bluuebunny/crossref_metadata_2025 huggingface dataset:
Demographic Factors Associated with Anterior Tibial Tendon Pathology
Authors: Levitsky Matt , Greisberg Justin , Vosseller J. Turner
Published: October 2019

Category:

Sports, tendon

Introduction/Purpose:

The tibialis anterior serves an important role in ankle motion as it provides the majority of strength with dorsiflexion. Despite the importance of this muscle, there is a relative dearth of information regarding risk factors and demographic information that might predispose people to tendinopathy or rupture. The goal of this study is to further investigate the features of patients in a single institution who presented with either tibialis anterior tendinopathy or rupture. We also examined the ways in which these patient characteristics might differ in traumatic (patient remembers feeling a pop after a specific activity) versus atraumatic tendon ruptures (happened spontaneously without patient realizing).

Methods:

We used ICD-9 and ICD-10 codes to find patients who presented with tibialis anterior pathology to two foot and ankle surgeons at one academic medical center from 2007-2018. We made note of patient characteristics such as age, gender, BMI, and medical comorbidities. Physical examination findings, such as gastrocnemius equinus, were noted as well. Characteristics of patients with traumatic and atraumatic tibialis anterior ruptures were compared using Student’s T-tests and chi-squared tests.

Results:

The characteristics of 93 consecutive patients between 2007 and 2018 were analyzed. There were 80 cases of tendinopathy, and 13 cases of tibialis anterior rupture. The average age of our patient group was 56 years, and the ratio of female to male was 73:20 (3.67:1). The average BMI was 27.2 kg/m2. 15 patients had a gastrocnemius equinus (16%). 75 patients had a neutral arch (81%), 16 patients had pes planus (17%), and two patients had pes cavus (2%). With regards to those who ruptured, there were two traumatic ruptures and 11 atraumatic ruptures. Average age for traumatic rupture was 39 years compared to 73 for atraumatic rupture (p<.05). Average BMI for traumatic rupture was 21 compared to 27 kg/m2 (p>.05).

Conclusion:

Our study investigates the features of patients in a single institution who presented with tibialis anterior pathology. This pathology was much more common in women and generally occurred in an older cohort. With regards to tendon ruptures, though, younger patients tend to suffer traumatic ruptures, while older patients are more likely to suffer more degenerative ruptures that required less energy for tensile failure of the tendon.
Percutaneous Treatment of Achilles Tendon Rupture: A Patient Report Outcome Study
Authors: Lima Mateus C. , Patel Milap S. , Kadakia Anish R.
Published: October 2019

Category:

Sports, Achilles Tendon

Introduction/Purpose:

Achilles tendon rupture is a common injury with increasing incidence in adults. While multiple studies have been conducted to determine the optimal surgery for an Achilles rupture, there is a lack of consensus around which surgical method serves as the best treatment. The predominant surgical options that are currently performed include open repair and minimally invasive or percutaneous Achilles rupture surgery (PARS), with comparative studies between open and PARS showing similar functional results. However, there is a lack of objective patient reported outcomes (PRO) for these procedures in the literature. To our knowledge, our study is the first prospective study to use validated patient reported outcomes (PROMIS®) to compare pre-operative and post- operative outcomes for the PARS surgery.

Methods:

Pre- and post-operative data for the PROMIS Physical Function and Pain Interference Computer Adaptive Tests (CATs) was collected for over 100 Achilles rupture patients at a major tertiary care facility and level I trauma center starting in 2014. Each of these patients were contacted at regular intervals for repeat survey evaluation at multiple post-operative time points via email or phone. Patients treated for chronic Achilles rupture as well as patients without adequate post- operative follow up of a minimum of 2 years were excluded. We conducted a preliminary analysis on a total of 21 patients with acute Achilles rupture Injury treated with PARS and 2 years post- operative PROMIS follow up. For each outcome, a Wilcoxon signed-rank test was used to assess the mean difference between pre-operative and post-operative scores. The statistical analysis was conducted by statisticians who were blinded and worked independently of the orthopedics department.

Results:

Based on the Wilcoxon signed-rank test, there was significant mean difference between pre-op and post-op physical function scores (p=0.0009 < 0.05) and no significant mean difference between pre-op and post-op pain scores (p=0.1743 > 0.05). Mean post-operative scores were at the 54th percentile for function and 44th percentile for pain.

Conclusion:

While our study is a preliminary investigation into the use patient-reported outcomes in determining the outcomes of PARS, we aim to expand on our findings as more patients reach 2-year post- operative status. Our preliminary findings are however consistent with the literature regarding the viability of PARS in treating acute Achilles ruptures with positive results similar to other techniques. While patients’ experience a minor loss in post-operative physical function as compared to their pre- injury status, PARS restores physical function scores to that of the mean population while restoring pain scores to baseline levels.
Radiographic Predictors for Adverse Outcomes Following Surgical Correction of Hammertoe Deformity
Authors: Maidman Samuel D. , Erwood Amalie A. , Brodsky James , Daoud Yahya , Fantry Amanda , Tenenbaum Shay , Bariteau Jason T.
Published: October 2019

Category:

Lesser Toes

Introduction/Purpose:

Hammertoe deformities are common, often painful deformities of the lesser foot and are known to severely affect physical function. When patients seek surgical management, x-ray imagining is utilized for diagnosis, evaluation for surgical candidacy, and selection of the operative technique. Postoperatively, radiographs are retaken to assess bone health, healing status, and alignment. Despite their frequent use, no previous data support particular X-ray findings as being indicative of clinical presentation nor surgical outcomes. The aim of this study is to identify specific radiographic parameters that are predictive of pain and function outcomes after surgical correction of hammertoe deformity.

