bluuebunny/crossref_metadata_2025 huggingface dataset:
Do We Really Need to Worry About Calcaneocuboid Subluxation During Lateral Column Lengthening for Planovalgus Foot Deformity?
Authors: Hedrick Brittany , Riccio Anthony , Siebert Matthew , Shivers Claire , Harris Mitchell , Pierce William A. , Thomas Danielle M. , Zide Jacob R.
Published: November 2020

Category:

Midfoot/Forefoot; Other

Introduction/Purpose:

While lengthening of the lateral column through a calcaneal neck osteotomy is an integral component of flatfoot reconstruction in younger patients with flexible planovalgus deformities, the procedure has been implicated in iatrogenic calcaneocuboid (CC) subluxation and subsequent degenerative changes at the CC articulation. The purpose of this study is to characterize alterations at the CC joint following lateral column lengthening (LCL) as well as to determine if Steinman pin stabilization of the CC joint prior to distraction maintains a normal CC relationship.

Methods:

Seven matched pairs of fresh frozen cadaveric feet underwent pre-procedure plain radiography and cross-sectional computed tomography (CT) imaging. LCL via a calcaneal neck osteotomy was then performed. One foot of each matched pair had a single smooth Steinman pin placed centrally across the CC joint prior to osteotomy distraction. Distraction across each osteotomy was then performed and maintained with a 12mm porous titanium wedge. Repeat imaging was obtained and compared to pre-procedure studies to quantify sagittal and rotational differences at the CC articulation

Results:

Following LCL, plain radiography demonstrated statistically significant increases in the percentage of the calcaneal articular surface dorsal to the superior aspect of the cuboid in both the pinned (8.2% vs 17.6%, p=0.02) and unpinned (12.5% vs 16.3%, p=0.04) specimens. No difference in the percentage of subluxation was found between the two groups following LCL. CT imaging demonstrated statistically significant increases in rotation between the calcaneus and cuboid following LCL in both the pinned (7.6O +- 5.6O, p=0.01) and unpinned (17O +- 12.3O, p=0.01) specimens. Though a greater degree of rotation was present in the unpinned specimens following LCL, this difference was not statistically significant (p=0.28).

Conclusion:

Both sagittal and rotatory subluxation seem to occur at the CC joint following LCL regardless of pin stabilization. As a single pin would be expected to limit pure translation while having little effect on rotation, it is possible that the rotational changes identified on three-dimensional imaging are interpreted as dorsal translation when viewed two dimensionally using plain radiography. Consideration should therefore be given to CC stabilization with two pins during LCL to prevent this rotatory subluxation.
Epidemiology of Lateral Ankle Ligament Injury: Trends in Clinical Management and Likelihood of Progression to Surgical Intervention
Authors: Hermanns Christina , Coda Reed , Messamore William G. , Vopat Matthew , Morris Brandon L. , Cheema Sana , Tarakemeh Armin , Schroeppel Paul , Mullen Scott , Vopat Bryan G.
Published: November 2020

Category:

Ankle

Introduction/Purpose:

Lateral ankle ligament sprains occur frequently in both general and athletic populations. Most patients recover from their injury without complication, however, some experience persistent pain and instability following lateral ankle injury, which requires treatment with surgical stabilization. The purpose of this study is to determine the utilization and associated costs of non-operative treatment modalities, such as physical therapy (PT), non-steroidal anti-inflammatory medication, and ankle bracing, as well the incidence of lateral ankle sprains that receive surgical treatment and the costs incurred by surgical treatment of chronic lateral ankle instability.

Methods:

Data was collected using the Pearl Diver Humana dataset using ICD-9, ICD-10, and CPT codes pertaining to ankle sprain, ankle ligament repair or reconstruction, physical therapy, ankle brace ordering, and non-steroidal anti-inflammatory medication (NSAID) ordering. Patients diagnosed with an ankle sprain were sub-divided into three categories: non-operative treatment, surgical ligament repair, and surgical ligament reconstruction. Incidence, cost, and PT usage was compared between patient groups. Cost analysis was performed per group using associated ICD/CPT cost and physical therapy cost. NSAID use and ankle bracing use was also examined.

