Schilde Sebastian , Gutteck Natalia , Delank Karl-Stefan
Published: November 2020

Category:

Midfoot/Forefoot

Introduction/Purpose:

First tarsometatarsal arthrodesis (modified Lapidus procedure) constitutes a sufficient treatment for moderate to severe hallux valgus deformity and first ray instability. The plantar plate arthrodesis was shown to provide superior mechanical stability and less postoperative complications than screw fixation or dorsal plating. Nevertheless, the in-brought hardware may cause irritation of the tibialis anterior or peroneus longus tendon requiring explanation of the material in some cases. The purpose of this study was to investigate the potential of tendon irritation after plantar first tarsometatarsal joint arthrodesis in a cadaver study.

Methods:

Plantar plate arthrodesis was performed as in real surgery on twelve pairs of fresh frozen cadaveric feet. Two different plate systems were randomly allocated to each pair of feet. After plate fixation careful dissection of the feet followed to analyze potential tendon irritation and to determine a ‘safe zone’ for plantar plate placement.

Results:

A ‘safe zone’ between the insertion sties of tibialis anterior and peroneus longus tendon was found and proven to be sufficiently exposed using a standard medio-plantar approach. Both plates were fixed in this zone without compromising central tendon parts. Peripheral tendon parts were irritated in42% using Darco Plantar Lapidus Plating System1 (Wright Medical, Memphis, TN) and in 8% using the Plantar Lapidus Plate1 (Arthrex, Naples, FL). Bending of the anatomically preshaped plates is often necessary to ensure optimal fit on the bone surface.

Conclusion:

Modified Lapidus procedure with plantar plating of the first tarsometatarsal joint can be performed safely without compromising central tendon parts via standard medio-plantar approach.
Outcomes of Modified Scarf Osteotomy for Male Hallux Valgus
Authors: Scott Daniel J. , Ford Samuel E. , Alejandro Shannon F. , Myer David K. , Taniguchi Akira , Brodsky James W.
Published: November 2020

Category:

Bunion

Introduction/Purpose:

Compared to women, hallux valgus in men is less common, more severe, and has higher rates of undercorrection, recurrence and greater distal metatarsal articular angle (DMAA). Bunionectomies that correct metatarsus primus varus (MPV) by valgus rotation paradoxically increase 1stMTP valgus in high DMAA, contributing to recurrence and undercorrection. While proximal valgus osteotomy or arthrodesis plus distal varus-producing metatarsal osteotomy can correct both components, there is a simpler solution. A modified Scarf osteotomy technique was developed in which the osteotomy is simultaneously translated laterally to correct MPV, while rotating the distal metatarsal in varus to correct DMAA. While previous literature on male hallux valgus is comprised of many studies using a combination of surgical techniques, all patients in this series had the same procedure.

Methods:

A retrospective review of prospectively collected data was performed in male patients treated with modified scarf osteotomy and soft tissue realignment for symptomatic hallux valgus, who failed conservative treatment. Preop and postop range of motion (ROM), radiographs, and validated patient reported outcome (PROM) scores including Pain VAS and SF-36, were tabulated, as well as complications, and AOFAS Hallux scores for historical comparison. There were 22 patients (26 feet), mean age 53 (17-79). Mean clinical and radiographic follow up was 24 months, and mean postop PROM’s follow up was 4.7 years. Six of 26 feet (23%) required a modified Akin osteotomy for a congruent 1stMTP joint. A subset of patients with minimum 4-year and mean 7.6 -year follow up (9 patients, 10 feet), was also analyzed. Weightbearing radiographs were evaluated for DMAA, hallux valgus angle (HVA) and 1st-2ndintermetatarsal angles (IMA).

Results:

Statistically significant improvements were found in VAS scores (5.8 to 1, p<0.001); SF-36 physical (44 to 56.7, p<0.001); IMA (15.9 to 8.7, p<0.001), HVA (36.1 to 15.1, p<0.001), DMAA (12.7 to 6.9, p=0.01) and AOFAS scores (44 to 79, p<0.001). Total 1stMTP ROM decreased from 60.9 to 50.8 degrees (p=0.06). One patient had delayed wound healing requiring oral antibiotics and wound vacuum application. Statistically significant improvements were maintained over time in the 7.6-year follow up sub-group, with VAS scores 6.2 to 1.3 (p<0.001), SF-36 physical from 40.8 to 61.3 (p=0.008), and SF-36 mental from 55.7 to 62.3 (p=0.002).