Methods:

Prospectively collected data was reviewed on 116 patients who underwent hammertoe correctional surgery. Patient demographics, comorbidities, and postsurgical complications were recorded from their electronic medical records. Clinical outcomes were assessed utilizing preoperative and postoperative pain Visual Analogue Scale (VAS) and Short Form Health Survey Physical Component (SF-36 PCS) scores with 1-year follow-up. Radiographs were scored by a foot & ankle fellowship-trained orthopaedic surgeon to assess preoperative severity, postoperative joint fusion, and both pre- and postoperative joint instability. Data was examined using chi-squared, t-test, and ANOVA analyses.

Results:

Preoperatively, 14.7% of patients had a deformity classified radiographically as mild, 37.1% as moderate, and 48.3% as severe. X-rays prior to surgery showed that 65.5% had MTP joint instability, 9.5% had joint dislocation, and 18.1% had joint arthritis. Postoperatively, 78.5% had PIP joint fusion, 38.8% had MTP joint arthritis, and 17.2% had MTP joint instability. A significant association was found between postoperative MTP joint instability and a lower 1-year SF-36 PCS (p=0.0032). There were no associations found between the other radiographic findings and postoperative outcomes, and no parameters were associated with pain VAS scores.

Conclusion:

After undergoing surgical correction of hammertoe deformity, the postoperative radiographic finding of MTP joint instability was determined to be predictive of physical function. However, neither metatarsophalangeal joint arthritis nor PIP fusion were predictive of outcomes. This work informs foot and ankle specialists that proper joint alignment and stabilization is critical to ensuring success in hammertoe surgery.
Octogenarian and Nonagenarians Are at a Higher Risk for Experiencing Adverse 30-Day Outcomes Following ORIF for Ankle Fractures
Authors: Malik Azeem Tariq , Khan Safdar N , Phieffer Laura , Ly Thuan V , Wiseman Jessica , Sheridan Elizabeth , Quatman Carmen E
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Despite an increasing number of elderly individuals undergoing surgical fixation for ankle fractures, few studies have investigated peri-operative outcomes and safety of surgery in an octogenarian and nonagenarian population (age >=80 years). Past literature has shown octogenarians to be a potentially vulnerable population that have drastically different adverse outcomes and higher resource utilization as compared to individuals below the age of 80 years.

Methods:

The 2012-2017 American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) was queried using Current Procedural Terminology codes for patients undergoing open reduction internal fixation (ORIF) for isolated uni-malleolar (CPT-27766, CPT-27769, CPT-27792), bi-malleolar (CPT-27814) and tri-malleolar (CPT-27822, CPT-27823) ankle fractures. The study cohort was divided into three distinct groups for comparisons (Age <65 years, Age 65-79 years and Age=>80 years/octogenarians + nonagenarians). Multi-variate regression analyses were used to compare the independent effect of varying age groups on 30-day post-operative outcomes while controlling for differences in baseline clinical characteristics (age, gender, sex, race, fracture type/severity, open vs. closed fracture, admission status, BMI, co-morbidities, functional health status, ASA group and operative time). For comparison purposes, Age<65 years was taken as reference group in multi-variate regression models.

Results:

A total of 19,585 patients were included – out of which 1,033 (5.3%) were octogenarians/nonagenarians (=>80 years). Following multivariate analysis, individuals aged =>80 years were at a significantly higher risk of 30-day wound complications (OR 1.84; p=0.019), pulmonary complications (OR 3.88; p<0.001), renal complications (OR 1.96; p=0.015), septic complications (OR 3.72; p=0.002), urinary tract infections (OR 2.24; p<0.001), bleeding requiring transfusion (OR 1.90; p=0.025), mortality (OR 7.44; p<0.001), readmissions (OR 1.65; p=0.004) and non-home discharge (OR 13.91; p<0.001). Individuals between the age of 65-79 years only had a higher risk of pulmonary complications (OR 2.30; p=0.004), urinary tract infections (OR 2.24; p<0.001), readmissions (OR 1.41; p=0.005) and non-home discharges (OR 3.55; p<0.001), with the effect sizes being small as compared to age >=80 years group.

Conclusion:

Based on the findings, it appears that octagenarians and nonagenarians (age =>80) are a fundamentally distinct and vulnerable age group that is at a higher risk of complications, readmissions, mortality and non-home discharges as compared to other geriatric (65-79 years) and non-geriatric (<65 years) patients. Providers should understand the importance of pre-operative counselling and risk-stratification in this vulnerable patient population.
Applications of the Vascularized Medial Femoral Condyle for Nonunion with Associated Bone Loss of the Foot: A Case Series
Authors: Mangold Devin , Bishop Allen T. , Moran Steven L. , Shin Alexander Y. , Ryssman Daniel B.
Published: October 2019

Category:

Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

Persistent nonunions with large bone defects continue to represent a challenging problem for foot and ankle surgeons. Vascularized corticocancellous grafts have been well described for various applications and represent a comprehensive solution to these difficult nonunion cases. We describe four cases of nonunions with concomitant large bony defects treated with a vascularized medial femoral condyle (VMFC).

