bluuebunny/crossref_metadata_2025 huggingface dataset:
Sex differences in pedobarographic findings and relationship between radiograph and pedobarograph measurements in young healthy adults
Authors: Lee Kyoung Min , Lee Seung Yeol , Park Moon Seok , Sung Ki Hyuk , Koo Seungbum , Kim Sung Jin , Choi Hyun , Sangyeop Shin , Chun Sangho
Published: September 2017

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Although pedobarographic measurement is increasingly used for clinical and research purposes, relatively few published studies have investigated normative data. This study examined pedobarographic findings in young healthy adults with regard to sex-related differences and correlations among measurement indices.

Methods:

Twenty young healthy adults (mean age 22.4 years, SD 1.2 years; 10 males and 10 females) were included. Weightbearing anteroposterior and lateral foot radiographs were taken, and dynamic pedobarographic data during treadmill walking and maximum ankle dorsiflexion were obtained. AP talo-first metatarsal angle, naviculocuboid overlap, lateral talo-first metatarsal angle, and plantar soft tissue thickness were measured on foot radiographs. Pedobarographic data including peak pressure and pressure-time integral were measured on five plantar segments: medial forefoot (MFF), lateral forefoot (LFF), medial midfoot (MMF), lateral midfoot (LMF), and heel.

Results:

Male and female subjects significantly differed in BMI (p<0.001), AP talo-first metatarsal angle (p=0.018), soft tissue thickness under the metatarsal head (p=0.04) and calcaneal tuberosity (p<0.001), maximum dorsiflexion during stance phase (p=0.041), peak pressure on the MFF (p=0.005) and LFF (p=0.004), and pressure-time integral on the MFF (p=0.018) and heel (p=0.001). Maximum dorsiflexion demonstrated significant negative correlations with pressure-time integral on the MFF (r=-0.595, p=0.007) and total pressure-time integral (r=-0.492, p=0.032). Pressure-time integral varus/valgus index was significantly correlated with pressure-time integral forefoot/heel index (r=0.472, p=0.036).

Conclusion:

Sex-related differences in pedobarographic examination were observed. Achilles stretching exercise was considered to reduce foot pressures, and subtalar joint was hypothesized to play an important role in pressure distribution.
Influence of surgery involving tendons around the knee joint on ankle motion during gait in patients with cerebral palsy
Authors: Lee Seung Yeol , Lee Kyoung min , Kwon Soon-Sun , Chun Sangho
Published: September 2017

Category:

Ankle

Introduction/Purpose:

The gastrocnemius, a biarticular muscle that crosses the knee and ankle, acts as a knee flexor as well as an ankle plantar flexor. Although simultaneous motion of the knee and ankle joints is required for many activities including standing, running, swimming, and cycling, the change in ankle motion during gait has not been described in patients with cerebral palsy who underwent distal hamstring lengthening or distal hamstring lengthening with rectus femoris transfer. Therefore, we aimed to evaluate the influence of surgery involving tendons around the knee on ankle motion during gait in cerebral palsy patients.

Methods:

The analysis included data regarding 55 limbs from 34 patients with spastic cerebral palsy, who were followed-up after they had undergone distal hamstring lengthening with or without additional rectus femoris transfer. Mean age of the patients at time of the knee surgery was 11.2 ± 4.7 years. Preoperative and postoperative kinematic variables that were extracted from three-dimensional gait analyses were compared to assess the change in ankle motion after surgery involving tendons around the knee. The postoperative 3D gait analysis was performed at a mean of 0.9 ± 1.3 years after the surgery. The outcome measures were relevant kinematics parameters including peak ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, ankle peak dorsiflexion during swing, and dynamic range of motion of the ankle. A linear mixed model was constructed to estimate the changes in ankle motion after adjusting for multiple factors.

Results:

We estimated that peak ankle dorsiflexion at initial contact, peak ankle dorsiflexion during stance, ankle peak dorsiflexion during swing, and dynamic range of motion of the ankle decreased, respectively, by 0.4º (p=0.016), 0.6º (p<0.001), 0.2º (p=0.038), and 0.5º (p=0.006) per degree increase in total range of motion of the knee after knee surgery (Table). Estimated ankle peak dorsiflexion in the swing phase increased by 0.4º per degree increased in postoperative peak knee flexion in the swing phase (Table). Age at the time of the knee surgery did not significantly affect ankle kinematics.

Conclusion:

Improvement in total knee range of motion was correlated with a decrease in ankle kinematics after surgery involving tendons around the knee. Knee surgery may reduce the need for an additional surgical procedure involving the ankle joint. Because the simultaneous motion of the knee and ankle joints is cross-linked, surgeons should be aware of potential changes in the ankle joint after knee surgery.
Variability and Quality of Physical Therapy Protocols after Surgical Repair for Achilles Tendon Rupture Available Online for Patient and Therapist Education
Authors: Lin Zilan , Boaz Ray , Wolf George , Makhni Eric , Gross Christopher
Published: September 2017

Category:

Sports, Trauma

Introduction/Purpose:

The Internet has gained popularity in patient education and communication with physical therapists. Orthopaedic practices post information on physical therapy exercises and post-surgical caution online. This includes the case for rehabilitation after Achilles tendon repair. Therefore, it is important to assess the consistency within the online available protocols and determine if they retain current evidence-based principles. The purpose of the current study was to evaluate the consistency and quality of online physical therapy protocols after Achilles tendon surgical repair available to patients and physical therapists.