Conclusion:

This study found statistically significant improvements in both subjective validated PROM’s and objective radiographic measures using a special modification of the scarf osteotomy to address the characteristic increased DMAA that underlies complications and under correction previously reported in male hallux valgus. The corrections were well maintained at long-term follow-up including a robust correction of the DMAA.
Transcuneiform Screw Fixation in Ligamentous Lisfranc Injuries
Authors: Shaheen Philip J. , Crawford Benjamin , Kopydlowski Nathan J. , Patel Shwetang , Bledsoe John G. , Kaar Scott G. , Karges David E.
Published: November 2020

Category:

Trauma; Midfoot/Forefoot

Introduction/Purpose:

Ligamentous Lisfranc injuries represent a devastating injury complex to the midfoot. Treatment with screw fixation across the first tarsometatarsal (TMT) joint and across the first cuneiform-second metatarsal joint (C1-M2) joint has been described, however there are no studies examining the utility of adding a transcuneiform screw across the first cuneiform-second cuneiform (C1-C2) joint. The purpose of this study was to evaluate the effectiveness of transcuneiform screws at minimizing interosseous displacement in ligamentous Lisfranc injuries when added to traditional Lisfranc screw fixation.

Methods:

Unstable ligamentous Lisfranc injuries were created on ten fresh-frozen cadaveric specimens by sectioning the interosseous ligaments in a manner that has been described previously. Simulated weight bearing stress (222.4 N) as well as manual abduction and adduction stresses were applied to each specimen and interosseous displacement at the C1-C2 and C1-M2 joints was measured on gross images using calibration with 2mm radiographic marker balls. These measurements were performed initially with no screws, followed by with two-screw fixation across the C1-M2 joint and the first TMT joint, and finally with a third transcuneiform screw across the C1-C2 joint. The images were analyzed and statistical analysis was performed to determine the effect of transcuneiform fixation on interosseous displacement at the C1-C2 and C1-M2 joints.

Results:

The addition of transcuneiform screw fixation to traditional two-screw fixation decreased the amount of interosseous widening at C1-M2 by an average of 0.03mm at rest, 0.39mm during abduction stress, 0.21mm during adduction stress, and 0.19mm during weight bearing. The interosseous widening at C1-C2 decreased with the addition of transcuneiform fixation by an average of 0.30mm at rest, 0.11mm during abduction stress, 0.18mm during adduction stress, and 0.05mm during weight bearing. Of these findings, only the change in interosseous widening at C1-M2 during abduction stress demonstrated a statistically significant difference (p=0.031) with the addition of the transcuneiform screw compared to traditional two-screw fixation.

Conclusion:

The addition of transcuneiform screw fixation in ligamentous lisfranc injuries allows less interosseous widening at the C1-M2 joint during abduction stress when compared to traditional two-screw Lisfranc fixation. Further research is required to determine the clinical significance of fixing the transcuneiform joint in Lisfranc injuries and whether or not this potential reduction in motion affects outcomes such as pain control, healing, or function.
Influence of Cannabinoid on Interleukin-1β Treated Cartilage: An In Vitro Study
Authors: Shang Jiangyinzi , Hu Yuning , Alexander Peter , Hogan MaCalus V. , Lin Hang , Yan Alan Y.
Published: November 2020

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Cannabinoids have been reported to possess the analgesic, immunomodulatory and anti-inflammatory properties. Recent studied further shown that cannabinoids attenuated joint damage in animal models of arthritis. However, the underlying mechanism has been completely understood. Interleukin-1β (IL-1β), a proinflammatory cytokine that can result in the degradation of cartilage, is associated with the pathogenesis of osteoarthritis. In this study, we hypothesize that cannabinoid can mitigate the detrimental effect of IL-1β on cartilage, thus reduce the progression of osteoarthritis. To test the hypothesis, we insulted human chondrocyte-derived cartilage with IL-1 β for 48 hours and then applied a synthetic cannabinoid agonist, Win- 55,212-2(Win-55), into the culture. The tissue phenotypes were assessed by real time polymerase chain reaction (PCR), histology and immunostaining.

Methods:

With the approval from CORID, human chondrocytes were isolated from healthy articular cartilage. P2 cells were used. MTS assay were employed to test the half-maximal (50%) inhibitory concentration (IC50). To generate cartilage in vitro, chondrocytes were pelleted and subjected to 14 days chondrogenic culture. The engineered cartilages were stimulated with 10 ng/ml IL-1β for 48 hours and then treated with different concentration of Win-55 (0.01, 0.1, or 1 µM) for another 48 hours. The tissue phenotype was assessed by glycosaminoglycan (GAG) assay, real-time PCR and histology.