Methods:

We retrospectively identified four cases of VMFC flaps used for foot nonunions with large bone defects. Surgical indications included talonavicular nonunion with associated avascular necrosis of the navicular, talonavicular-cuneiform nonunion, navicular-cuneiform nonunion, and first metatarsophalangeal nonunion. All cases had large associated segmental bone defects. The average age at the time of surgery was 62-years-old. The average follow up was 2.6 years (1.5-5.0). One patient had a remote history of tobacco use. Another patient quit smoking pre-operatively and had normal nicotine metabolite levels at the time of surgery. There was one Type II diabetic.

Results:

Two patients underwent staged reconstruction with placement of an antibiotic cement spacer, but intra-operative cultures were negative. No patient had a previous infection. The average graft dimensions were 3 x 2.25 x 1.5 cm. After obtaining adequate compression, all grafts were secured with bridge locking plates. The average time to weight bearing was 14.5 weeks. All patients had knee pain post-operatively that resolved with time. Two patients required reoperation. In one patient, the VMFC graft did not adequately fill the defect requiring supplement allograft. The VMFC-allograft interface went on to nonunion requiring tricortical iliac crest bone grafting. Another patient developed a split-thickness skin graft (STSG) infection requiring debridement and repeat STSG. There were no VMFC graft failures, and all patients went on to successful union.

Conclusion:

Vascularized medial femoral condyle autografts are a technically demanding solution to difficult nonunion cases with significant associated bone loss of the foot.
Late Abduction Deformity of the Midfoot Following the “Medial Double” (Diple) Procedure for Hindfoot Valgus Deformity
Authors: Manoli Arthur
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

There has been considerable interest in recent years in performing a combined talonavicular and subtalar arthrodesis instead of a standard triple arthrodesis for a rigid hindfoot deformity. The ”medial double” (diple) avoids fusing the calcaneocuboid joint with its lateral incision, common bone block graft and high rate of complications. Although the results of the “medial double” are generally satisfactory, there are no reports of late midfoot abduction deformity, although it was predicted by Evans in 1975.

Methods:

A 79 year-old-male with long-standing skin psoriasis with joint involvement presented with severe bilateral flatfoot deformities. The left hindfoot was arthritic, deformed and painful. Despite a conservative course of orthotics and ankle braces, the pain persisted. Because there was a psoriatic plaque over the lateral side of the foot, it was decided to perform a ”medial double” arthrodesis with screw fixation, a plantarflexing 1st tarsometatarsal joint fusion for medial column stabilization, and a heel cord lengthening

Results:

Skin and bony healing were uneventful. Over the subsequent three years a progressive abduction deformity developed through the naviculocuneiform joints and the unfused calcaneocuboid joint. The patient had only occasional pain in the midfoot and wore wide shoewear to accommodate the deformity.

Conclusion:

A late abduction deformity can develop through the midfoot in patients who have the ‘medial double” procedure for hindfoot valgus. The cuboid settles proximally against the short distal calcaneus, and the naviculocuneiform joints sublux laterally. In patients with hindfoot valgus with severe lateral column shortening secondary to calcaneocuboid joint remodeling, it may be better to perform an actual triple arthrodesis with a bone graft in the calcaneocuboid joint instead of a “medial double.” Alternatively, one could add a naviculocuneiform arthrodesis to the ”medial double” arthrodesis to prevent this complication.
Fracture Immobilization in an Austere Environment: A Comparative Study of Military Special Operations Medical Personnel using a SAM Splint vs a One-Step Spray on Foam
Authors: Martin Kevin D. , Unangst Alicia , Chisholm Jaime
Published: October 2019

Category:

Trauma

Introduction/Purpose:

Improved body-armor and mine resistant vehicles have improved battlefield survivability, but now nearly 50% of casualties have a musculoskeletal extremity injury. The purpose of the current study was to evaluate current SAM splint techniques utilized for a distal Tib/Fib fracture verse a new one-step spray on foam immobilization technique.

Methods:

A cadaveric model with a distal third combined tibia-fibula fracture was used for testing. The specimens were placed in an austere environment and participants immobilized the injury with standard equipment (SAM splint, 6in Ace wrap). The test group immobilized the injury with a one-step in-situ spray on foam splint.

Results:

Twenty-one military Joint Special Operations Command (JSOC) medical personnel (11 Medics, 4 PAs, 6 Physicians) participated with an average of 7.7 years as a provider and 25.4 months deployed in a combat theater. Each participant was observed and scored by a single orthopedic foot and ankle surgeon using a Likert scale based on 10 splinting criteria. Standard SAM splinting resulted in an average score of 32.2 (range, 5-50), with significant deficiencies in fracture traction (1/5), fracture motion (2.9/5), protection of neurovascular structures (3/5), and soft tissue manipulation (3/5). The average time to completion was (203 sec), with one splint failure. The spray on foam splinting technique yielded a significantly higher score of 48.5 while completing the task significantly faster at 68 sec with no failures.