Methods:

Protocols were searched on Google by using the term “(achilles AND repair) AND (rehabilitation OR physical therapy) AND (protocol OR guidelines)” on three different computers. Methodical protocols on rehabilitation after Achilles tendon rupture repair from the first 100 websites with each search were collected. Duplicated protocols and non-operative treatment protocols were excluded. A comprehensive, custom scoring system was created to assess the source and each rehabilitation components of the protocols, including ankle immobilization, weight bearing status, range of motion, strengthening exercises, proprioceptive activities, functional return, as well as the time line for each component.

Results:

Fifty-three protocols were included in the current study (35.8% academic). Orthopaedic surgeon-affiliated websites accounted for 86.8% (Fig. 1). Thirty-six studies (67.9%) advised non-weight-bearing immediately after surgery. The timeline of weight bearing advancement varies among protocols and is illustrated in Fig.2. Forty-four protocols (83.0%) mentioned utilization of heel lifts throughout the protocol with different recommendations on specific timing (Fig.3). Non-ankle specific exercises were recommended in forty-three (81.1%) protocols. Considerable variation existed in the types and time line of recommended exercises, including the ones for range of motion, strength, proprioception, overall function, and functional return (Figs 4-8).

Conclusion:

Considerable variation existed in many components of physical therapy protocols for Achilles tendon repair after rupture, which subsequently could lead to confusion and misinterpretation among patients, and even therapist. Greater effort should be paid to create more evidence-based protocols that are both easy for patients and physical therapists to understand and execute.
Transfibular Total Ankle Replacement Outcome at 2 Years Follow Up
Authors: Maccario Camilla , Indino Cristian , Manzi Luigi , Usuelli Federico Giuseppe , Di Silvestri Claudia
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Primary ankle osteoarthritis is very uncomon, in fact 70-78% of the case ankle arthritis has a post- traumatic cause. Ankle arthrodesis (AA), has been considered a reliable procedure for resolution of ankle osteoarthritis. Recent modifications in Total ankle replacement (TAR) designs have challenged the perception that AA is the treatment of choice for end-stage ankle arthritis. Trabecular Metal Total Ankle system is a fixed-bearing prosthesis. The new design is flanked by use of new materials. The tibial articular surface is constructed of highly crosslinked UHMWPE and Trabecular Metal lining the talar and the tibial base component. The purpose of this retrospective study was to show the preliminary result in 31 patients underwent to ankle replacement using Zimmer Trabecular Metal Total Ankle system.

Methods:

We retrospectively assessed prospectively collected data on the initial cohort of 31 patients undergoing TAR with this implant. Clinical evaluation was determined pre and postoperatively for a minimum of 24 months after surgery. Pain was rated using the visual analogue scale (VAS). Functional results were assessed as well as ankle range of motion (ROM). Clinical outcomes used where the Short Form SF-12 Quality of Life score, the American Foot and Ankle Society (AOFAS). The imaging follow-up included ankle radiographs done at 6, 12 and 24 months. Radiological parameters were angles??(normal values 90 +- 2),?? (normal value 85 +- 2),??? normal values 20 +- 2) and TTratio? normal values: 27% to 42%).

Results:

The study included 31 ankles of TM Ankle Replacement in 31 consecutive patients over a period of 2 years (2013–2015). Out of 31 patients, 13 were females and 18 were males (average age 49.4 years, range, 30–75 years). All procedures were performed by a single surgeon. The ROM plantarflexion and dorsiflexion improved significantly (p <0.001) at the last follow up. The mean VAS pain score decreased significantly from 7.42 points (range 4 – 10 points) preoperatively to 1.42 points (range, 0 - 3 points) at the time of the latest follow-up (p <0.001). AOFAS and SF-12 scores both improved from postoperatively to the last follow up. (Table 1). We noted stable implants based on our radiographic parameters, with no corrections loosening. (Table 2)

Conclusion:

Our study evaluated the new fixed bearing Zimmer TM total ankle replacement approved by the US FDA in 2012 and is the first studies to evaluate the clinical and radiographic outcomes of this prosthesis. Of 31 ankles treated with a new transfibular arthroplasty system, only two asymptomatic fibular delayed union were registered. No implant failure was noted at 24 months postoperatively. Four ankles underwent secondary surgery for symptomatic fibular hardware with good outcome. The findings suggest that this total ankle system is safe and effective at short-term follow-up.
Total ankle replacement and simultaneous subtalar arthrodesis
Authors: Manzi Luigi , Indino Cristian , Maccario Camilla , Di Silvestri Claudia , D’Ambrosi Riccardo , Usuelli Federico Giuseppe
Published: September 2017

Category:

Ankle, Ankle Arthritis, Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

Patients with arthritis or severe dysfunction involving both the ankle and the subtalar joints can benefit tibiotalocalcaneal (TTC) arthrodesis or total ankle replacement and subtalar fusion. With the evolution of prosthetic design and surgical techniques, total ankle replacement (TAR) has become a reasonable alternative to arthrodesis. The aim of this study was to investigate the fusion rate of the subtalar joint and talonavicular joint in patients simultaneously treated with total ankle replacement (TAR) and subtalar joint fusion.