Results:

We tested 10 doses, from 0.001µM up to 10 µM, and determined that the IC 50 of Win-55 on human chondrocytes for 2 days was ˜ 2 µM. Interestingly, this dose is significantly lower than the doses reported in similar studies. As shown in Figure 1, treatment with 2µM Win-55 causes the complete loss of GAG from engineer cartilage. In a relatively safe dose (<=1 µM), we did not observe obvious changes in all tested genes after the treatments of Win-55 (Figure 2).

Conclusion:

High dose of Win-55 may directly cause the degeneration of cartilage, while low dose of Win-55 doesn’t show beneficial influence on the phenotype of IL1-β-insulted cartilage. The reported anti-inflammatory effect of Win 55 on chondrocytes may due to the cytotoxicity or global inhibition of high dose Win 55 on cell activities. Therefore, if cannabinoid can be used to treat OA requires further investigation.
Functional Implications of the Flat-Topped Talus Following Treatment of Idiopathic Clubfoot Deformity
Authors: Shivers Claire , Siebert Matthew , Zide Jacob R. , Tulchin-Francis Kirsten , Stevens Wilshaw , Borchard Justine , Riccio Anthony , Zide Jacob R.
Published: November 2020

Category:

Hindfoot; Other

Introduction/Purpose:

The flat-top talar dome is a well-known potential consequence of both operative and non-operative clubfoot management. While it is assumed that patients with a flat-top talus will have greater problems with daily activity, the functional impact of this deformity has not been characterized in the literature. The purpose of this study is to analyze the relationship between talar dome morphology and ankle function at skeletal maturity in patients treated for idiopathic clubfoot deformity during infancy.

Methods:

33 skeletally mature patients (average age 17.9 years, SD 1.6 years) with 52 idiopathic clubfeet were identified from our institution’s clubfoot registry. Plain weight bearing lateral foot films, gait analysis and patient reported outcomes (PRO) using the Pediatric Orthopaedic Data Collection Instrument (PODCI) were obtained in all patients. Radius of curvature (ROC) of the talar dome and tibial plafond were measured along with numerous other parameters of talar and calcaneal morphology. Other measurements included talar dome radius to talar length (R/L) ratio, opening angle of the talar dome (alpha-angle), and talar dome to tibial plafond ROC (TD/TP) ratio. All measurements were correlated to PODCI scores and gait analysis data.

Results:

Patients demonstrated variability in talar dome ROC (mean 33.1mm, SD 19.6mm), R/L ratio (mean 0.60, SD 0.39), alpha- angle (mean 88.7°, SD 29.5°) and TD/TP ratio (mean 1.17, SD 0.44). Increased TD/TP ratio correlated negatively with maximal plantarflexion (r=0.404, p=0.005), ankle range of motion (ROM) (r=0.383, p=0.008) and maximum power generation during step off (r=0.381, p=0.008). Higher alpha-angle correlated positively with plantarflexion (r=0.404, p=0.005), ankle ROM (r=0.383, p=0.008) and maximum ankle power generation (r=0.381, p=0.008). Lower talar dome ROC correlated with increased maximum power generation (r=0.326, p=0.025). Increased R/L and TD/TP ratios correlated negatively with PODCI happiness domain scores (r=-0.353, p=0.044; r=-0.377, p=0.025, respectively). Talar length correlated with higher happiness and global function scores (r=0.393, p=0.024; r=0.360, p=0.040, respectively) and lower pain scores (r=0.354, p=0.043).

Conclusion:

While flatness of talar dome correlates significantly with altered gait mechanics, the effects on patient reported function are more modest during the second decade of life. Further study is required to assess the longer-term effects of the flat top talus on function and joint health.
A Multicenter Retrospective Study Examining Complication Rates Following Syndesmotic Screw Removal
Authors: Shoap Seth C. , Freibott Christina , Baumbach Sebastian F. , Herterich Viktoria , Polzer Hans , Vosseller J. Turner
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

20% of ankle fractures in the US involve a concomitant injury to the syndesmosis. What syndesmotic fixation is most appropriate is a subject of some debate. When syndesmotic screws are used, many of the variables surrounding treatment are unclear. One recent study quoted an alarmingly high rate of complications after syndesmotic screw removal (reference). The authors of the current study have routinely removed syndesmotic screws with little in the way of complications. This multicenter study was conducted in order to compare complication rates following syndesmotic screw removal in two institutions that regularly remove syndesmotic screws.