Conclusion:

JSOC medical personnel demonstrated overwhelming success in immobilizing a complex extremity fracture with a SAM splint. Testing demonstrated the inherent inability of the SAM splint to provide longitudinal traction while simultaneously allowing excessive fracture motion and potential injury to the soft tissues. In addition, our spray-on foam proof of concept technique eliminated motion and provided traction by allowing in-situ application with adequate rigidity.
Bone Anchor Suture Tape Fixation Technique for the Treatment of Calcaneal Avulsion Fractures
Authors: Miskiel Sandra A. , Pagliaro Andre J.
Published: October 2019

Category:

Hindfoot, Trauma

Introduction/Purpose:

Surgical treatment of avulsion fractures of the calcaneus has a reported fixation failure rate as high as 23%, and there is much controversy surrounding the best method of treatment for these fractures. We present a technique for fixation of calcaneal avulsion fractures utilizing a bone anchor suture tape fixation technique that can be utilized with or without additional standard internal fixation.

Methods:

Five patients (2 male, 3 female), with an average age of 73 years old, presenting with a closed extraarticular avulsion fracture of the calcaneus, are included in this case series. Patients underwent bone anchor and suture tape fixation of fracture by a single foot and ankle-fellowship trained orthopaedic surgeon. Patients were additionally assessed pre-operatively, using the contralateral uninjured limb, for gastrocnemius equinus; and if present, patients underwent a gastrocnemius recession. If appropriate, a single compression lag screw and washer inserted perpendicular to fracture line was utilized for additional fixation. Outcomes observed were time to radiographic consolidation, failure of fixation, reoperation rate, presence of post-operative infection, and return to previous function.

Results:

Of the included patient cohort, all fractures went on to union, and there were no failures of fixation. There was one removal of a compression screw and washer due to hardware pain, and one superficial infection, which resolved with local wound care. All patients went on to weight-bearing as tolerated within 8 weeks post-operatively. Radiographic consolidation was observed at approximately 12 weeks. 4 out of 5 patients returned to previous function, with 1 patient expiring due to unrelated causes prior to determination of final function.

Conclusion:

Use of a bone anchor suture tape fixation technique appears to hold promise and warrants further investigation for its potential utilization as a reliable technique for fixation for avulsion fractures of the calcaneus. Our technique increases the distribution of surface area forces over the cortical bone while incorporating multiple points of fixation, including through the Achilles tendon insertion, neutralizing the distraction forces of the tendon directly.
Bi-Radial Curvature Morphology of the Healthy Talus
Authors: Myerson Mark , Clancy James , Paxson Bob , Obert Richard , Anderle Mathew , Brinker Laura , Daniel Lee Eng M.
Published: October 2019

Category:

Ankle

Introduction/Purpose:

In order to design an implant for the ankle joint that mimics normal joint motion, the condylar geometry of the talus must be anatomically accurate. Previous attempts to describe the curvature of the talus have typically involved fitting single-radius arcs to the medial and lateral facets. The purpose of this investigation was to determine if the curvature of the medial and lateral sides of the talus can be more accurately described by dividing the condyles into anterior and posterior regions, thus creating bi-radial curves for both the medial and lateral sides of the talus.

Methods:

After IRB approval, 18 subjects (9 male, 9 female; mean age 34.5 years) underwent weight-bearing CT scans at mid- stance of simulated gait. All subjects were deemed to have a healthy right ankle by the surgeon investigator. CT images were used to generate 3D models of each talus. A coordinate system was defined and the articular surface of the talus was separated into four sections: medial-anterior (MA), medial-posterior (MP), lateral-anterior (LA) and lateral-posterior (LP). The curvature of each section was defined by selecting points on the articular surface at 10° intervals. The extent of each radius was 30° of arc and the magnitude of each radius was selected to minimize the gaps between the radii and the spline curve to define a best-fit bi-radial approximation to the spline curve using geometry that could be easily used to define the articular surface of the talus. Ratios of the aforementioned radii were calculated.

Results:

The average MA, MP, LA and LP radii were 18.3 mm, 26.6 mm, 21.5 mm and 25.1 mm, respectively. The medial (A/P), lateral (A/P), anterior (M/L) and posterior (M/L) radii ratios were 0.70, 0.87, 0.88 and 1.07, respectively. The anterior and posterior ratios were compared using a paired t-test and found to be statistically different (P=.019). Further, the data were compared against a hypothesized value of 1 using a one-tailed one-sample t-test. The anterior ratio was significantly lower than 1 (P=.014) while the posterior ratio was significantly greater (P=.037). On the lateral side, 83.3% of the subjects exhibited a larger posterior radius than anterior radius. Only one subject (5.6%) had a larger anterior radius than posterior radius on the medial side.

Conclusion:

This study shows that the radius increases in the sagittal plane from the anterior portion to the posterior portion of both the medial and lateral sides of the talus. Furthermore, the MA radius is smaller than the LA radius. Conversely, the MP radius is larger than the LP radius. These results substantiate the validity of an implant design that incorporates a condylar radius ratio that is smaller for the anterior dorsiflexion surface and greater for the posterior plantar flexion surface. Implants with more accurate anatomical geometry may allow for more normal kinematics and potentially prolong the life of the implant.
Location and Morphology of Acute Lateral Ligament Injury of the Ankle
Authors: Noguchi Hideo
Published: October 2019

Category:

Ankle, Sports, Trauma

Introduction/Purpose:

Acute ankle ligament injuries are usually treated non-operatively, even if the injury is severe. However, when chronic ankle instability is symptomatic, operative treatment is required. When planning local repair, the condition of the remaining ligament is important. We surgically treated acute severe lateral ligament injuries in 103 ankles and investigated the locations of the injuries in the anterior talofibular (ATF) and calcaneofibular (CF) ligaments, subdividing each into three parts. This paper should facilitate more precise planning of the surgical reconstruction procedure.