Methods:

This study includes 11 patients who underwent primary TAR and simultaneous subtalar and talonavicular fusion from May 2011 to January 2015. Six males and five females were enrolled with a mean age of 61 years (41-75). Patients were clinically assessed preoperatively and at 6 and 12 months postoperatively. Total follow-up time was 24.2±11.6 months. Radiographic examination included a postoperative CT scan obtained 12 months after surgery. Three surgeons independently reviewed the CT scans and interobserver reliability was calculated. Functional scores were also assessed.

Results:

At 12 months postoperatively, the subtalar fusion rate in patients treated with TAR and simultaneous subtalar fusion was 92% and the talonavicular fusion rate was 88%. There was a statistically significant increase in American Orthopedic Foot & Ankle Society ankle/hindfoot score from 25.9 to 74.1 at 12 months post-operatively. Ankle range of motion significantly increased from 10.2° to 30.8 degrees. Additionally, there was a statistically significant decrease in visual analog scale (VAS) pain score from 8.8 to 1.9.

Conclusion:

TAR and simultaneous subtalar and talonavicular joint fusion are reliable procedures for the treatment of ankle and subtalar joint arthritis. Furthermore, CT scans showed an excellent reliability among orthopaedic surgeons in determining the degree of successful fusion of subtalar and talonavicular arthrodesis.
Exaggerated Pre-Operative Patient Reported Visual Analog Pain Scale, A Retrospective review of 201 consecutive surgical patients
Authors: Martin Kevin , Dawson Laura , Cameron Kenneth , Van Buren Jeffrey
Published: September 2017

Category:

Patient Reported Outcomes

Introduction/Purpose:

The visual analog scale (VAS) is a reliable and validated measure of patient reported acute pain. The clinical implications of the VAS in patients with chronic pain or postoperative pain is less clear. As patient reported outcome measures are becoming the standard of care throughout the orthopaedic community, interpretation and clinical applications are still under investigation. The aim of the current study was to evaluate preoperative patient reported VAS score reported to nursing staff as compared to the surgeon at the same clinical visit. Our hypothesis was that there would be no difference in the scores reported by a single patient to two different healthcare providers during the same clinic visit.

Methods:

The current study was a retrospective cohort of 201 consecutive foot and ankle patients treated by a signal surgeon. The patients were asked by the nursing staff to rate their pain intensity using a standard horizontal VAS 0-10, from “no pain” to the “worst possible pain”. At the same office visit the patients were asked by the treating surgeon to rate their pain using the same VAS. Dependent t-tests were calculated to evaluate mean differences in VAS pain reported by each patient to two different healthcare professional. All data were analyzed using STATA v10.1 with an alpha level of p<0.05.

Results:

The results demonstrate that patients reported higher pain scores to the surgeon within 81% of the encounters, nursing staff 8% and equal 11%. On average the VAS score reported to the surgeon (6.17 ±2.12) was significantly higher higher than that reported to the nursing staff (3.30 ±2.26), respectively. The mean difference between the scores was 2.87 ±2.46 (p=<0.001).

Conclusion:

The current study demonstrates a clear and significant difference in patient reported pain scores between that given to nursing staff verses the treating surgeon. The cause for the exaggerated pain scores is unclear, but does lead surgeons to consider patients may have a predetermined desire for surgery. The findings of this study may also have implications for comparing patient reported outcome measures prior to surgery to post-surgical outcomes depending on who administers the instrument.
Contact Stresses in a Fixed-Bearing Total Ankle Replacement
Authors: Martinelli Nicoló , Baretta Silvia , Prati Alberto Bianchi Castagnone , Malerba Francesco , Bonifacini Carlo Corrado , Galbusera Fabio
Published: September 2017

Category:

Ankle, Ankle Arthritis, Basic Sciences/Biologics

Introduction/Purpose:

Third-generation ankle implants with good clinical results continued to increase the popularity of total ankle arthroplasty (TAA) to address end-stage ankle osteoarthritis preserving joint movement. Newer TAA used fixed-bearing designs, with a theoretical increase of contact stresses leading to a higher polyethylene wear. The purpose of this study was to investigate the contact stresses in the polyethylene component of a new third-generation TAA, with a fixed-bearing design, using 3D finite element analysis.

Methods:

A three-dimensional finite element model was developed based on the Zimmer Trabecular Metal Total Ankle (ZTMTA) and a finite element analysis was employed to evaluate the contact pressure, contact area and Von Mises stress in the polyethylene articular surface in the stance phase of the gait cycle.

Results:

The peak values were found at the anterior regions of the articulating surface, where reached 19.8 MPa at 40% of gait cycle. The average contact pressure during the stance phase of gait was 6.9 MPa. The maximum von Mises stress of 14.1 MPa in the anterior section was reached at 40% of the gait cycle. For the central section the maximum von Mises stress of 10.8 MPa was reached at 37% of the gait cycle, whereas for posterior section the maximum of 5.4 MPa was reached at the end of the stance phase (60% of the gait cycle).

Conclusion:

Although, the average von Mises stress was less than 10 MPa, high peak pressure values were recorded. Advanced models to quantitatively estimate the wear are needed to assess polyethylene and metal component survivorship.
Relations of ankle alignment and MRI findings of ankle osteoarthritis
Authors: Mitsui Hiroyuki , Hirano Takaaki , Yui Akiyama , Maeda Shingo , Niki Hisateru
Published: September 2017

Category:

Ankle Arthritis

Introduction/Purpose:

MRI is gaining attention as a tool for examining the severity of osteoarthritis (OA) over X-ray findings. However, there are few reports on the relationship between MRI and X-ray findings in ankle joints. We assessed the combination of ankle joint alignment and MRI to find the factor to predict MRI findings from X-ray findings in OA.

