bluuebunny/crossref_metadata_2025 huggingface dataset:
Ankle Fracture-Dislocations
Authors: Lawson Kevin A. , Ayala Alfonso E. , Morin Matthew L. , Latt L. Daniel , Wild Jason R.
Published: September 2018

Ankle fractures are common musculoskeletal injuries that may result in tibiotalar joint dislocations. Ankle fracture-dislocations occur via similar mechanisms as ankle fractures, although the persistence or magnitude of the deforming force is sufficient to disrupt any remaining bony or soft-tissue stability. Ankle fracture-dislocations likely represent distinct clinical entities, as the pathology, management, and patient outcomes following these injuries differ from those seen in more common ankle fractures without dislocation. Ankle fracture-dislocations have higher rates of concomitant injury including open fractures, chondral lesions, and intra-articular loose bodies. Long-term outcomes in ankle fracture-dislocations are worse than ankle fractures without dislocation. Higher rates of posttraumatic osteoarthritis and chronic pain have also been reported. In this review, we discuss the current literature regarding the history, management, and outcomes of ankle-fracture dislocations and highlight the need for future study.
Clinical and Radiographic Outcomes of Midfoot Arthrodesis Using Different Fixation Methods
Authors: Bejarano-Pineda Lorena , Huh Jeannie , DeOrio James , Lampley Alexander , Easley Mark
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Midfoot arthritis is a disabling condition, causing chronic foot pain and functional disability. The goals of midfoot arthrodesis are to a plantigrade, stable, and pain-free foot. The procedure can be technically demanding and associated with a number of complications. The use of midfoot-specific plate fixation has become more popular as an alternative to screw-only fixation. The purpose of this study was to compare the clinical and radiographic outcomes following midfoot arthrodesis using different fixation methods.

Methods:

This was a retrospective study of all midfoot arthrodeses performed at a single institution between January 2005 and December 2014. Patients qualified if they had a minimum of 12 months follow-up, specifically with patient-reported outcomes. Demographic and surgical information were collected. Final post-operative outcomes were reviewed and consisted of patient-reported functional measures, union rate, complications, and radiographic outcomes. Patient-reported functional measures included the American Orthopedic Foot and Ankle Score (AOFAS) midfoot scale, Visual Analogue Scale (VAS) for pain, and Lower Extremity Functional Score (LEFS). Radiographic outcomes included alignment in the antero-posterior (AP) and lateral views, as measured by the talo-first metatarsal angle during the pre-operative and final follow-up visits. Outcomes were compared among the following groups: Screw fixation group (SFG), plate fixation group (PFG), and combined fixation group (CFG), which had screw and plate fixation.

Results:

A total of 79 midfoot fusions in 75 patients had a mean follow-up of 61 months (range 13-122) with patient-reported outcome measures. At final follow-up, the SFG had a higher median LEFS (72.5 versus 53 in the PFG and 56 in the CFG; p>0.1) and a higher mean AOFAS score (87 versus 78 in the PFG and 77 in the CFG; p>0.15). The complication and nonunion rate was highest in the PFG, with 13 (50%) and 4 (50%) cases, respectively; however, the differences were not statistically significant. The talo-first metatarsal angle improved in all three groups from a median of 6.4 degrees pre-operatively to 3.9 degrees on final post-operative imaging.

Conclusion:

Although not statistically significant, there was a trend towards higher patient-reported outcomes, union rate, and less complication rate in midfoot fusions treated with screw fixation compared to plate fixation and combined fixation. There was no difference in radiographic correction among the difference fixation methods. Although new techniques and implants continue to be introduced, we found no significant difference in outcomes when compared to the traditional technique of screw fixation.
Clinical and Radiological Outcomes of Transfibular Total Ankle Arthroplasty at 2-years Follow-up
Authors: Granata Francesco , Maccario Camilla , Manzi Luigi , Tan Eric , Usuelli Federico Giuseppe
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthritis is a highly limiting pathology that causes pain and functional limitation with subsequent deterioration of quality of life. With recent advances in surgical instrumentation and techniques, prosthetic replacement of the ankle has proved to be a valid alternative to arthrodesis with comparable outcomes. The purpose of this study was to evaluate clinical and radiological findings in a transfibular total ankle replacement with two years follow-up.

Methods:

This prospective study included 59 patients who underwent transfibular total ankle arthroplasty from May 2013 to December 2015. The mean age was 51.6 ± 13.4 years. All patients were followed for at least 24 months postoperative with an average follow-up of 42.0 ± 23.5 months. Patients were assessed clinically and radiologically preoperatively and at 6, 12, and 24 months postoperatively.

Results:

At 24 months, patients demonstrated statistically significant improvement in the American Orthopaedic Foot and Ankle Society score from 33.6 to 88.1 (P<0.01), VAS scale from 79.3 to 14.0 (P<0.01) and SF-12 Physical and Mental Composite Scores from 29.9 and 44.6 to 74.4 and 95.3, respectively (P<0.01). Ankle dorsiflexion and plantarflexion improved from 5.5 and 8.8 degrees to 24.2 and 20.0 degrees, respectively (P<0.01). Radiographically, patients demonstrated neutral alignment of the ankle with a tibio-talar ratio of 34.9 ± 9.2 and hindfoot alignment view angle of 1.2 ± 7.0 degrees. No patient demonstrated any radiographic evidence of tibial or talar lucency at 24 months. Seven patients underwent reoperation for removal of symptomatic hardware; one patient developed a postoperative prosthetic infection requiring placement of an antibiotic spacer.