Methods:

From 2006 to 2014, 1,042 patients visited our outpatient clinic with a diagnosis of acute lateral ligament injury of the ankle. In total, 103 feet underwent surgical treatment and the locations of the ATF and CF ligament ruptures were investigated. The rupture location in the ATF ligament was subclassified as fibular side, body, or talar side, while for the CF ligament it was classified as fibular side, body, or calcaneal side.

Results:

The ATF ligament was ruptured on the fibular side in 38 feet (36.9%), body in 30 feet (29.1%), and talar side in 35 feet (34.0%). The CF ligament was ruptured on the fibular side in 15 feet (14.6%), body in 26 feet (25.2%), and calcaneal side in 62 feet (60.2%).

Conclusion:

Almost all surgical reports on lateral ligament reconstruction procedures (Brostrom et al.) describe ATF ligament repair and advancement on the fibular side, although only one-third of the ligaments were injured on the fibular side in our series. About two-thirds of the CF ligaments had damage to the calcaneal side structure of the entheses. When CF ligament repair is needed, surgeons should be aware of our finding that this ligament was ruptured at the fibular attachment in only 15% of cases, and on the calcaneal side in 60%. This knowledge should lead to better results of surgical reconstruction.
Preoperative PROMIS Scores as a Predictive Method for Postoperative Success in Posterior Tibial Tendon Dysfunction Surgery
Authors: Nayak Rusheel , Patel Milap , Kadakia Anish
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

Patient Reported Outcomes Instrumentation System (PROMIS) pain interference (PI) and physical function (PF) scales were recently validated for foot & ankle surgery. Few studies have explored PROMIS in advanced posterior tibial tendon dysfunction (PTTD) surgery. We examined the change in PROMIS scores after PTTD reconstruction surgery and aimed to determine whether preoperative PROMIS scores, radiographic data, and demographic data can model and predict surgical improvement.

Methods:

PF and PI scores were prospectively obtained on 215 patients between November 2013 and May 2017. Of the 34 patients who had PTTD surgery, 25 patients were included with a minimum follow-up of 7-months (mean 21.8). Paired t-tests and multivariable linear regression models tested the difference in PROMIS scores pre- to postoperatively. Minimal clinically important differences (MCID) and receiver operator curve (ROC) analysis determined the accuracy of using preoperative scores in predicting postoperative change. The MCID for PROMIS PI and PF was defined as half of its respective standard deviation. Multivariable linear regressions with preoperative PROMIS scores, changes in radiographic imaging, and BMI were created to model change in PROMIS scores.

Results:

There was a significant difference in pre- to postoperative mean PI PROMIS scores (p = 0.0016, average change = -7.16). Mean PF scores improved postoperatively, but not significantly (p = .0595, average change = +4.17). Improvement in PI remained significant (p= 0.02) after adjusting for significant predictors (education level and diabetes status). Multivariable regression models utilizing preoperative PROMIS scores, radiographic variables, and BMI were unable to predict changes in PF and PI scores (p > 0.05). Using pre-determined MCID criteria, 68% achieved surgical success for PI (defined as change of at least -3.45) and 52% achieved surgical success for PF (defined as change of at least +3.00). However, preoperative PI (p=0.310) and PF (p=0.054) scores were unable to significantly predict MCID surgical success or failure.

Conclusion:

After major PTTD reconstruction, PI scores improve to significance but PF scores may not. After PTTD reaches an advanced stage, surgery may provide significant pain relief and improvement in physical function and radiographic parameters, but it may be difficult to predict clinical improvement based solely on preoperative PROMIS scores. Realistic expectations of improvements in pain and functionality should be maintained postoperatively in advanced PTTD surgery.
Outcomes of Revision Total Ankle Replacement: A Minimum of 2 Year Follow-up
Authors: Nicolas Andrea Pujol , Ramaskandhan Jayasree Ramas , Nurm Triin , Siddique Malik
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Total ankle replacement as a valid treatment for end stage ankle arthritis, is gaining popularity and every year there is an increasing number of procedures. With revision rates as high as 21% at 5 years and 43% at 10 years there is a need for understanding and reporting the outcome of revision ankle replacement. Our aim was to study the patient reported outcomes following revision TAR with a minimum of 2 year follow up.

Methods:

All patients that underwent a revision total ankle replacement between 2012 and 2016 were included in the study. All patients received a post-operative questionnaire comprising of MOX-FQ score, EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) and patients satisfaction questionnaire with a minimum of 2 years follow up.

Results:

32 patients had a revision total ankle replacement between 2012 and 2016. 2 patients were deceased therefore 30 patients were included in the study. 5 patients declined participation for completing questionnaires. We received 21 (66%) completed questionnaires. The mean MOX-FQ average domain score for pain was 58.8, walking/standing 65.8 and social function was 48.2. The mean FAOS scores were 50.7 for pain, 50.6 for symptoms, 54.9 for ADL and 28.2 for quality of life. The mean overall health score today for EQ-5D was 67.8/100. 45% of patients were satisfied with the pain relief and return to sports and recreation obtained following the operation, 48% were satisfied with the improved in daily activities. 52% were overall satisfied with the results from surgery.