Results:

Of patients who sustained lateral ankle injury, 64% were female and 36% were male. 306,180 (98.8%) patients successfully completed non-operative management. 2,774 (1.2%) patients underwent surgical intervention. 63,276 (20.7%) non- operative patients received physical therapy, whereas 1,536 (55.4%) surgically treated patients received PT after surgery. Only 725 (26.1%) surgical patients received pre-operative PT. Median time for total PT treatment of surgical patients was 21.8 weeks, while non-operative patients received treatment for a median time of 58.7 weeks. On average non-operative patients generated 11 billed days in PT while surgical patients received 8 days of PT before surgery and 11 days in PT after surgery. Average total cost per patient was $923.32 for non-operative patients, $3,384.63 for surgical ligament repair, and $3,659.98 for surgical ligament reconstruction.

Conclusion:

The vast majority of patients with lateral ankle ligament sprains do not progress to surgical treatment. Patients treated non-operatively used fewer physical therapy visits per patient and generated less cost compared to surgically treated patients. Only 20% of non-operative patients received physical therapy. Additionally, a higher proportion of surgically treated patients participated in PT compared to patients treated non-operatively.
Review of Variability in Rehabilitation Protocols after Lateral Ankle Ligament Surgery
Authors: Hermanns Christina , Coda Reed , Cheema Sana , Vopat Matthew , Bechtold Megan , Tarakemeh Armin , Mullen Scott , Schroeppel Paul , Vopat Bryan G.
Published: November 2020

Category:

Ankle; Sports

Introduction/Purpose:

Ankle sprains are one of the most common athletic injuries. If a patient fails to improve through conservative management, surgery is an option to restore ankle stability. The purpose of this study is to analyze the variability across rehabilitation for patients undergoing lateral ankle ligament repair, reconstruction, or suture tape augmentation.

Methods:

26 protocols were found. Inclusion criteria was protocols for ankle ligament surgery. Protocols for nonoperative care were excluded. A rubric was created to analyze weightbearing, range of motion (ROM), immobilization, single leg exercises, return to running, and return to sport (RTS).

Results:

There was variability especially in recommendations for immobilizing brace, partial and full weigh bearing, specific ROM movements of the ankle, and return to single leg exercise and running. For repair and reconstruction, none of these categories had greater than 60% agreement. 100% (12/12) of repair and 86% (12/14) of reconstruction protocols recommended no ROM postoperatively, and 86% (6/7) repair and 78% (11/14) reconstruction recommended no weightbearing postoperatively, making postoperative ROM and weightbearing status the most consistent aspects across protocols. Suture tape augmentation protocols generally allowed rehabilitation on a quicker timeline with full weightbearing by week 4-6 in 100% (3/3) of protocols and full ROM by week 8-10 in 66% (2/3). RTS was consistent in repair protocols (100% at week 12-16).

Conclusion:

ROM was variable across protocols and did not always match up with supporting literature. Return to sport was likely to correlate between protocols and the literature. Weightbearing was consistent between protocols. The variability between programs demonstrated the need for standardization of rehabilitation.
Incidence and Trends in Lower Extremity Amputations in the United States
Authors: Herzog Leah , Johnson Charles , Gross Christopher E.
Published: November 2020

Category:

Trauma

Introduction/Purpose:

Currently there is minimal focus on traumatic lower extremity amputations due to their relatively low incidence, but they often come with a higher morbidity and mortality than its upper extremity counterparts. The purpose of this study was to evaluate the incidence and trends of lower extremity amputations in the United States over a ten-year period.