Conclusion:

This study demonstrates that transfibular total ankle replacement is a safe and effective option for the patients for ankle arthritis with improvements in patient-reported outcomes, range of motion, and radiological parameters. However, further studies are required to determine the mid- and long-term performance of these implants.
External Fixation in the Emergency Department Is Equally Efficacious to Placement in the Operating Room
Authors: O’Donnell Seth , Shah Kalpit , Gil Joseph , Johnson Joseph , Hayda Roman , Born Christopher
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Pilon and unstable ankle fractures are often treated initially with an external fixator (ex-fix) due to soft tissue concerns. Typically, the second stage involves open reduction internal fixation of the fracture as the definitive management. Ex-fix application in the emergency department (ED) has been described previously. We aimed to determine if an ex-fix applied in the ED would have any difference in rate of ex-fix revision, deep infection, and hospital length of stay when compared to an ex-fix that is applied in the operating room (OR).

Methods:

This is a retroscpective, case-cohort study performed at an urban, level-1 trauma center. Using CPT codes in our billing database, we identified all patients from 2011-2015 who had operative fixation of pilon (AO classification 43B or 43C) or unstable ankle fractures (AO classification 44C) and had application of an ex-fix (either ED or OR) prior to definitive fixation. Patients with open injury, those placed in ex-fix at outside institutions and those treated definitively with ex-fix were excluded.

Results:

Ninety-six patients met the inclusion criteria. Average age was 47 years and 54 (56%) were male. Thirty-three patients had ex-fix placed in the OR and 63 patients had ex-fix placed in the ED. Post-surgical complications (prominent implant, nonunion, deep infection, DVT, loss of reduction) were seen in 6/33 in the ED and 8/63 in the OR group (χ2=0.44, p=0.51). Deep infections occurred in 2/33 OR ex-fix and 5/63 ED ex-fix patients (χ2=0.137, p=0.71, OR= 1.4 [95% CI = 0.25 to 7.5]). Revision ex-fix for loss of reduction was performed 4/33 in the OR group and 10/63 in the ED ex-fix group (χ2=0.296, p=0.59). Mean length of stay was 14 days for the OR and 13 days for the ED group (p=0.35).

Conclusion:

We found no significant difference in post-surgical complications (surgical or infectious) or ex-fix revision rates for an ex-fix placed in ED compared to one placed in the OR. Total hospital days were similar in both groups. Prospective studies are needed to validate this method of provisional stabilization in the ED; however, these results indicate that the ED ex-fix is equally efficacious to an OR ex-fix.
Preoperative Picture Improves Postoperative Satisfaction in Bunion Surgery
Authors: Taylor Michel
Published: September 2018

Category:

Bunion

Introduction/Purpose:

Hallux valgus (HV) is the most common conditions affecting the forefoot. Typically, the patient’s main concern is a prominent medial eminence (bunion) with difficulty with shoe wear and the cosmetic appearance of the toe. Patient satisfaction following HV correction surgery is between 73-94% however a poor cosmetic result can have a negative impact on the post-operative outcome. There is surprisingly a dearth of knowledge in the forefoot literature exploring the impact of cosmesis on the subjective outcome following HV surgery. The purpose of this prospective, blinded, randomized trial is to determine whether showing patients a preoperative photograph would improve post-operative satisfaction following HV corrective surgery.

Methods:

Patients undergoing HV corrective surgery were randomized to a picture group (P) or no picture group (NP). Inclusion criteria were patients over 18 and a diagnosis of HV. Pre-operatively, all patients had a picture taken of the operative foot. Patients were seen in follow up at 3 and 6 weeks and 3 months. P-group patients were shown the picture by the research assistant for 5 minutes at each visit. Patients completed the FFI and FAOS pre-operatively and at each post-operative visit. Patients also completed a satisfaction questionnaire at each post-operative visit which included a 5-point scale addressing overall satisfaction, satisfaction with the appearance of the foot and whether they would undergo the procedure again. Pre-operative and post-operative HVA and IMA were recorded by a fellowship trained orthopaedic surgeon not involved in the patient’s care. The operative surgeon was blinded to the treatment groups.

Results:

29 patients were enrolled in the study (15P). No difference with respect to age, gender, smoking, presence of comorbidities, underlying diagnosis, HVA or IMA, FFI or FAOS. At 3 months, patients in the picture group were more likely to be “completely satisfied” with the appearance of their foot and this difference was statistically significant (p<0.05). There were no differences between treatment groups with respect to post-operative HVA, IMA, FAOS, or FFI.