Methods:

Of the 341 patients who had a diagnosis of ankle OA in our hospital from May 2009 to August 2015, we assessed 46 feet of 45 patients who underwent MRI. We determined ankle joint alignment by measuring tibial anterior surface (TAS) angle, and tibial lateral surface (TLS) angle on X-ray, and determined the areas of Bone Marrow Edema (BME) appearing on STIR, by partitioning 22 areas for talocrural, tarocalcaneal, Chopart joint. In the statistics analysis, we divided into two groups with and without BME, and we compared TAS angle and TLS angle. Moreover, for predicting the occurrence of BME, we divided the disease group into 2 groups, training set and validation set. We then verified the validity of the results by measuring cut-off value of TAS angle and TLS angle from ROC curve, an area which had statistically significant difference.

Results:

TAS angles or TLS angles were significantly lower in the group which showed BME at the anterior medial part of the tibia canopy and medial malleolus joint surface. From the ROC curve of the training set, the cut-off value (TAS angle of 82 degrees or less and TLS angle of 76 degrees or less) was obtained. Applying the obtained cut-off value to the validation set, it was possible to predict the occurrence of BME on the medial malleolus joint surface (sensitivity 71%, specificity 67%).

Conclusion:

Association with BME and clinical symptoms as well as disease prognosis has been reported in the OA area, so predicting the appearance of BME can be a useful index for prescribing a treatment plan. It was suggested that the appearance of BME could be predicted from X-ray findings because it was related to ankle alignment and MRI. It is possible that these findings could be used as a new diagnostic tool to estimate disease severity in the future.
Proximal Tibiofibular Joint Dislocation as a Maissoneuve Equivalent Fracture
Authors: Palma Joaquin , Nussbaum Jorge Filippi , Ponce Pablo Mery , Briceño Jorge , Villa Andres , Abarca Mario
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Dislocation of the proximal tibiofibular joint (PTFJ) in association with ankle fracture is an infrequent injury. The mechanism involves a pronation-external rotation injury in which the energy exits through the PTFJ instead of the proximal fibula, like in a Maissoneuve fracture. Early diagnosis and treatment is of paramount importance to avoid complications such as pain, posterolateral knee instability and peroneal nerve injury due to chronic traction by the dislocated fibular head. In addition, an anatomical reduction of the PTFJ is mandatory to restore the fibular length in order to obtain anatomic reduction at the ankle. The objective is to report 3 cases with PTFJ dislocation in association with ankle fracture and to provide a treatment guide based on the management of these patients.

Methods:

Three cases of PTFJ dislocation in association with ankle fracture, surgically treated in our institution between 2009 and 2016, were retrospectively analyzed. For each case, clinical history at admission, pre and post operative radiographs and computed tomography (CT) were obtained. Clinical follow up time was between 1 and 6 years.

Results:

Diagnosis of the PTFJ dislocation required a high degree of suspicion. All the patients had subtle radiographic abnormalities at the PTFJ, thus requiring a CT of the knee to confirm the diagnosis. The first surgical step was to perform an open reduction of the PTFJ. Common peroneal nerve was identified and retracted. Reduction was performed with a clamp and for fixation we used one cortical positioning screw from the fibula to the tibia. After the achievement of an anatomic reduction, the second step was to approach the ankle according the specific fracture pattern. Anatomical reduction was obtained in all the patients checked by ankle and knee CT. At final follow up none of the patients had knee pain, and all returned to their activities.

Conclusion:

The PTFJ dislocation in association with ankle fracture is an infrequent injury and should be considered as a Maissoneuve equivalent fracture in terms of mechanism and diagnosis. A high index of suspicion is needed and the diagnosis is confirmed with a knee CT. As the Essex Lopresti injury of the upper extremity, this type of lesion requires proximal and distal stabilization. Our recommended treatment, based on the good clinical results of our 3 patient, is open reduction and screw fixation of the PTFJ as the first step in order to allow anatomical reduction of the distal injury at the ankle.
The Usefullness of Subtalar Arthroscopy in Surgical Treatment of Sanders Type 2 Calcaneal Fractures Using a Sinus Tarsi Approach
Authors: Park Chul-Hyun , Chun Dong-Il , Choi Hongjoon , Cho Jaeho , PARK JAEWOO
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

The sinus tarsi approach was designed to provide a direct view of the posterior facet and reduce soft tissue and neurovascular injuries. However, it is difficult to expose posterior facet using sinus tarsi approach because of limited surgical view. Confirmation of reduction status in intra-articular calcaneal fractures has traditionally been performed by intraoperative fluoroscopy such as Brodens view. Recently some reports indicate that there is a role for subtalar arthroscopy in these fractures. We thought that combination of intraoperative fluoroscopy and subtalar arthroscopy could more accurately restore joint congruity and provide better clinical outcomes. The purpose of this study was to clarify whether this combined checking has better clinical and radiological results comparing with intraoperative fluoroscopy only.