Methods:

The National Electronic Injury Surveillance System (NEISS), was used for evaluation of lower extremity amputations that presented to the United States emergency departments. The overall incidence rate of lower extremity amputations within the United States was calculated as per 100,000 persons. After grouping mechanisms of injury, the data were stratified by both age groups and gender. Chi-square tests were used for direct comparisons of proportions. The five most common mechanisms were ranked for each age group and the most common overall age group for lower extremity amputations were determined using descriptive statistics. Trends for injury incidence and hospital admissions were evaluated using linear regression and Pearson correlation with Bonferroni correction.

Results:

From 2008 to 2017, 393 patients were reported to have sustained lower extremity amputations via the NIESS database with an estimated 11,475 patients sustaining a lower extremity amputation over the past ten years and an incidence of 2.2/100,000 person-years. The incidence of lower extremity amputations is highest in those less than five years old. Lawnmower incidents are the most common mechanism of injury in all age groups.

Conclusion:

Due to the high morbidity and mortality associated with these injuries, it is prudent to follow the trends in lower extremity amputations.
Increased Strength following Achilles Tendon Rupture Repair is Associated with Return to Same Level of Play in Patients with Higher Pre-Injury Level of Activity
Authors: Holzgrefe Russell E. , McCarthy Timothy , Wilson Jacob M. , Bariteau Jason T. , Labib Sameh A.
Published: November 2020

Category:

Hindfoot; Sports; Trauma

Introduction/Purpose:

Rupture of the Achilles tendon is a common injury that requires a lengthy duration of recovery and rehabilitation. Patients of various levels of physical activity, ranging from professional high-impact sports to low-impact recreational activities, can be affected by this injury. Often, one of the most important outcomes from the patient’s perspective is the ability to return to the same pre-injury level of sporting activity after recovery. The objective of the current study is to examine the relationship between global ankle strength and the ability to return to previous level of play following surgical repair of an Achilles tendon tear.

Methods:

Patients aged 18-50 years old at a minimum 1-year post-op from surgical repair of an isolated Achilles tendon rupture were recruited to return for a study visit. Patients reported both pre-injury and current activity level using the 10-point Tegner Activity Level Scale. Isokinetic strength testing was performed and the Isokinetic Strength Score (ISS) was calculated using maximal effort dorsiflexion and plantarflexion strength at 30o/s, 90o/s, and 240o/s comparing the operative and uninvolved extremity. The primary outcome was the patients’ ability to return to same level of play or within 1 Tegner activity level. Logitistic regression analysis was used to determine the relationship between ISS and return to play. Subgroup analysis was performed on patients participating in high level athletic activity (pre-injury Tegner >= 7) an those participating in only recreational or low level activity (pre-injury Tegner <7).

Results:

A total of 36 patients (mean 35 years, 72% male) completed the study protocol at a mean 1.8 years post-op (range 1 year to 3.6 years). Logistic regression revealed no association between ISS and return to play in the complete cohort. Subgroup analysis revealed that for 20 patients who had participated in high level competitive athletics prior to injury (Pre-injury Tegner >= 7), for every 16 point increase in ISS, the odds ratio for return to same level of play was 8.3 (p=0.055) and the OR for return to within 1 Tegner level of play was 6.3 (p=0.043). There was no association between ISS and return to previous activity in the 16 patients with lower pre-injury levels of activity.

Conclusion:

Improved ankle strength was associated with return to previous level of activity only in patients who participate in high level athletic activity. These results suggest that patients with more strenuous athletic activity prior to injury are more dependent on recovery of ankle strength in the post-operative time period in order to return to their previous high level of play. In contrast, regaining strength may be less important for returning to normal activities for less active patients. [Table: see text]
Cartiva Hemiarthroplasty for the Treatment of Hallux Rigidus
Authors: Hoskins Tyler , Patel Jay , Goyette David , Mazzei Christopher , Gianakos Arianna L. , Koss Justin , Wittig James , Epstein David M.
Published: November 2020

Category:

Lesser Toes; Arthroscopy; Other

Introduction/Purpose:

Hallux rigidus, degenerative arthritis of the first metatarsophalangeal (MTP) joint, is the most common type of arthritis of the foot, affecting nearly 2.5% of the population over the age of 50. The standard of treatment is non-operative in nature followed by surgical intervention if pain is not alleviated. Currently, first metatarsal dorsal cheilectomy and proximal phalanx osteotomy remain the two most common surgical interventions. Recently, first metartasophalangeal hemiartshroplasty with synthetic cartilage implant has become more popular. This procedure involves the implantation of synthetic cartilage in order to preserve motion and maintain joint space of the first metatarsophalangeal joint. Due to the scarce amount of literature reported on this technique, the goal of this study was to examine its efficacy in patients treated for hallux rigidus.