Conclusion:

Hallux valgus corrective surgery is a very successful procedure with high post-operative patient satisfaction. Frequently reminding a patient of the pre-operative appearance of their foot, through the use of photographs, appears to have a beneficial impact with regards to patient satisfaction in the early post-operative period.
Osteochondral Autograft Transfer Combined with Periarticular Osteotomy for the Treatment of Osteochondral Defect of the Talus in Varus Ankle
Authors: Zhu Yuan
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Osteochondral lesion of the talus (OLTs) is among the most common foot and ankle disorders. Varus ankle malalignment causes stress concentration on medial side of the joint, resulting in OLTs and osteoarthritis. For large symptomatic OLTs (> 15 mm in diameter) involving posteromedial aspect of talar dome, osteochondral autograft transplantation is usually warranted. This article highlights the distal tibial double osteotomy for the management of patient with concomitant large OLTs and varus ankle malalignment.

Methods:

From January 2012 to July 2015, 15 patients (8 males, 7 females) received the surgery in our department. The average age was 55.4 (range, 34 to 69) years old. Oblique medial malleolar osteotomy was performed to expose the talar lesion, following by osteochondral autograft transplantation and distal tibial opening-wedge osteotomy. Weight bearing X-rays were obtained for the measurement of tibial articular surface (TAS) angle and tibial lateral surface (TLS) angle. The American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) questionnaires and Visual Analog Scale (VAS) were evaluated for ankle function. In 5 cases arthroscopy was performed 12 months postoperatively and the cartilage repair was assessed with the criteria of the International Cartilage Repair Society.

Results:

Thirteen patients completed the follow-up with a mean of 21.2 months. The average talar lesion was 170.0mm2, and the average depth was 11.4 mm. The mean time of bone healing was 8.5 weeks. No patient reported donor site morbidity by the last follow-up. The mean AOFAS-AH score and VAS score improved from 53 to 90 points (p < 0.05), 6.7 to 1.9 points (p < 0.05), respectively. The mean TAS angle improved from 83.1 to 90.3 degrees (p < 0.05). The radiolucent area of the cysts disappeared on the plain radiographs in all cases. The mean International Cartilage Repair Society arthroscopic score from follow-up arthroscopy was (9±1) points.

Conclusion:

The use of osteochondral autograft transfer combined with supramalleolar osteotomy is an effective option for the treatment of osteochondral defect of the talus in varus ankle. It provides excellent visualization of the talar defect and favorable biomechanical environment for the ankle joint.
Surgical versus non surgical management of Geriatrics ankle fractures. A Systematic Review and Meta-analysis
Authors: Alhammoud Abduljabbar , Khamis Karim Mahmoud , Mekhaimar Mohamed Maged
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Ankle fractures are common orthopedics injuries especially in elderly. Bone quality, activity, and other comorbidities play a role in the management of ankle fracture in older age group. Conservative treatment by casting with or without reduction consider valid option whereas the open reduction and internal fixation still the stander of care for all age groups. This review aims to provide evidence-based difference between surgical and non-surgical management of geriatrics ankle fracture in regards to healing, complication and functional outcome.

Methods:

Relevant comparative studies in English literature were identified up to October 2017 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic-based search on MEDLINE (PubMed), EMBASE, Google Scholar and Cochrane databases, and hand searching of abstracts in orthopedics, trauma and foot and ankle journals. The research team systematically reviewed published studies according to the following criteria:(1) subjects whom sustained ankle fractures with age above 50 years;(2) the intervention was done through surgical management (open reduction and internal fixation) or conservative management (closed reduction and casting or casting alone) (3) the study reported at least one desirable outcome(non-union/mal-union rate, hospital stay, period on cast, mortality, re-admission rate, functional outcome, complication rate)(4) followed up at least one year after surgical /conservative management. The data analysis was done by Comprehensive meta-analysis software using a random-effect model and SPSS 22. Statistical heterogeneity across the studies was tested using I2.

Results:

The non-union rate in surgical group was significantly less than conservative group, (OR: 0.127, 95% CI: [0.055, 0.292], [P <0.001])and the mal-union was similarly less in surgical group (OR: 0.128, 95% CI: [0.063, 0.262], [P <0.001]). No difference in the hospital stays detected between two groups and similarly in re-admission rate. No difference in the period in cast reported between two groups. The return to pre-injury level was better in surgery group comparing to surgical one, whereas no difference in patient satisfaction was reported between two group. The mortality rate was less in the surgical group. The total number of skin complication was more in the conservative group.No difference in the incidence of DVT between two groups whereas the PE was in the surgical group.

Conclusion:

Geriatrics ankle fractures are challenging injury. The surgical management of such injuries showed superior results comparing to conservative management in terms of non-union /mal-union rate and return to pre-injury level with less mortality rate, whereas no difference in complications rate, hospital stay and patient satisfaction.
Distal Fibula Osteotomies Improve Tibiotalar Joint Compression
Authors: Arena Christopher , Aydogan Umur , Roush Evan , Juliano Paul
Published: September 2018

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Compression is a vital component of achieving a successful ankle arthrodesis. Various modifications of the fibula are used in hopes of achieving higher clinical rates of successful fusion in ankle arthrodesis procedures. We hypothesized that distal fibula osteotomies would improve tibiotalar joint compression under various loading conditions. The purpose of this study was to evaluate the effect of various distal fibula osteotomies on tibiotalar joint compression.