Methods:

Forty-five displaced calcaneal fractures involving the posterior facet were consecutively treated using a sinus tarsi approach by a single surgeon. Among them, 25 fractures were confirmed reduction of posterior facet by fluoroscopy (Fluoroscopy group) and 20 fractures were confirmed by combined fluoroscopy and subtalar arthroscopy (Arthroscopy group). Clinical evaluations were performed using the visual analogue scale (VAS) and the Ankle-Hindfoot Scale developed by the American Orthopaedic Foot and Ankle Society (AOFAS), and short form (SF)-36 v2 questionnaires. Radiographic evaluations were performed using calcaneal lateral radiographs and CT. Changes in Böhler’s angle were evaluated from the preoperative and last follow-up lateral radiograph of calcaneus. Reduction of the posterior facet was graded according to articular step, defect, and angulation of the posterior facet in CT.

Results:

There were no significant differences in terms of VAS, AOFAS score, and SF-36 v2 between Fluoroscopy and Arthroscopy groups at the last follow-up. No significant difference was observed in change of Böhler’s angles between the groups. Reduction of the posterior facet was graded excellent in 5 feet (20%), good in 12 (48%), and fair in 8 (32%) in Fluoroscopy group and excellent in 7 feet (35%), good in 11 (55%), and fair in 2 (10%) in Arthroscopy on postoperative CT. Screw penetration of posterior facet were observed in 4 feet of Fluoroscopy group and 1 foot of Arthroscopy group on postoperative CT.

Conclusion:

Subtalar arthroscopy appears to be useful in detecting joint incongrucencies in sinus tarsi approach of intra-articular calcaneal fractures.
Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy
Authors: Park Young-Uk , Seo Youngwook , Jegal Hyuk , Lee Kyung-Tai
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Isolated Lateral malleolus fracture, like any other fractures can be treated by operative or conservative treatment. Stability of ankle joint is the most important factor in deciding the type of treatment. Unstable ankle joints present superior clinical outcomes with surgical management. There are many methods to assess the stability of ankle joint such as plain x- ray films, stress radiographies and physical examination. Many studies have suggested the usage of ultrasound for diagnosis of ankle ligament injury. But, there are no reports about its use for stability assessment of isolated lateral malleolar ankle fracture. Therefore, the purpose of this study is to evaluate the value of ultrasound for stability assessment of isolated lateral malleolar fractures, compared to simple x-ray, stress radiography and arthroscopy.

Methods:

We have conducted a prospective study which included 13 consecutive patients who underwent arthroscopic exam and subsequent open reduction and internal fixation for isolated lateral malleolar ankle fracture. Before operation simple x-ray, external rotation stress radiographs were done. Stress ultrasound was performed to assess the anterior inferior tibiofibular ligament (AITFL) and medial deltoid ligament prior to operation. The arthroscopic findings were used as the reference standard. A standardized physical examination (tenderness and ecchymosis, external rotation stress test), simple radiography, stress radiography and ultrasound images were compared to assess the stability.

Results:

Deltoid ligament injury and or syndesmosis injury were verified arthroscopically in 12 cases with a clinical diagnosis (92.3%). There were 9 cases who showed unstable ankle fracture on the simple radiography. (69.2%). There were all cases who showed unstable ankle fracture on the external rotation stress radiography. (100%) In addition, for 12/13, there were acute tear of the deltoid ligament or AITFL injury on the ultrasound (92.3%).

Conclusion:

The results suggest that ultrasound could be used for the assessment of the instability of isolated lateral malleolar fracture.
Long Term Outcomes Following Syme’s Amputation
Authors: Pinzur Michael , Schiff Adam , Finkler Elissa
Published: September 2017

Category:

Ankle, Diabetes, Trauma

Introduction/Purpose:

The metabolic cost of walking following Syme’s ankle disarticulation amputation is minimally more than similar non-amputees. The ability to end-bear makes prosthetic fitting relatively simple, and very few patients require extensive rehabilitation or placement in a skilled nursing or rehabilitation facility. In spite of these potential benefits, there is a paucity of objective information on the actual long term outcomes.

Methods:

Fifty-one patients were identified who underwent single stage Syme’s ankle disarticulation amputation with excision of the lateral and medial malleoli by a single surgeon during a twenty three year period. None of these patients had sufficient tissue to allow amputation at the transmetatarsal or tarsal-metatarsal levels. Thirty-three underwent amputation due to diabetic forefoot infection, eleven secondary to crush injury, three for non-diabetic infection, three for non-correctable acquired deformity and one for neoplasm. The average age at surgery for the di-abetic patients was 62.1 (range 36-81) years, with a follow-up of 6.8 (4-11.6) years. The nondi-abetic patients averaged 37.8 (range 21-65) years, with a follow-up of 9.3 (range 2.2-25.0) years. Patients who were alive and could be contacted were invited to complete a Short Musculoskele-tal Functional Assessment (SMFA) questionnaire that was scored for functional, mobility and bothersome indices.

Results:

Seventeen of the 33 diabetics died. Four (12.1%) were converted to the transtibial amputation level. One of the non-diabetics had died and one (5.5%) was converted to the transtibial amputation level. Eleven of the thirty-three patients who were con-tacted completed the SMFA. All of these patients demonstrated favorable outcome scores in the mobility, functional and bothersome indices (non-diabetic mean mobility score of 17.2, function-al index of 14.7 and bothersome of index of 16.7 compared to 34.7, 29.9 and 30.6 in the diabetic patients, respectively).