Conclusion:

Revision total ankle replacement gives overall satisfactory results demonstrated from patients reported outcomes at a minimum of 2 years following surgery.
Patient Knowledge of Provider Training Background and Preferences for Treatment of Foot and Ankle Conditions
Authors: Nielsen Alex W. , Law Brian C. , Shi Glenn G. , Kraus Jonathan C.
Published: October 2019

Category:

Professional, Patient Care

Introduction/Purpose:

Differences exist in the training backgrounds of medical providers who treat foot and ankle disorders. Considerable overlap and similarities also exist between podiatric and orthopaedic surgeons, though patients may be unaware of the differences. It is not known to what extent professional training influences how patients seek care. The purpose of this study is to understand patients’ knowledge of the differences in professional training background between podiatry and orthopedic surgery and to determine which factors are important to patients when selecting a provider.

Methods:

Patient survey data was gathered from Froedtert Memorial Lutheran Hospital and the Mayo Clinic. A 27-question survey was administered to new patients who were referred to the foot and ankle service in an orthopedic department at both institutions. Survey questions included data on patient demographics, patient opinion, and knowledge of differences between podiatry, orthopedics, and other foot and ankle providers. Patients were grouped by provider preference. Univariate and multivariate regressions were used to characterize the study population and determine provider preference. Significance was determined through t-tests, Fisher’s Exact test, and chi-square tests.

Results:

Of the 169 patients who completed the entire survey, 99 chose “orthopedic surgeon” as their provider of preference for any foot or ankle injury. Between the groups, there was no significant difference in age, healthcare affiliation, previous podiatric visits, level of education, and perceived knowledge about the differences between the two specialties (Table 1). For patients who listed podiatry as their preference, they were less likely to expect their doctor to have completed residency (76.2% vs. 90.7-94.9%, p=0.03). Patients preferred an orthopedic surgeon over a podiatrist for ankle (63.3% vs. 9.5%, p<0.001) and knee injuries (82.8% vs. 5.8%, p<0.001), while they preferred a podiatrist for toe pain (42.6% vs. 27.8%, p<0.001). 76.3% of patients thought orthopaedic surgeons and podiatrist undergo the same professional training.

Conclusion:

Foot and ankle patients have poor understanding of the different medical and surgical training backgrounds between a podiatrist and orthopedic surgeon. The majority of patients believe podiatrist and orthopaedic surgeons have the same professional training. However, patients also believed orthopaedic surgeons have a longer training period, though it was still underestimated by three years. Patients preferred care for podiatrist with conditions affecting the toes and orthopaedic surgeons for all other conditions.
Absence of ATFL Remnant Does not Affect the Clinical Outcomes of the Modified Broström Operation for Chronic Ankle Instability
Authors: Park Sunghoon , Kim Taehun , Park Younguk
Published: October 2019

Category:

Ankle, Arthroscopy, Sports

Introduction/Purpose:

The modified Broström operation (MBO) for chronic ankle instability (CAI) has demonstrated good clinical results. Absence of ligamentous tissue was known as a risk factor for recurrence of ankle instability after the sugery. The aim of this study was to evaluate the effect of quality of ligament tissue (anterior talofibular ligament, ATFL) on prognosis in a cohort of patients with CAI after the MBO.

Methods:

This study was a retrospective case series. A total of 60 patients underwent the MBO for CAI with a mean follow-up of 30.1 months (range, 24-47 months). Presence of ATFL remnant was assessed on ultrasound (US), magnetic resonance imaging (MRI), and arthroscopy in all patients. The foot and ankle outcome score (FAOS) was used to evaluate functional outcomes. Clinical outcomes were compared according to the condition of the ligament remnant. Association with other risk factors was evaluated using multiple linear regression analysis.

Results:

ATFL was visible in 51/60 cases on US. Thirty patients had thin or absent ATFL on MRI; 22 patients, normal thickness ATFL; and 8 patients, thick ATFL. ATFL was visible in 15 patients on arthroscopy and nonvisible or not clear in 45 cases. Significant differences in FAOS were not noted according to the presence of ATFL remnant on US, arthroscopy, and the grade of ATFL thickness on MRI. No correlation was found between FAOS and the thickness of ATFL.

Conclusion:

The results suggest that the MBO for patients with CAI had good results, regardless of the presence or absence of ATFL remnant.
Platelet Rich Plasma Therapy and Understanding the Risk Factors of Heel Pain Syndrome
Authors: Pitarini Astuti , Tham Wilson , Hong See Kwok , Prabhakaran Abinaya , Han Chee Yu
Published: October 2019

Category:

Basic Sciences/Biologics, Hindfoot, Sports

Introduction/Purpose:

Heel pain syndrome is a complex condition causing morbidity and decreases the quality of life in our adult population. It is known that individuals with a body mass index (BMI) of more than >30 kg/m2 have increased risk of plantar fasciitis. However, heel pain consists of larger entities not merely to plantar fasciitis alone. Limited study mentioned the association between hypertension and musculoskeletal pain. Platelet rich plasma (PRP) therapy is an emerging treatment option for its regenerative properties in the treatment of degenerative enthesopathic conditions as in plantar fasciitis and lateral elbow epicondylitis. We hypothesize that obesity (BMI>30 kg/m2) and hypertension do influence the poorer outcome after PRP injection in individuals with heel pain.