Methods:

Eight paired adult cadaveric lower extremity specimens with an intact ankle joint and syndesmosis were prepared by exposing and fixating together the proximal tibia and fibula. A jig was constructed to secure the specimen in a vertical position while allowing free axial loading. An anterior surgical approach to the ankle was performed and the joint cartilage denuded. A pressure transducer was used to record baseline ankle pressure distribution. The proximal specimen was loaded with 30, 50, and 100 N static weight and ankle pressure measurements repeated for each load. The fibula was surgically modified with the three procedures: (1) oblique fibular osteotomy 3 cm proximal to the ankle joint; (2) 1 cm long distal fibula resection; (3) complete distal fibula excision. Increasing loads of 30, 50, and 100 N following each surgical procedure were applied and the ankle pressure measurements repeated.

Results:

Distal fibula resection increased tibiotalar joint force, peak pressure, and contact area compared to intact fibula control for 30, 50, and 100 N loads applied (p<0.05). Compared to intact fibula control, an oblique osteotomy performed and 30 N applied force resulted in a mean ankle joint force increase of 7.5 N (p = 0.007). A 1 cm excisional fibula osteotomy under a 30 N load significantly increased the ankle joint force by 6.6 N (p = 0.015). Complete distal fibula resection under 30 N load significantly increased the ankle joint force compared to control by 13.9 N (p < 0.001). Similar trends were seen for 50 N and 100 N loads with significance reached (*) as represented in Figure 1 (error bar = standard error).

Conclusion:

A distal fibula oblique osteotomy, 1 cm excisional osteotomy, or complete distal fibula excision may increase the amount of force transmitted to the ankle joint under loading. Our findings suggest complete distal fibular resection results in the highest ankle joint force, contact area, and peak pressure of the surgical options tested. Leaving the fibula intact may decrease tibiotalar compression during ankle arthrodesis. Clinical testing would be important to ultimately test the effects on rates of successful fusion.
Floating toe
Authors: Caicedo Nathaly , Radkievich Ruben , de Solminihac Diego Zanolli , Calvo Rafael , Wagner Pablo , Wagner Emilio
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

The Weil osteotomy (WO) is frequently used for treating metatarsalgia and metatarsophalangeal (MTP) instability. Nevertheless, it presents complications, being the floating toe the most frequent one. A modification has been proposed to decrease the beforementioned complication, removing a slice from the osteotomy (modified Weil osteotomy, MWO). Additionally, it has been proposed that stabilizing the toe interphalangeal joints when treating hammer toes may contribute to decrease the floating toe complication, given that all flexors contribute to MTP flexion. The objective of this research is to describe complications and functional score in patients operated with MWO with and without interphalangeal stabilization.

Methods:

110 patients (250 toes) treated for metatarsalgia and hammer toe deformity were retrospectively collected and prospectively followed for 66 months (SD 15). 2 groups were studied, 45 adults with isolated MWO and 65 adults with MWO with toe stabilization. Average age 55. Patients with Diabetes, previous surgeries and infections were excluded. LEFS, AOFAS and satisfaction index were recorded. A physical examination looking for floating toe, MTP instability and metatarsalgia was performed. Statistical analysis included logistic regression spearmen correlation test, Mann-Whitney test and student T test.

Results:

LEFS and AOFAS scores were 70 and 73 respectively, with no differences between patients operated with isolated MWO or with toe stabilization. Satisfaction index average result was “minor reservations”. Floating toe incidence was 24%, with no difference between groups. There was no difference in functional scores and satisfaction index if floating toe was present or absent. There was no correlation between functional scores and satisfaction index. Metatarsalgia was present in 31% of patients, and there is a direct correlation of floating toe occurrence and pain (4 times more chance to have pain).

Conclusion:

There was no clinical significant consequence of floating toe on LEFS, AOFAS or satisfaction. There was no difference in complication rate, functional scores and patient satisfaction if the interphalangeal joint was fixed or not. Although floating toe didn’t influence on functional scores, it was associated with pain. It can be suggested that the scores utilized were not able to detect the negative influence of floating toe on every patient. The high prevalence of floating toe using the MWO should make us look for additional factors which we may be overlooking when treating metatarsalgia, such as plantar plate damage.
Porous Titanium Wedges are an Alternative in Lateral Column Lengthening for Adult Acquired Flatfoot Deformity
Authors: Carstensen Samuel , Moore Spencer , Park Joseph , Cooper M. Truitt , Perumal Venkat
Published: September 2018

Category:

Hindfoot

Introduction/Purpose:

Lateral column lengthening (LCL) is a common procedure for reconstruction of stage II flexible adult acquired flatfoot deformity (AAFD). The recent development of porous titanium wedges for this procedure provides an alternative to allograft and autograft. The purpose of this study was to report radiographic and clinical outcomes achieved with porous titanium wedges in LCL.

Methods:

A retrospective analysis of 34 feet in 30 patients with AAFD that received porous titanium wedges for LCL from January 2011 – October 2014. Deformity correction was assessed using both radiographic and clinical parameters. Radiographic correction was assessed using the lateral talo-first metatarsal angle, the talonavicular uncoverage percentage, and the first metatarsocuneiform height. The hindfoot valgus angle was also obtained.