Methods:

Patient selection was based on the ankle fracture databases of the orthopedic department in two major academic institutions. At both institutions, databases includes all patients treated surgically for any type of ankle fracture between 01/2010 and 12/2016 in patients older than 18 years. Patients meeting the following inclusion criteria were selected: patients suffering any type of an acute, closed ankle fracture, syndesmotic disruption treated using a syndesmotic screw, removal of the syndesmotic screw in the same institution, and patient chart available for review. Exclusion criteria: pilon fractures, and tibial shaft fractures, as well as any postoperative infection following the original osteosynthesis. Data from the chart included age, sex, height, weight, BMI, days until screw removal, smoking status, alcohol use, diabetes status, and any wound complications or complication related to the screw removal. A logistic regression analysis was conducted to assess for predictors of wound complications after syndesmotic screw removal.

Results:

In our cohort of 152 patients, 1.3% of patients had wound complications. When looking at the cohorts separately, there was a reported wound complication in 3.2% (1 out of 31) of patients in institution 1, whereas there was a 0.83% (1 out of 121) wound complication rate in the cohort at institution 2 (p=0.296). There were no significant predictors of wound complications when looking at age (p=0.992), height (p=0.511), weight (p=0.735), BMI (p=0.755), days until screw removal (p=0.80), sex (p=0.404), smoking status (p=0.999), alcohol use (p=0.102), or diabetes status (p=0.269). Chi-square analysis revealed that there was not a significant association between wound complication and smoking (p=0.177), alcohol use (p=0.461) and diabetes status (p=0.602) in each cohort.

Conclusion:

A recent study reported a high rate of complications as a result of syndesmotic screw removal. Our multicenter study found minimal complications after syndesmotic screw removal. Further, out of two patients that did have reported complications, neither required secondary intervention as a form of treatment. These complications were considered minor and were treated with oral antibiotics.
Retrospective Comparison of Complications with Open versus Minimally Invasive Achilles Tendon Repair
Authors: Shoap Seth C. , Freibott Christina , Polzer Hans , Vosseller J. Turner
Published: November 2020

Category:

Sports; Other

Introduction/Purpose:

Despite the relatively high frequency of Achilles ruptures, there is no clear consensus on the optimal treatment method. The debate has traditionally been framed by the tension between the risk for rerupture seen with nonoperative treatment and the risk for wound issues seen with operative treatment. Studies have demonstrated conflicting results when comparing complications associated with each treatment. The current study analyzed complications of patients with Achilles tendon ruptures that received either minimally invasive repair or open standard repair by a single surgeon.

Methods:

We conducted a retrospective chart review of patients that had Achilles tendon repair performed by the senior author between July 1st 2011 and January 22nd 2020. The senior author’s preferred operative technique transitioned from an open standard procedure to a minimally invasive procedure within this time frame, and patients were divided accordingly. Patient demographics, medical history, social history, surgical details, and additional surgeries were recorded. Patient outcomes and any complications were also recorded. Complications included any wound related issues or infection, erythema, DVT, wound breakdown, drainage, equinus contracture, and calcaneus stress reaction. Pain, swelling and/or tenderness were not considered complications. Independent sample t-tests and chi-square analyses were conducted to assess for differences in patient demographics and operative outcomes between the minimally invasive and open procedure treatment groups.

Results:

Of the 127 included patients, 75.6% were male with an average age of 41.85 (+-14.02). 30 (23.6%) patients had the minimally invasive approach, while 97 (76.4%) had the open approach. 82.7% were non-smokers, and the average BMI was 31.47(+-29.84). A majority of injuries (63.8%) occurred while playing sports. There were 10 complications, all of which were wound-related and all of which were in the open group (p=0.06). There were no revision surgeries in the minimally invasive group, and 10 in the open group (p=0.06). There were no recorded reruptures in either group.

Conclusion:

This study sought to determine the complication profile of two operative treatments for Achilles tendon ruptures, open standard and minimally invasive repair. Recent literature has suggested that minimally invasive repair results in superior outcomes to open repair. Our study found that both repeat surgery and complications trended towards a higher rate following open repair compared to minimally invasive repair, although the difference was not statistically significant (p=0.06). It is notable, however, that there were fewer total patients in the minimally invasive group and that there was not a single wound complication in the minimally invasive group.
Minimally Invasive Surgery for Correction of Adult Acquired Flat Foot Deformity: An Anatomic Study
Authors: Shofoluwe Ademola I. , Bailey Erroll J. , Stewart Gary W.
Published: November 2020

Category:

Midfoot/Forefoot; Hindfoot

Introduction/Purpose:

Adult acquired flatfoot deformity (AAFD) is a complex and chronic debilitating condition characterized by a decrease in the medial arch height and, in advanced stages, a decrease in the talonavicular coverage angle as the forefoot drifts into pronation and abduction. Operative treatment of stage II deformity has changed significantly over the past few decades. Joint sparing procedures which aim to realign the hindfoot and augment the diseased tibialis posterior tendon with the flexor digitorum longus transfer are commonly performed. The introduction of minimally invasive surgery (MIS) has been associated with smaller incisions, less blood loss, and quicker recovery times. The purpose of this study was to qualitatively and quantitatively observe the tendinous and neurovascular structures at risk with MIS AAFD osteotomy procedures in cadaveric feet.

Methods:

MIS technique was used to perform medial displacement calcaneal, Evans, and Cotton osteotomies on nine cadaveric feet under fluoroscopic guidance. The sural nerve, superficial peroneal nerve and its branches, deep peroneal nerve, dorsalis pedis artery, saphenous vein, and peroneal and extensor hallucis longus tendons were carefully dissected from each cadaveric foot and evaluated for injuries following the MIS osteotomy cuts. The distance from the osteotomy cuts and these anatomic structures were measured and recorded.

Results:

On average, the sural nerve was 8.4 mm and 9 mm from the calcaneal and Evans osteotomy sites, respectively. The intermediate dorsal cutaneous nerve was on average 68.3 mm and 41.1 mm from the calcaneal and Evans osteotomy sites, respectively. The peroneal tendons were on average 16.7 mm and 0 mm from the calcaneal and Evans osteotomy sites, respectively. The extensor hallucis was an average of 1 mm from the Cotton osteotomy site. There was a partial tear injury to the peroneus brevis in four of the cadaveric specimens at the Evans osteotomy site without complete laceration. There was no injury to the sural nerve, superficial peroneal nerve and its branches, saphenous vein, deep peroneal nerve, dorsalis pedis artery, or extensor hallucis longus tendon.

Conclusion:

Tendinous and neurovascular structures are at risk with MIS AAFD osteotomy procedures. Care should be taken with soft tissue handling and blunt dissection to decrease iatrogenic injuries to these structures. Specifically, extra care and recognition of the peroneal tendons during the Evans osteotomy may prevent damage, as this structure was at greatest risk among the three osteotomy cuts. Future research studies evaluating this technique and the functional outcomes in patients in a clinical setting is warranted. Surgical technique studies are underway to implement smaller, yet appropriate bone grafts through mini incisions.
A Retrospective Chart Review Examining Gabapentin’s Potential Neuroprotective Effects in Peripheral Nerve Blocks
Authors: Shuster David M. , Brower Jacob , Cheney Nicholas A. , Clark Brian C.
Published: November 2020

Category:

Other

Introduction/Purpose:

Regional anesthesia is routinely used in association with outpatient surgical procedures to mitigate postoperative pain. This has been associated with better surgical outcomes and decreased post-surgical opioid consumption. Administration of a nerve block; however, can lead to complications. These complications are typically due to nerve damage caused by the injection and leading to lasting neurologic symptoms unrelated to the surgical procedure itself. Although nerve block complications are rare and temporary, lasting complications can be debilitating. Based upon a few total knee arthroplasty studies this study theorized that Gabapentin could be used as a neuroprotectant thereby decreasing the rates of lasting complications from peripheral nerve blocks. This study compares the number of nerve block complications with and without the use of Gabapentin peri/post operatively.

Methods:

This study was completed through retrospective chart analysis of the senior author’s patients from January 2019 to September 2019. Charts of patients that received a preoperative nerve block were used to calculate rates of lasting complications. The rate of complications in this subset of patients was compared to the group of patients who did not receive this medication pre and post operatively from an earlier study.

Results:

Nerve block complication rates when administering 600mg of gabapentin 1-hour pre-surgery along with 100 mg of gabapentin three times daily for three days post-surgery, was 7.69% (N = 78; P=0.4261). However, there was an insufficient number of study participants to make a definitive conclusion.