Conclusion:

The objective information derived from this investigation supports the opinion that patients with Syme’s ankle disarticulation amputation appear to fare better than sim-ilar patients with transtibial amputation. This data also refutes the notion of high complication rates and difficulties with prosthetic fitting. These patients require less rehabilitation and achieve improved levels of functional independence as demonstrated by favorable functional, mobility, and bothersome indices.
Pain course after foot and ankle surgery
Authors: Plaass Christian , Ettinger Sarah , Claassen Leif , Stukenborg-Colsman Christina , Daniilidis Kiriakos , Hayn Konstantin
Published: September 2017

Category:

Pain managment

Introduction/Purpose:

Most surgeons believe, that the postoperative pain course after foot and ankle surgery differs from other joints due to the initial protection and immobilization. The knowledge of the normal pain course after foot and ankle surgery is important to know for the surgeon and correctly inform patients preoperative and may help to identify abnormal postoperative healing courses.

Methods:

180 patients were enclosed in a prospective study. 66,7% were female and 33.3% were male. All patients had primary surgery for foot and ankle diseases at a tertiary care foot and ankle center. The pain course was measured using a VAS over a one year period. The mean age was 53,2 (±13.6) years.

Results:

The mean pain level was 4.56 (± 2.0) preoperative. In the first postoperative week it was 3.5 (± 2.18) and declined until the 6th postoperative week to 1.57 (± 1.52) it increased again after the sixth week up to 1.95 (± 1.63) and decreased then again to 1.09 (± 1.51) one year postoperative. The pain level in patient with tendon surgeries tended to be higher in the first 12 weeks postoperative than that of patients with bony procedures.

Conclusion:

The pain course after Foot and ankle surgery shows a characteristic curve with a significant increase of the pain level after 6 weeks. A comprehensive patient information can increase satisfaction rates of the patient. Any abnormal postoperative pain course should arise suspection of a complicated healing period.
Chopart Joint Injuries – 10-Year Results in 75 Cases
Authors: Rammelt Stefan
Published: September 2017

Category:

Hindfoot, Midfoot/Forefoot, Trauma

Introduction/Purpose:

Fractures and dislocations at the mid-tarsal (Chopart) joints have a relatively low incidence but a highly variable clinical presentation. They are among the most commonly overlooked or misinterpreted injuries to the human body with potentially deleterious consequences for global foot function. There are only few reports available on the long-term outcome of operative treatment following a standardized protocol in these injuries.

Methods:

From 1994 to 2009 a total of 122 patients with mid-tarsal fractures and fracture-dislocations were entered into a pospective database. Injury patterns, comorbidities, treatment, and complications were documented. Seventy-three patients with 75 Chopart fracture-dislocations were available for follow-up treatment at an average of 10 years (range, 4-18 years). Mean patient age was 37.6 years, 68.5% were male. Foot function was assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, the Foot-Function-Index (FFI-D) and the SF-36 physical and mental component summary scores. Weight-bearing radiographs were obtained to assess alignment and posttraumatic arthritis.

Results:

Motor-vehicle-accidents accounted for 53.4% of injuries, The navicular and cuboid bones were fractured more than twice as often as the talar head and anterior process of the calcaneus. In 54.7% of cases more than one of these bones was fractured. 29.3% of the patients were polytraumatized, another 26.7% had accopmanying injuries to the same foot. At latest followup the AOFAS score averaged 71.5, the FFI averaged 26.9, and the mean SF-36 physical and mental summary scores were 43.5 and 51.2, respectively. Negative prognostic factors were a high ISS, work-related accidents, open injuries, multiple fractures and purely ligamentous dislocations (4%) at the Chopart joint, two-step operations, delay of treatment for more than 4 weeks, postoperative infection, closed reduction and the use of primary or secondary arthrodeses.

Conclusion:

Fractures and fracture-dislocations at the Chopart joint are rare but severe injuries to the foot that lead to lasting functional restrictions in most cases in the long term. Purely ligamentous dislocations have the worst prognosis while injuries with fractures of a single bone have a better prognosis with open reduction and anatomical internal fixation. Fusions should be restricted to cases with completely destroyed joint surfaces.
Combination of PedCAT with Pedography Shows Relationship of Morphology (Bone) Based Foot Center (FC) and Force/Pressure Based Center of Gravity (COG)
Authors: Richter Martinus , Lintz Francois , Zech Stefan , Meissner Stefan
Published: September 2017

Category:

Basic Sciences/Biologics

Introduction/Purpose:

PedCAT (Curvebeam, Warrington, USA) is a technology for 3D-imaging with full weight bearing which has been proven to exactly visualize the 3D-bone position. Center of gravity (COG) and Foot Center (FC) are discussed to be important parameters for corrections/fusion around the hindfoot and for total ankle replacement. For this study a customized pedography sensor (Pliance, Novel, Munich, Germany) was inserted into the pedCAT. The aim of this study was to analyze difference of morphology (Bone/PedCAT) based FC and Force/Pressure (Pedography) based COG. Motion of COG during PedCAT/Pedography scan should also be registered and analyzed.