Results:

Patients were followed from a minimum of six months up to 48 months (mean 16.1 months). Patients underwent concomitant procedures including medial displacement calcaneal osteotomy (94.1%), flexor digitorum longus transfer (70.6%), posterior tibial tendon tenolysis (64.7%), gastrocnemius recession (20.6%), and cotton osteotomy (4.9%). Postoperative radiographs demonstrated significant correction in all three radiographic criteria as well as the hindfoot valgus angle compared to their preoperative measurements. There were no cases of nonunion, no wedge migration, no infections, and no patients required removal of hardware. The most common complication was calcaneocuboid joint pain (14.7%).

Conclusion:

AAFD is a problem with various treatment modalities. Porous titanium wedges in LCL can achieve good radiographic and clinical correction of AAFD with a low rate of nonunion and other complications.
Population-based Projections of Ankle Arthrodeses
Authors: Gross Christopher , Rabinowitz Justin , Durante Elizabeth
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthrodesis is commonly performed for patients with end stage ankle arthritis. However, with improvements in long-term outcomes following total ankle arthroplasty it is possible that rates of ankle arthrodesis will decrease as utilization of ankle arthroplasty increases. The purpose of this study is to assess the current and future trends of ankle arthrodesis utilization.

Methods:

National Inpatient Sample (NIS) data from 1997-2014 was used to identify trends in the utilization of ankle arthrodesis. United States Census Bureau data from 1997-2014 was used to identify historical population data and future population estimates. A linear regression model was created using Mathematica v11.3 to project future demand for ankle arthrodesis. The data was stratified to show past and future trends based on gender and age.

Results:

The overall utilization rate of ankle arthrodesis remained relatively constant from 5897 procedures in 1997 to 5330 procedures in 2014. The overall demand for ankle arthrodesis is expected to increase slightly by 15 percent with 6141 procedures projected in 2045. Stratified by age groups, the number of procedures is predicted to decrease by 75% in ages 18-44 and 6% in ages 45-64, and predicted to increase by 133% in ages 65-84 by 2045. Stratified by gender, ankle arthrodesis is predicted to increase by 47% in males and decrease by 14% in females in 2045.

Conclusion:

Based on our projection model, the rate of ankle arthrodesis is predicted to stay relatively stable overall but decrease in younger populations. A projected increase in total ankle arthroplasty will likely contribute to decreased utilization of ankle arthrodesis. However, ankle arthrodesis will still be a valuable tool in the surgeon’s armamentarium to treat ankle arthritis.
The Influence of Obesity on Ankle Fracture Treatment
Authors: Hillam Jeffery , Smyth Niall , Kaplan Jonathan , Aiyer Amiethab
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Obesity is a public health concern in the United States, with an overall prevalence of greater than one-third. From a surgical perspective, obesity may increase risk for postoperative complications, including delayed wound healing, infection or compromise of fixation/repair constructs. The purpose of this study was to retrospectively review outcomes data from the American College of Surgeons: National Surgical Quality Improvement Program (NSQIP) to delineate the impact that obesity has on operative treatment of ankle fractures.

Methods:

Perioperative data was collected from patients undergoing operative intervention for distal fibular or bimalleolar ankle injuries. Patients were identified from the 2006-2015 NSQIP database using current procedural terminology (CPT) codes. Obese (body mass index>30 kg/m2) and non-obese (body mass index<30 kg/m2) cohorts were identified to elucidate the influence of obesity on perioperative /postoperative complications after undergoing operative treatment for distal fibular or bimalleolar ankle injuries. Univariate and multivariate logistic regression models were created to identify independent risk factors for complications.

Results:

Our study identified a total of 8,377 patients including, 4,357 undergoing surgical bimalleolar ankle fracture repair and 4,020 patients undergoing surgical repair of distal fibular ankle fracture. Obese patients undergoing surgical repair of either distal fibular or bimalleolar ankle fractures were more likely to have a longer length of hospital stay (p < 0.05). Patients undergoing distal fibular fixation were found have a longer operative time. Analysis using logistic regression demonstrated no significant association obesity and DVT/sepsis (bimalleolar ankle fracture fixation) and re-operation/deep incisional SSI/wound complication/UTI (distal fibular ankle fracture fixation) Obesity was not determined to be associated with postoperative complications following distal fibular nor bimalleolar ankle fracture repair. ankle fracture repair.

Conclusion:

This study demonstrated that, after adjusting for potential confounders, obesity is not significantly associated with adverse outcomes following bimalleolar or distal fibular ankle fracture repair. Further analysis demonstrated that operative time and length of stay are lengthened in ankle fracture fixation in obese patients.
Can Patient Reported Outcomes Guide Therapy Needs in Foot and Ankle Patients?
Authors: Houck Jeff , Santer Jillian , Baumhauer Judith
Published: September 2018

Category:

Other

Introduction/Purpose:

The patient acceptable symptom state (PASS) is a validated question establishing if patients activity and symptoms are at a satisfactory low level for pain and function. Surprisingly, ~20% of foot and ankle patients at their initial visit present for care with an acceptable symptom state (i.e. PASS yes). These patients are important to identify to prevent over treatment and avoid excessive cost. It is also unclear what health domains (Pain Interference (PI), Physical Function (PF), or Depression (Dep)) influence a patients judgement of their PASS state (i.e. why they are seeking treatment). The purpose of this analysis is to document the prevalance of PASS state and determine the health domains that discriminate PASS patients and predict PASS state at the initiation of rehabilitation.