Conclusion:

Administration of pre and post-operative gabapentin does not decrease nerve block complication rates when compared to no pre and post-operative gabapentin to a statistically significant amount. This was largely due to limited sample size, which was a major limitation of this study. A previous study was done with the same physician and the same patient population. In this study they found a 10.1% complication rate, seen in the evaluation of 855 patients charts. Due to a discrepancy in sample size, a conclusion cannot be made but further research is necessary to understand gabapentin’s potential neuroprotective effects in nerve blocks.
Evaluation of the Anterior Talofibular Ligament by Stress Ultrasound for Assessing Generalized Joint Hypermobility
Authors: Song Jaehwang , Kang Chan , Jeon Je Hyung , Ham Chang Uk
Published: November 2020

Category:

Ankle; Basic Sciences/Biologics

Introduction/Purpose:

Chronic ankle instability with generalized joint hypermobility (GJH) is considered a relative contraindication for the modified Bröstrom procedure. Most clinicians use the Beighton score to assess GJH. However, the Beighton score itself does not involve investigation of the ankle joint. In our experience, resting, longitudinal ultrasound images of the uninjured, intact ATFL frequently show a loose, wavy pattern in patients with high Beighton scores. We evaluated anterior talofibular ligament (ATFL) status according to Beighton score and the manual anterior drawer test (ADT). It was hypothesized that the value of ultrasound for ATFL would be significantly different between participants with GJH (Beighton score >= 5) and without GJH and show a correlation with participant’s Beighton scores and manual ADT grades.

Methods:

Forty-four healthy young patients (44 ankles) aged 20 to 40 years and without a history of ankle trauma or disease were included in the study. To assess GJH and ankle instability, Beighton scores and manual ADT grades were evaluated, respectively. For the investigation of ATFL, resting and stress ultrasonography were performed to assess its length, height, and thickness. Ultrasound images were taken in resting position and during maximal plantar-flexion and inversion (Figure: Ultrasound images of the ATFL in (a) the resting position and (b) stress position in a 21-year-old woman with Beighton score of 9. Dotted red line: Length, Yellow line: Height, Green double-headed arrow: Thickness). Beighton scores, manual ADT grades, and ultrasound parameters of participants with and without GJH were compared and the correlation coefficients among Beighton scores, manual ADT grades, and the length, height, and thickness of resting and stress ATFLs were analyzed.

Results:

The participants were divided into two groups, those without GJH (24 ankles) and with GJH (20 ankles). Mean Beighton scores and manual ADT grades were significantly different between the two groups (P < .05). The mean length, height of resting, stress ATFL and mean difference in height between resting and stress ATFL were significantly different between the two groups (P < .05). The resting and stress ATFL length, height, and difference in height between resting and stress ATFL showed a moderately positive linear relationship with Beighton scores and manual ADT grades (P < .05). Among the ATFL parameters, resting ATFL height showed the strongest relationship with the Beighton score (r = 0.763, P < .001) and ADT grade (r = 0.763, P < .001).

Conclusion:

The ATFL stress ultrasound parameters showed significant differences between participants with high and low Beighton scores and were correlated with Beighton scores and manual ADT grades. We believe that this ankle joint specific method might provide significant, quantitative parameters for assessing GJH in addition to the Beighton score.
Fracture of the Posteromedial Tubercle of the Talus: Case Series of Fifteen Patients Along with Cadaveric Dissection and Anatomic Considerations for Surgical Approach
Authors: Steffensmeier Andrew M. , Matar Robert , Chung David , Yue Ruixian A. , Dixon Tonya L. , Sagi Claude , Laughlin Richard T. , Steffensmeier Andrew M.
Published: November 2020

Category:

Ankle; Hindfoot; Trauma

Introduction/Purpose:

Fractures of the talus are among the most commonly fractured bone of the foot, with 10 to 21% involving the posterior process. These fractures have not been well characterized or reported in the literature and is limited to case reports and case series. The primary objective of this study is to characterize posterior process fractures, describe a surgical approach for open reduction internal fixation (ORIF) with the use of cadaveric dissection pictures of surgical technique and describe 15 cases.

Methods:

A search query of the institutional database was performed for all adult patients that sustained talar fractures at the University of Cincinnati Medical Center from 1/1/2010 to 12/31/2018. Patients sustaining posterior process talus fractures who underwent operative fixation and nonoperative treatment were identified. All radiographs and CT images were then reviewed by three orthopedic surgeons and the electronic medical record was reviewed for injury characteristics, method of operative fixation, and postoperative complications.

Results:

15 cases of posterior process fractures were identified. Overall, 4 patients had fixation placed in the posterior process fracture while 11 did not. None of the patients who underwent ORIF of the posterior process developed subtalar arthritis at their latest follow-up, while 3 of the 11 (27.3%) that did not receive fixation suffered from subtalar arthritis and 1 (9.1%) required surgery for removal of retained loose bodies. 13 patients (86.67%) initially had plain radiographs that missed the diagnosis. Cadaveric specimens were used to illustrate surgical approach for ORIF of these talus fractures. Anatomic pictures of the surgical dissection were taken to show the extent of exposure to the posterior process fracture using traditional techniques, as well as methods of distraction to enhance visualization are demonstrated.