Methods:

In a prospective consecutive study starting November 28, 2016, 36 patients / 72 feet were included. Inclusion criteria were 18 years of age or older, and indication for PedCAT scan based on the local standard. A pedCAT scan with simultaneous pedography with full weight bearing in standing position was performed. The morphology based definition of the FC was performed with the pedCAT data following the TALAS algorithm. This algorithm takes different bony landmarks (Posterior calcaneal process, center of talar dome/tibial plafond, metatarsal heads) into consideration and calculates the FC. The force/pressure based COG was defined with the pedography data using a software based algorithm. The distance between FC and COG and the direction of a potential shift (distal-proximal; medial lateral) was measured and analyzed. COG motion during data acquisition was recorded and analyzed.

Results:

Mean age of patients was 54.5 (range, 27-80) years, 27 (75%) were female. COG motion was 1.4 mm on average (range, 0-4.8 mm). The distance between FC and COG was 22.6 mm on average (range, 5-52). FC was distally to COG in all feet (mean, 27.4 mm; range, 3-50), and laterally in 49 feet (68%; shift 0 mm in remaining feet; mean for all feet, 3.3 mm; range, 0-12). No difference between right and left side occurred (t-test, each p>.05).

Conclusion:

COG is not relevantly moving during combined PedCAT/Pedography scan. There is a difference between FC and COG. This expected finding was quantified with this study. There is a typical/standard shift between COG and FC in the investigated 32 subjects / 64 feet (26 mm distally and 3 mm laterally on average) which might allow for prediction of COG based on FC without additional pedography. Definition of COG might be taken into consideration for planning and followup for corrections/fusion around the hindfoot and for total ankle replacement.
Tibiotalocalcaneal Arthrodesis with a Retrograde Triple Bending Nail - Results of 200 Cases
Authors: Richter Martinus , Meissner Stefan , Zech Stefan
Published: September 2017

Category:

Ankle, Ankle Arthritis, Hindfoot

Introduction/Purpose:

The aim of the study was to analyse the clinical aspects including minimum 1-year-followup of tibiotalocalcaneal arthrodeses (TTCA) with a triple-bend retrograde intramedullary nail (A3, Stryker, Airview Boulevard, MN, USA).

Methods:

In a prospective consecutive non-controlled clinical followup study, all patients with TTCA using A3 from October 18th, 2011 to October 10th, 2015 were analyzed. The time and accuracy of the alignment and implant position (Visual analogue scale, 0-10) for implant placement, complications, radiological fusion, and Visual Analogue Scale Foot and Ankle (VAS FA) were recorded. Fusion (=50% bony bridge at ankle and subtalar joints assessed on radiographs) was assessed at 6, 9, 12 weeks, then latest follow-up. VAS FA was recorded at latest follow-up.

Results:

200 cases were included (age, 59.3 (22-83) years; VAS FA, 31.9 (0-79.3)). Indications were specified as follows (multiple possible): osteoarthritis, n=182 (91%); instability, n=48 (24%); deformity, n=154 (77%), failed total ankle replacement, n=12 (6%); failed previous fusion, n=15 (8%), diabetes, n=28 (14%). The time for implant preparation and positioning was 17.2 (5-32) minutes. The accuracy of alignment and implant position was 9.4 (7 - 10). Complications were registered in 12 (6%; n=6 (3%) infection, n=6 (3%) wound healing delay. One hundred and sixty-eight (84%) patients completed follow-up at 32 (12-60) months: VAS FA 60.4 (t-test (comparison with preoperative scores), p=.01)), fusion rate 96%.

Conclusion:

TTCA with the A3 implant system showed accurate correction and implant position. Thirty-two month (average) followup of 168 patients (84%) showed good clinical outcome scores and 96% fusion rate.
Stabilization of Proximal Interphalangeal Arthrodesis of Lesser Toes Using K-wires vs. Implants
Authors: Rothermel Shane , Aydogan Umur , Lewis Gregory , Roush Evan
Published: September 2017

Category:

Lesser Toes

Introduction/Purpose:

Lesser toe proximal interphalangeal (PIP) joint arthrodesis is one of the most common foot and ankle elective operative procedures. Currently, the most common method for fixation of the PIP joints is utilization of intramedullary Kirschner wires (K-wires). Implantation of K-wires have been shown to be associated with a fair number of complications including hardware failure, loosening, bending, mal-union, non-union, wire migration, and infection. These complications have led to the development of intramedullary devices for fixation. Our hypothesis was that the memo-metal X-fuse PIP joint arthrodesis implant (Stryker, Kalamazoo MI) would provide a stronger and stiffer arthrodesis than Kirschner wire fixation.

Methods:

Six matched fresh frozen cadaveric second toe pairs were used in the study. Six PIP joints were prepared and fixed with K-wires and the six contralateral PIP joints were prepared and fixed with the X-fuse system. All specimens were then potted and fixed to a custom jig. Specimens were then cyclically loaded with extension bending force of the PIP joint mimicking natural upward bending force in walking using 2 N step increases of force with 10 cycles per step. Failure was defined as 4 mm of actuator displacement. Load to failure was then assessed. Paired t-test was utilized for statistical analysis.

Results:

The average force at failure (defined as 4 mm of displacement) for the Kirschner wire was 93.3 N (SD 25.8) which was significantly greater than the average for the X-fuse system, 65.0 N (SD 13.8). P-value was 0.0053. Failure of the K-wire resulted from bending of the K-wire itself or breaching of cortical bone. Failure of the X-fuse typically resulted from implant pullout.