Methods:

Patient reported outcomes measurement information system (PROMIS) computer adaptive test (CAT) scales PF, pain PIand Dep and PASS ratings starting in summer 2017 were routinely collected for patient care. Of 746 unique patients in this data set, 114 patients had ICD-10 codes that were specific to the foot and ankle. Average age was 51years (±18) and 54.4% were female. Patients were seen an average of 19.8(±15.9) days from their referral and were billed as low (51.7%), moderate (44.7%) and high complexity (2.7%) evaluations per current procedural code (CPT) visits. ANOVA models were used to evaluate differences in PROMIS scales by PASS state (Yes/No). The area under receiver operator curve (AUC) was used to determine the predictive ability of each PROMIS scale to determine a PASS state. Thresholds for near 95% specificity were also calculated for a PASS Yes state for each PROMIS scale.

Results:

The prevalance of PASS Yes patients was 13.2% (15/114). Pass Yes patients were significantly better by an average of 7.2 to 8.0 points across all PROMIS health domains compared to PASS No patients (Table 1). ROC analysis suggested that Dep (AUC=0.73(0.07) p=0.005) was the highest predictor of PASS status followed by PI (AUC=0.70(0.08) p=0.012) and PF (AUC=0.69(0.07) p=0.18). The threshold PROMIS t-score values for determining PASS Yes with nearest 95% specificity were PF = 51.9, PI = 50.6, and Dep = 34.

Conclusion:

Surprising, yet consistent with previous data, 13.2% of patients at their initial physical therapy consultation rated themselves at an acceptable level of activity and symptoms. Health domains of physical function, pain interference, and depression were better in these patients and showed moderate ability (AUC~0.7) to identify these patients. The PROMIS thresholds suggest patients are identified by pain and physical function equal to the average of the US population (PROMIS T-Score ~50) and extremely low depression scores (34). Clinically it is important to recognize these patients and purposefully provide treatments that reinforce their self efficacy and prevent unnecessary costly treatments.
Scientific Production and total ankle arthroplasty
Authors: Indino Cristian , D’Ambrosi Riccardo , Usuelli Federico Giuseppe
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

The purpose of this systematic review was to report clinical outcomes on total ankle replacement (TAR) whose data were extracted from national registers.

Methods:

A systematic review of the literature, to identify all studies reporting outcomes after total ankle replacement, was performed. Two independent investigators performed the research using MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase and Cochrane Databases (1950 to December 2017).

Results:

Analysis of the literature included 18 articles from 2007 to 2017. Of these 5 articles performed a comprehensive analysis of the national registers, 5 articles evaluated complications and reasons of failure after TAR, 6 articles made a specific outcome register analysis, one article compared TAR and ankle arthrodesis while the last one analysed the role of TAR in patients with rheumatoid arthritis.

Conclusion:

Scientific publications extracted from national joint registers for total ankle replacement provide useful but heterogeneous information on implants survivorship, implant models and risk factors. There is still a discrepancy between the data reported by designers in clinical studies and the data reported by the registries. The centralization of registers in specialized hospitals with dedicated surgeons, the use of patient reported outcomes (PROMs) in association with surgeon assessments and periodical publications can improve the development of registries and consequently of the literature in this regard.
Predictors of compartment syndrome of the foot after fracture of the calcaneus
Authors: Kim Hak Jun
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Identifying predictors of compartment syndrome in the foot after a fracture of the calcaneus may lead to earlier diagnosis and treatment. The aim of our study was to identify any such predictors.

Methods:

We retrospectively reviewed 303 patients (313 fractures) with a fracture of the calcaneus who presented to us between October 2008 and September 2016. The presence of compartment syndrome and potential predictors were identified by reviewing their medical records. Potential predictors included age, gender, concomitant foot injury, mechanism of injury, fracture classification, time from injury to admission, underlying illness, use of anticoagulant/antiplatelet agents, smoking status and occupation. Associations with predictors were analyzed using logistic regression analysis

Results:

Of the 313 fractures of the calcaneus, 12 (3.8%) developed a compartment syndrome. A Sanders type IV fracture was the only strongly associated factor (odds ratio 21.67, p = 0.007). Other variables did not reach statistical significance.

Conclusion:

A Sanders type IV fracture is the best predictor of compartment syndrome after a fracture of the calcaneus.
Reconstruction of Kuwada grade IV chronic achilles tendon rupture by minimally invasive technique
Authors: Miao Xu-dong , Cao Le
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Transfer of a flexor hallucis longus (FHL) tendon can not only reconstruct the Achilles tendon but also provide ischemic tendinous tissues with a rich blood supply to enhance wound healing. This retrospective study aims to investigate clinical outcomes in patients who underwent repair of Kuwada grade IV chronic Achilles tendon rupture with long hallucis longus tendons harvested using a minimally invasive technique.