Conclusion:

Providers must have high suspicion for posterior process talus fractures as many are missed on the initial radiographs. CT scans are recommended for all patients with subtalar dislocations. Those with subtalar dislocation tend to have comminuted fragments. Significant morbidity is associated with this injury regardless of whether it is treated operatively or nonoperatively. We describe a surgical technique using distractors to adequately visualize the posteromedial process fracture of the talus.
Reliability of Evaluating Methods using Weightbearing Radiograph of the Foot in Lisfranc Injuries
Authors: Sugino Yuki , Yoshimura Ichiro , Hagio Tomonobu , Nagatomo Masaya , Yamamoto Takuaki
Published: November 2020

Category:

Trauma; Midfoot/Forefoot

Introduction/Purpose:

Lisfranc ligament is a strong interosseous ligament located between the medial cuneiform (C1) and base of the second metatarsal (M2). Lisfranc injuries occur in approximately 0.2% of all fractures and are often overlooked or misdiagnosed. Weightbearing radiograph of the foot has been used as a diagnostic method for Lisfranc injuries; however, there is no study to evaluate the reliability of the measurement techniques on weightbearing radiographs. While several measurement techniques on weightbearing radiograph have been proposed for evaluating Lisfranc injuries, it remains unclear which measurement is the most reliable. This study aimed to evaluate the intra- and inter-observer reliability of the measurement techniques using weightbearing radiographs.

Methods:

Seventeen patients who were diagnosed with Lisfranc injuries using weightbearing radiographs and were treated with open reduction and internal fixation in our hospital between January 2013 and April 2019 were included in this study. Patients with multiple fractures were excluded. Four observers were selected, of which two were orthopedic specialists with more than six years of experience, while the remaining two were orthopedic surgeons with less than five years of experience. Observers evaluated the intra- and inter-observer reliability of the five measurement points on weightbearing radiographs on the affected and unaffected sides. The measurement points included the proximal, middle, and distal C1-M2 distance and parallel distance of C1-M2 and C1- the medial cuneiform (C2).

Results:

The proximal, middle, and distal C1-M2 distance and parallel distance of C1-M2 of The affected sides were wider than those of the unaffected sides with significant difference (p<0.01). The middle C1-M2 distance of the affected sides showed the highest intra-observer reliability (0.92) and the second highest inter-observer reliability (0.8). Other measurements of the affected sides showed comparable intra- (0.76-0.91) and inter-observer reliability (0.62-0.84). In addition, the middle C1-M2 distance of the unaffected sides showed the highest intra- (0.76) and inter-observer reliability (0.64); however, all measurements of the unaffected sides showed lower reliability than all measurements of the affected sides.

Conclusion:

The most reliable measurement point on the weightbearing radiograph was the middle distance of C1-M2. This result may help avoid overlooking or misdiagnosis of Lisfranc injuries.
Minimal Invasive Hallux Valgus Surgery
Authors: Tenenbaum Shay A. , Thein Ran , Ari Erel Ben , Dreiangel Niv , Bariteau Jason T. , Bruck Nathan , Coifman Oded R.
Published: November 2020

Category:

Bunion; Other

Introduction/Purpose:

Hallux valgus is one of the most common deformities of the adult foot, and can adversely affect quality of life, with common complaints including pain, footwear restrictions and cosmesis. Minimal Invasive Surgery (MIS) has re-emerged lately, gaining growing popularity as a surgical approach for surgical treatment of HV deformity. Advantages such as short operating time, quicker recovery, and fewer complications have attributed to MIS. However published data are still inconclusive.

Methods:

The study included 40 feet (33 pts) with hallux valgus treated with MIS technique, between Apr 20016 to March 2018. Patients were included only if pre- and postoperative weightbearing X-rays at final followup (min 6m) were available. The average age was 51.3 years (range, 21 to 77), with average follow-up of 12 months (range, 6 to 24). Patients’ radiographic records were studied to evaluate postoperative change in hallux valgus angle (HVA), intermetatarsal angle (IMA) and DMAA. Clinical outcome was recorded with Patient reported outcome questioners PROMS10 and MOXFQ.

Results:

Following surgery deformity was corrected with preoperative mean HVA of 29.8° and IMA of 14.4° compared to postoperative mean of 7.1° and 4.7°, respectively. Patient reported outcome measures recorded the efficacy of MIS for HV in terms of pain reduction and function improvement. In six feet surgery for hardware removal was performed. In one case non- union was treated with revision surgery.