Methods:

We analysed 154 heel pain cases from orthopaedic outpatient clinic that were treated with PRP injection. BMI and BP were taken as preadmission measurements with at least three readings for blood pressure. PRP was harvested from the antecubital vein, and spun in a centrifuge machine. Follow-up was conducted with AOFAS Ankle Hindfoot system before injection, 6 weeks and up to 2 years after injection.

Results:

Mean age was 49.96 (range 20-81 years old) with 52.60% female and 47.4% male. Plantar fasciitis was the majority source of heel pain (71.43%) followed by achilles tendinopathy (26.62%), posterior tibial tendon disorder (1.3%), and peroneal tendinopathy (0.65%). One hundred and twenty-eight (83.1%) patients achieved resolution of heel pain and related symptoms after injection. Statistical analysis was performed using one sample student t-test. No statistical significant result was found in both overweight (p =0.29) and obesity grade 1 (p = 0.40). Statistical significant result found in the prehypertension group (p<0.04).

Conclusion:

Based on this preliminary data, we recommend weight loss with trials of lifestyle modification in individuals with obesity, and better control of our patients’ blood pressure in order to achieve comparable outcome with normal BMI population.
Dorsiflexory Wedge First Metatarsal Osteotomy: Does an Oblique Cut Increase Surface Area?
Authors: Prissel Mark , Van Dyke Bryan , Brandao Roberto , Halverson Adam , McGann Maria , Hyer Christopher
Published: October 2019

Category:

Ankle

Introduction/Purpose:

A plantarflexed first metatarsal can contribute to a forefoot driven cavus foot deformity or result in plantar ulcerations from forefoot pressure overload in a neuropathic patient. Often, this deformity is managed via a dorsiflexon first metatarsal base osteotomy. This osteotomy is often described as a vertical wedge, with a dorsal base, in the proximal metatarsal. Alternatively we propose an oblique wedge, which may also allow for increased surface area for osseous healing to occur, in addition to being more theoretically stable to weightbearing with greater fixation options.

Methods:

Ten cadaveric below-knee specimens were randomized into an oblique wedge (5 specimens) and vertical wedge (5 specimens) groups. The osteotomies were performed by a single surgeon on the same date. Digital calipers were utilized to obtain measurements to calculate surface area for each osteotomy. Demographic data including patient age at death, height, weight, BMI, sex, and laterality were obtained.

Results:

The mean surface area of the proximal metatarsal for the vertical group was 298.2±76.5 mm2, whereas the oblique group was significantly larger at 538.6 ± 200.4 mm2 (CI 95%, p=0.0255). Similarily, but not to significance the distal side of the osteotomy demonstrated increased surface area for the oblique group with 397.8±191.4 mm2 compared to the vertical group with 265.8±75.3 mm2 (CI 95%, p=0.13. The groups were demographically similar, including height (CI 95%, p=0.62) and BMI (CI 95%, p=0.19).

Conclusion:

Our results demonstrate significantly greater surface area for the oblique dorsiflexory wedge first metatarsal osteotomy, compared to the vertical dorsiflexory wedge first metatarsal osteotomy. Further analysis is recommended for large cohort head-to-head clinical comparison of these techniques with consideration for cost effectiveness of fixation constructs, procedural complications and patient reported clinical outcome measures.
Mid-term (4-7 years) Results of Matrix-Associated Stem Cell Transplantation (MAST) in Chondral Defects of the First Metatarsophalangeal Joint
Authors: Richter Martinus , Zech Stefan , Meissner Stefan , Naef Issam
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Matrix-associated stem cell transplantation (MAST) has shown good short-term results for treatment of chondral defects at first metatarsophalangeal joint (MTP1). The aim of the study was to assess mid-term results (=4-year-follow- up).

Methods:

In a prospective consecutive non-controlled clinical follow-up study, 61 patients with 81 chondral defects at MTP1 that were treated with MAST from October 1, 2011 to October 31, 2014 were analysed. Degree of osteoarthritis, range of motion (ROM), size and location of the chondral defects, pedographic parameters, and the Visual Analogue Scale Foot and Ankle (VAS FA) before treatment and at follow-up were registered and analysed. Bone marrow aspirate was harvested from the ipsilateral pelvic bone marrow and centrifuged (10 minutes, 1,500 RPM). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Guide). The matrix was fixed into the chondral defect with fibrin glue.

Results:

Following mean (range) values were registered at time of surgery: age 44 (35-72) years, VAS FA 49.4 (12.3-82.3), ROM 20.4/0/8.4° (dorsiflexion/plantarflexion), degree of osteoarthritis 1.9 (1-3). The 81 chondral defects were located as follows, dorsal metatarsal head, n=28 (35%), plantar metatarsal head, n=12 (15%); dorsal & plantar, n=21 (26%); medial sesamoid, n=14 (17%); lateral sesamoid, n=6 (7%)(two defects, n=14, three defects, n=3). The defect size was 0.9 (.5 - 3.0) cm2. Fifty-six patients (92%) completed follow-up at 62 (48-84) months. VAS FA increased to 82.5 (45.6-100; t-test, p<.01). ROM increased to 30.2/0/15.4 (p=.05). Degree of osteoarthritis decreased to 1.1 (0-3, p=.04)