Methods:

35 patients who were treated for Kuwada grade IV Achilles tendon injuries from July 2006 to June 2011 were included in this retrospective study. The age ranged between 23 and 71 years. The duration from primary injury to surgery ranged from 29 days to 34 months (mean value, 137.6 days). All 35 patients had difficulties in lifting their calves. 32 were followed up for a mean 32.2 months (range 18-72 months), whereas 3 were lost to follow-up. Magnetic resonance imaging (MRI) showed that the tendon rupture gap ranged from 6.0 to 9.2 cm. Postoperative appearance and function were evaluated by physiotherapists based American Orthopedic Foot and Ankle Society-ankle and hindfoot score (AOFAS-AH), and Leppilahti Achilles tendon ratings.

Results:

Results were assessed in 32 patients. Except for one patient who suffered complications because of wound disruption 10 days after the operation, all other patients had primary wound healing, with 28 of 32 able to go up on their toes at last follow-up. The AOFAS-AH score was increased from preoperative (51.92 ± 7.08) points to (92.56 ± 6.71) points; Leppilahti Achilles tendon score was increased from preoperative (72.56 ± 7.43) to (92.58 ± 5.1). There were statistically significant differences. The result of the total excellent and good rate was 93.8% (30/32). MRI of Achilles tendon showed even signal without evidence of tear or cystic degeneration.

Conclusion:

Reconstruction of a chronic Achilles tendon rupture with an FHL tendon harvested using a minimally invasive technique showed good outcomes.
Return To Sports And Physical Activities After Open Reduction And Internal Fixation For Lisfranc Injuries In Recreational Athletes
Authors: Mora Allan David , Lunz David , Kao Mark
Published: September 2018

Category:

Trauma

Introduction/Purpose:

To assess participation in sport and physical activity following open reduction and internal fixation of a Lisfranc injury in a cohort of recreational athletes.

Methods:

Our study identified all adult patients aged 55 or less, who presented to our institution with a Lisfranc injury and underwent open reduction and internal fixation (ORIF) using a Lisfranc screw combined with bridge plating technique. Sports and physical activity participation was assessed with a new sports-specific, patient-administered questionnaire. Clinical outcomes were assessed with the Foot and Ankle Outcome Score (FAOS).

Results:

Thirty-three patients qualified for the study (21 males/12 females). Mean age and follow-up: 31.2 (range, 18-55) years and 2.9 (range, 1.5-5.4) years, respectively. Post operatively, 31 patients (94%) were able to return to some form of sport. Twenty-two patients (66%) returned to playing sport at or above their pre injury level. Of the 11 patients who played less sport, 6 had ongoing pain, and the remaining 5 were asymptomatic but were participating less frequently due to other lifestyle reasons. In addition, of the 33 patients, 11 (33%) had some degree of ongoing pain that might limit their ability to return to sports and physical activities. There was strong correlation between overall FAOS and the Sports Questionnaire.

Conclusion:

The majority of patients sustaining a Lisfranc injury can return to sport and physical activity after ORIF. Patients should be counseled preoperatively that about one in three might experience continued pain at the injury site
Does Use of Demineralized Bone Matrix Affect the Union Rate in Arthroscopic Ankle Fusions?
Authors: Neumann Julie , Weinberg Maxwell , Zhang Chong , Saltzman Charles , Barg Alexej
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Despite DBM having positive effects on union rates in other subspecialties of orthopaedics, there is a general lack of evidence about bone graft substitutes in foot and ankle surgery. To our knowledge, orthopaedic surgeons have never evaluated the use of demineralized bone matrix (DBM) as it pertains to the union rate of arthroscopic ankle fusions. The purpose of this clinical study is to compare the rate of union in arthroscopic ankle fusions in patients that have had DBM to those without DBM. The hypothesis of this study was that use of DBM would increase the union rate in all patients undergoing arthroscopic ankle arthrodesis.

Methods:

This is a retrospective review of 521 consecutive patients from October 2002 to April 2016. Seventy-one ankles from 68 patients met inclusion criteria. These patients underwent primary arthroscopic ankle arthrodesis. Forty patients had DBM and 31 patients did not have DBM. Age, gender, body mass index, smoking, and preoperative radiographic deformity were controlled. The primary outcome measure was union rate of arthroscopic ankle arthrodesis. Secondary outcome measures were time to union, rate of wound complications, rate of return to operating room, and rate of development of post-operative deep vein thrombosis (DVT).

Results:

Seventy-one patients were available for final follow-up. Average age of the patients was 55.3 +/- 17.6 years. The mean follow-up time was 39.5 months. Unions were assessed on routine post-operative radiographs. If there was a concern for nonunion, patients were further assessed with a computerized tomography scan. Nonunion rate of patients who did have DBM was 7/40 (18%) and nonunion rate of those who did not have DMB was 8/31 (26%) (p=0.40). There was no statistically significant difference between those who did have DBM and those who did not have DBM in wound complication rate (5% vs 6%, p=1.0), rate of return to the operating room (35% vs 39%; p=0.75), and DVT rate (0% vs 0%), respectively. There were no major complications in this study.