Conclusion:

This study shows that MIS for HV is safe, effective and offers satisfactory surgical and clinical results.
2-Week Post-Operative Opioid Use after Primary Hallux Valgus Correction
Authors: Thier Zachary T. , Altobello Kenna C. , Gonzalez Tyler A. , Jackson J. Ben
Published: November 2020

Category:

Bunion; Other

Introduction/Purpose:

More than 200,000 surgeries for hallux valgus correction occur annually in the United States. Due to the post-operative pain associated with the procedure, opioids are often prescribed to help manage pain. The opioid epidemic has led to a 78-billion-dollar economic impact. Given the lack of objective data on opioid use and the difficulty of addressing a patient’s post-operative pain, we sought to quantify, through a prospective analysis, patient’s narcotic use after hallux valgus surgery. Objective data may help guide the surgeon in the type and number of opioids utilized after surgery.

Methods:

Adult patients undergoing primary hallux valgus surgery were recruited from two surgeon’s institution. At the pre- operative visit, patients were consented and completed a demographical questionnaire. Data was collected from the operative and PACU record, as well as the 2-week post-operative visit. A simple statistical analysis was performed to determine average quantity and type of opioid and non-opioid pain medication used in the PACU and for post-operative pain management.

Results:

33 subjects were prospectively enrolled and followed. The average time until the first post-operative clinic visit was 13.53 days. The average opioid pain medication consumption during this period was 20.766 (0-66) pills, with a morphine milligram equivalents (MME)/kg of body weight at 1.69. (78.8%) were prescribed hydrocodone/acetaminophen 5/325mg and 7 subjects (21.2%) were prescribed oxycodone/acetaminophen 5/325 for post-operative pain management. 84.8% of subjects (28/33) received a local block, including 2 femoral, 2 ankle, 13 popliteal, 3 sciatic, 3 adductor canal, 4 popliteal and saphenous, and 1 popliteal and adductor canal. 24.2% (8/33) of subjects received opioid pain medication in the PACU post-operatively with a MME/kg of body weight at 0.135 per subject.

Conclusion:

Based on our prospective study, we recommend an initial prescription of 30 5mg hydro/oxycodone pain pills, as this represents the 3rd quartile of consumption.
Efficacy of the Glidepath Technique for Ankle Syndesmosis Reduction
Authors: Unangst Alicia M. , Ryan Paul M. , Harris Mitchell , Song Daniel
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

Syndesmotic screw fixation is frequently required in rotational ankle injuries. Fibular malreduction after syndesmotic screw fixation occurs in as many as 52% of cases, which has been shown to detrimentally affect subjective outcomes and increase the probability of developing arthritis. The glidepath technique has been proposed as a useful technique to prevent malreduction. We hypothesize that the glidepath technique reduces the occurrence of fibular malreduction and results in improved outcomes compared to clamping.

Methods:

A retrospective cohort study comparing 25 patients reduced with a clamp compared to 18 patient using the glidepath technique. The glidepath technique, described by Needleman, the fibula is manually reduced and a Kirschner wire is placed through the fibula and tibia along the transmalleolar axis, parallel to the superior border of the ankle mortise. CT scans of the injured and contralateral ankles were obtained postoperatively to assess reduction. Malreduction is defined as >2mm difference between the anterior or posterior incisura-fibular distance of the injured ankle compared to the contralateral side. Prospective outcomes were assessed using the AOFAS and VR-12 scores at preoperative, 3 month, 6 month and 1 year followup of the glidepath cohort only.

Results:

We found a statistically significant reduction in malreduced syndesmoses using the glidepath technique when compared with the clamping technique. In our study, 17% (3/18) were malreduced using the glidepath technique, compared with 48% (12/25 patients) with clamping (p=0.005). The three malreductions seen in our study were anterior, we had no posterior malreductions. Compared with the clamping cohort that had 10/25 posterior malreductions and 2/25 anterior malreductions. Mean outcomes at 3,6 and 1 year scores were AOFAS 76, 86,86; VR-12 46,53,50/ 42,44,47 (physical/mental) respectively.

Conclusion:

Historically, malreduction for syndesmotic fixation is as high as 52%. The glidepath technique is a viable reduction maneuver that has lower rates of malreduction compared to clamping in our study. This is the first ever CT confirmed study measuring syndesmosis reduction utilizing manual reduction. The value of this technique is that is does not require an open reduction, arthroscopic visualization/reduction or CT guidance to achieve syndesmotic reduction.