Conclusion:

The surgical treatment of chondral defects at MTP1 including MAST led to improved clinical scores, ROM and degree of osteoarthritis after 4-7 years. No adverse effects of MAST were registered. Even though a control group is missing, we conclude that MAST is an effective method for the treatment of chondral defects at MTP1.
What is Too Swollen? Correlation of Soft Tissue Swelling and Timing to Surgery with Acute Wound Complications for Operatively-Treated Lower Extremity Fractures
Authors: Riedel Matthew D. , Parker Amber , Zheng Mingxin , Briceno Jorge , Staffa Steven J. , Miller Christopher P. , Kaiser Philip B. , Wu Jim S. , Zurakowski David , Kwon John Y.
Published: October 2019

Category:

Trauma, Soft Tissue

Introduction/Purpose:

Considerable debate exists regarding how soft-tissue edema should influence timing of surgery for lower extremity fractures. Assessment of swelling is subjective and timing varies amongst surgeons. However, timing of surgery is one of the few modifiable factors in fracture care. Ultrasonography can objectively measure swelling and help determine optimal timing. The purposes of this study are: 1) determine whether objective measures of swelling, timing to surgery, and patient-specific risk factors correlate with wound complications and; 2) create a prediction model for post-operative wound complications based on identified modifiable and non-modifiable risk factors.

Methods:

Patients with closed lower extremity fractures requiring surgery with an uninjured, contralateral extremity were included. Demographic information and sonographic measurements on both lower extremities were obtained pre-operatively. Subjects were followed for 3 months and wound complications were documented. A predictive algorithm of independent risk factors was constructed, determining wound complication risk.

Results:

93 subjects completed the study with 71/93 sustaining ankle fractures. Overall wound complication rate was 18.3%. Timing to surgery showed no correlation with wound complications. A heel-pad edema index >1.4 was independently associated with wound complications. Subgroup analysis of ankle fractures demonstrated a 3.4x increase in wound complications with a heel- pad edema index >1.4. Tobacco history and BMI >25 kg/m2 were independent predictors of wound complications. An algorithm was established based on heel-pad edema index, BMI >25, and tobacco history. Patients with none of the 3 factors had a 3% probability of a wound complication. Patients with 1/3, 2/3 and 3/3 factors had a 12-36%, 60-86% and 96% probability of a wound complication, respectively.

Conclusion:

Timing to surgery had no correlation with wound complications. Heel-pad edema index >1.4, BMI >25, and tobacco- use correlated with wound complications. Risk of wound complications significantly increased with each factor. In patients with increased BMI and/or tobacco-use, resolution of heel edema may significantly reduce wound complications in lower extremity trauma.
Biomechanical Comparison of Plantar-To-Dorsal and Dorsal-To-Plantar Screw Fixation Strength for Subtalar Arthrodesis
Authors: Rodriguez Ramon , Dun Schouchen , He Jun Kit , McKissack Haley , Fleisig Glenn S. , Jain Mohit , Brahmbhatt Ashish , Shah Ashish
Published: October 2019

Category:

Basic Sciences/Biologics, Hindfoot

Introduction/Purpose:

Arthrodesis of the subtalar joint is performed for various arthritic and instability problems to correct alignment and relieve pain. For talocalcaneal pathologies, isolated subtalar arthrodesis has been advocated with the advantages of lower risk of adjacent joint arthritis and nonunion of the transverse tarsal joint. Internal fixation techniques have varied over time and use of compression screws is common. The screws may be oriented from dorsal to plantar or plantar to dorsal. Arguments favoring one approach over another are based more on “expert opinion” than hard data. The goal of this study was to compare the biomechanical stability of these two constructs to evaluate which creates a more stable construct.

Methods:

Eight matched pairs of cadaver feet underwent subtalar joint arthrodesis with two 7.3-mm cannulated screws. Randomization was used to assign screw orientation, such that one foot in each pair was assigned dorsal to plantar screw orientation (DP group), and the other foot plantar to dorsal orientation (PD group). Standard surgical technique with fluoroscopy was used for each approach. Following fixation, each specimen was loaded to failure with a Bionix 858 MTS device, applying a downward axial force at a distance to create torque. Torque to failure was compared between DP and PD groups using Student’s T-test, with p = 0.05 used to determine statistical significance.

Results:

The force to failure was 585.9 ± 201.1 N for the plantar-to-dorsal fixation and 667.2 ± 449.4 N for the dorsal-to-plantar fixation. The moment arm was 55.1 ± 4.7 mm for the dorsal-to-plantar fixation and 54.8 ± 3.9 mm for the plantar-to-dorsal fixation. Statistical analysis demonstrated that the mean torque to failure slightly favored the DP group (37.3 N-m) to the PD group (32.2 N-m). However, the difference between the two groups was not statistically significant (p = 0.55).

Conclusion:

There is no significant difference in strength between subtalar arthrodesis performed with dorsal-to-plantar screw orientation and plantar-to-dorsal screw orientation. This suggests that selection of technique should depend on the situation and the required advantages of each. Placing the screw from the heel up has the benefit of being an easier approach, allows access to tenser talar bone once the screw is through, and has less risk of neurovascular injury. The dorsal-to-plantar technique allows simple supine positioning of the patient, needs only two fluoroscopic views to check pin position, and allows the surgeon to manipulate the foot more easily.