Conclusion:

This study is the largest study to directly compare union rate and complications in patients who had DBM versus those who did not in the setting of arthroscopic ankle fusion. In this study, use of DBM does not affect union rate in patients undergoing arthroscopic ankle arthrodesis. Additionally, use of DBM does not affect the rate of wound complications, return to the operating room, and development of post-operative DVT.
An Independent Interobserver Reliability and Intraobserver Reproducibility Evaluation of the New Pilon Fracture Classification System Based On CT-Scan
Authors: Palma Joaquin , Nussbaum Jorge Filippi , Mery Pablo , Abarca Mario , Mora Andres , Peña Andres
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Objective: To perform an independent inter-observer and intra-observer agreement assessment of the new pilon fracture classification system based on CT-scan. Summary of Background Data: Multiple classification systems have been proposed for pilon fractures, with no consensus to date of which is the most useful tool nor the one that provides the best prognostic orientation. Currently, pilon fractures are classified according to AO and Ruedi Allgower systems based on X-rays. A new pilon fracture classification system based on CT-Scan was recently described by Leonetti and Tigani in 2017. It showed substantial inter- and intra-observer agreement in the study describing it; however, an independent evaluation has not yet been performed, which is required for its wide use in clinical practice and research.

Methods:

CT-scans of 71 patients with acute traumatic pilon fractures were selected and classified using the morphologic grading of the new pilon fracture classification system by six evaluators (three foot and ankle surgeons and three orthopaedic surgery residents). After a six-week interval, the 71 cases were presented to the same evaluators in a random sequence for repeat evaluation. The Kappa coefficient (k) was used to determine the inter- and intra-observer agreement.

Results:

The inter-observer agreement was substantial when considering the fracture main types (I, II, III or IV), with k= 0.635 (0.59 - 0.67), but moderate when considering the sub-types (I, IIF, IIS, IIIF, IIIS or IV): k= 0.588 (0.56 - 0.61). The intra-observer agreement was substantial considering the fracture types, with k= 0.65 (0.62 - 0.71) and considering sub-types, k= 0.62 (0.57 - 0.66). No significant differences were observed between foot and ankle surgeons and orthopaedic residents in the overall inter- and intra-observer agreement, or in the inter- and intra-observer agreement of specific I, II, III or IV type of injuries.

Conclusion:

The new pilon fracture classification system based on CT-scan allows adequate agreement among different observers and by the same observer on separate occasions. Therefore, studies that use this system should be considered reliable. Future prospective studies should determine whether this classification allows surgeons to decide the best treatment for patients with tibial pilon fractures.
Comparison of outcomes of osteosynthesis in type II accessory navicular by variable fixation methods
Authors: Park Hyun-woo , Jang Ho-seong , Suh Jae Wan , Kim Sunghyun
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

To compare the outcomes of fixation methods for osteosynthesis of a type II symptomatic accessory navicular between screw and tension band wiring.

Methods:

Forty-four patients (mean age, 29.2 years; range, 13–54 years; 21 males and 23 females) who had undergone operative treatment after failed conservative treatment were chosen for the study between 2007 and 2014. The patients were divided into two groups by the method of osteosynthesis: group 1 (screw) and group 2 (tension band wiring). Pre and postoperative evaluations were performed, using the midfoot scale from the American Orthopaedic Foot & Ankle Society (AOFAS), a visual analog scale, time to return to social activities, and plain radiography.

Results:

The AOFAS midfoot and visual analog scale scores of both groups were improved at the last postoperative follow-up. The time to return to social activities was 12.3 weeks in the screw group and 11.9 weeks in the tension band wiring group (p = 0.394). A broken screw was observed in one case in the screw group and a broken k-wire was detected in two cases in the tension band wiring group. Nonunion was observed in two cases in each group.

Conclusion:

The tension band wiring technique could be another treatment choice of osteosynthesis for fixation of the accessory navicular bone.
The impact of smoking, diabetes and the site of surgery on post-operative infection in foot and ankle surgery
Authors: Tomlinson Clare , Mangwani Jitendra
Published: September 2018

Category:

Diabetes

Introduction/Purpose:

Smoking and diabetes are thought to increase the risk of post-op infection. Surgery on the hindfoot and ankle is also thought to carry an increased risk. This study looks at whether this is demonstrated in a cohort of patients undergoing foot and ankle (F&A) surgery.

Methods:

Six hundred and twenty patients underwent F&A surgery between 2013 and 2016. Patients either underwent surgery electively (group 1; n= 383) or had open reduction and internal fixation for ankle fracture (group 2; n= 237). Data was collected on patient demographics, site of surgery, smoking and diabetes. The primary outcome was the rate of surgical site (SSI) and deep infection. A standard statistical online package was used for statistical analysis.

Results:

The mean age was 50.8 years and the standard deviation was 17.1 years. The incidence of SSI was 4.2%; 0.48% developed a deep infection. There was no significant difference in infection prevalence between group 1 and 2 (p = 1.0). When comparing the site of surgery, no significant differences were found for forefoot, midfoot, hindfoot or ankle surgery (p=0.16, p=0.22, p=1.0, p=0.48 respectively). There was no significant difference in the prevalence of smoking or diabetes in those who developed an SSI in the overall cohort (p=1, p=1) or in separate analysis within groups 1 and 2 (p=1).

Conclusion:

Both trauma and elective patients had a similar rate of SSI and deep infection; neither diabetes nor smoking had an impact on this rate. For elective patients, there wasn’t a relationship between site of surgery and infection incidence. However, due to the low SSI rate, group sizes were small for this comparison. There was no increase in the incidence of SSI in hindfoot or ankle surgery contrary to common belief.