Conclusion:

Contrary to our hypothesis, K-wires provided a stiffer and stronger construct than the X-fuse system. Successful bony fusion is the clinical outcome of interest, and this cadaver study was used to assess stability of the fusion site at time zero after surgery. Limitations of this study include a relatively small sample size.
Dismounted complex blast injuries
Authors: Ryan Paul , Anderson Claude , Wilding Steven
Published: September 2017

Category:

Trauma

Introduction/Purpose:

The United States Medical Corps has continued to evaluate and define the injury patterns of our service members in an effort to prevent injury and improve combat casualty care. The pattern of injury can be predicted by the mechanism of injury. One of the more recently described and studied mechanisms has been coined the ‘dismounted complex blast injury. This injury pattern involves traumatic amputation of at least one leg with a second injury involving another extremity in addition to an injury to either the pelvis, the abdomen, or the urogenital region. The purpose of this study was to better define and describe the injuries occurring to the non amputated extremity.

Methods:

This is a retrospectively review of data from the US and UK Joint Theater Trauma Registries (JTTR) of consecutive patients admitted to the UK Role 3 hospital at Camp Bastion, Afghanistan, from January 1, 2009, to February 29, 2012. Data was obtained from the US JTTR (Joint Theatre Trauma Registry). Each patient was assigned an Injury Severity Score (ISS) and an Abbreviated Injury Scale (AIS) score. Only those patients with an AIS of 3 or greater (a serious injury) were included. All xrays and CT scans were evaluated by two board certified orthopaedic surgeons and one board certified musculoskeletal radiologist. Fisher’s exact test was used to compare categorical data and binomial logistic regression was be used to compare proportions of types of injuries by traumatic amputation level observed.

Results:

There were 295 patients with lower extremity injuries identified. 201 had traumatic lower extremity amputations, 140 with bilateral lower extremity amputations, 61 with single leg amputations. The mean age was 23.38 +/-3.77 years. All were male. Below the knee amputation was the most frequent amputation type observed, representing 55.7% of the amputations (29/52), the next most frequent was the through knee amputation representing 25%. The least frequent was the through ankle amputation. The presence of a symes level amputation was associated with an 8.1% increase in the odds of the presence of a skeletal foot injury in the rear lower extremity. There was also an association found between AKA level amputation and skeletal injury in the contralateral upper extremity .

Conclusion:

This is among the first studies to correlate level of injury and associated musculoskeletal injury for the Afghanistan theater of operations. The results of this data set demonstrate that proximal lower extremity amputation levels are significantly associated with distal upper extremity skeletal injury. In addition, the Symes level of amputation is significantly associated with contralateral foot fractures. Amputation levels proximal to the ankle often present with associated Genitourinary injuries. Unique to this study is the demonstration of a significant association of upper extremity injury with a more proximal lower extremity amputation level .
A National Comparison of Total Ankle Replacement Versus Arthrodesis. Is There a Paradigm Shift?
Authors: Sabour Andrew , Alluri Ram , Tan Eric
Published: September 2017

Category:

Ankle, Ankle Arthritis, Diabetes

Introduction/Purpose:

Total ankle replacement (TAR) and tibiotalar arthrodesis (TTA) are both utilized in the surgical management of ankle osteoarthritis. Over the past decade, foot and ankle surgeons have broadened the indications for TAR, and subsequently have performed less TTA. Currently, no studies exist evaluating the epidemiological, pre-operative, and temporal trends between TTA and TAR. The purpose of this study was to compare nationwide trends of TAR and TTA in the treatment of ankle osteoarthritis.

Methods:

The Nationwide Inpatient Sample (NIS) from 2007 to 2013 was used to extract data on patients over 50 years of age who underwent either primary TAR or TTA. Patients who underwent both procedures or revision procedures were excluded. Univariate and multivariate analysis were performed to assess for differences in temporal, demographic, and primary diagnosis trends between TAR and TTA.

Results:

15,060 patients underwent TAR and 35,096 underwent TTA between 2007 and 2013. Patients undergoing TTA had significantly more comorbidities (2.17 vs 1.55, P<0.001). Temporal analysis demonstrated a significant 15% increase every 3 years in TAR performed from 2007 (14%) to 2013 (45%) (Figure 1) (P<0.001). Multivariate analysis comparing TAR and TTA demonstrated that in patients with a primary diagnosis of post-traumatic osteoarthritis, the odds of having a TAR in 2013 was 12 times higher than in 2007 (P<0.05). Similar increases in TAR utilization was demonstrated in patients with primary osteoarthritis (4.93 times) and rheumatoid arthritis (3.12 times) (P<0.001). Analysis of comorbid diagnoses revealed that patients with diabetes, hypertension, or CAD were 4.66 times more likely to have a TAR in 2013 compared to 2007 (P<0.001).

Conclusion:

Over the past decade the indications for TAR have increased, and foot and ankle surgeons are performing TAR with greater frequency. This has been most evident in patients undergoing TAR for post-traumatic arthritis and rheumatoid arthritis. Foot and ankle surgeons still prefer to perform TAR in patients with fewer comorbidities compared to TTA. However, as technology has advanced and surgeons have become more facile with the technique, patients with specific comorbidities are undergoing TAR at a significantly higher annual incidence.