Methods:

From 2017 to 2019 twenty patients underwent a synthetic cartilage implant hemiarthroplasty for the treatment of hallux rigidus. Functional outcome scores were assessed using the American Orthopaedic Foot & Ankle scoring system (AOFAS) and the Foot and Ankle Outcome Score Survey (FAOS). Outcomes, complications, and any reoperations were recorded through retrospective chart review, direct patient examination, and phone calls to patients and their families. A statistical analysis was performed using Fischer’s Exact Test. Results were deemed statistically significant if the calculated p-value was less than 0.05.

Results:

The mean follow up for our patient cohort was 17.16 months (range, 12 to 26). The average age was 55.61 years (range, 47 to 73). Mean pre-op AOFAS and FAOS were 56.37 and 55 respectively, compared to 91.89 and 88.84 after surgery (p-value <0.05). There were no significant complications or reoperations reported in any of the patients at the time of publication.

Conclusion:

The pre-op and post-op AOFAS and FAOS scores were deemed statistically significant. Synthetic cartilage implant hemiarthroplasty, although new, offers promising results and remains a viable treatment option to decrease pain, improve function, and maintain motion for advanced hallux rigidus. However, a prospective randomized controlled trial comparing the efficacy of this procedure to other surgical methods would be necessary to further evaluate and validate our findings.
Comparison of Patient Reported Outcomes (PROs) for Major Pathologies of the Forefoot, Midfoot, Hindfoot, and Achilles Using PROMIS
Authors: Hu Daniel A. , Nayak Rusheel , Ogunkoya Elijah O. , Patel Milap , Kadakia Anish R.
Published: November 2020

Category:

Other; Hindfoot; Midfoot/Forefoot

Introduction/Purpose:

Many legacy patient reported outcomes (PROs) lack sufficient validity and reliability for the evaluation of clinical outcomes following foot and ankle procedures. Patient-Reported Outcomes Measurement Information System (PROMIS) is a newly developed PRO that has been validated for the general foot and ankle surgical population. It has since been used to assess the clinical outcomes of a variety of specific foot and ankle procedures. However, there is little data regarding clinical outcomes of patients at a more intermediate subgroup level. There has been some preconceptions that the different anatomic aspects of foot and ankle surgery have disparate functional and pain improvement. Thus, our study utilizes PROMIS to assess postoperative outcomes based on anatomical location in patients undergoing forefoot, midfoot, hindfoot, and Achilles procedures.

Methods:

Preoperative and one year postoperative PROMIS Physical Function (PF) and Pain Interference (PI) were prospectively collected from a cohort of patients undergoing a foot and ankle procedure at a tertiary medical center. The cohort was split into forefoot, midfoot, hindfoot, and Achilles procedure groups with 355, 95, 356, and 135 patients, respectively. Paired-t tests were used to compare preoperative versus postoperative outcomes within operative groups, while a one-way ANOVA was used to detect differences in PROMIS scores between operative groups.

Results:

Paired t-tests indicated that all four operative groups had significantly improved PROMIS PF and PI scores preoperatively versus one year postoperatively (all P <.001)(see attached figure). One-way ANOVA demonstrated that there were no differences in postoperative PROMIS PF and PI scores between the groups. A majority of patients achieved the minimal clinically important difference (MCID) level of improvement in PROMIS PF and PI scores following surgery.

Conclusion:

All four operative groups (forefoot, midfoot, hindfoot, Achilles) had significantly improved PROMIS PF and PI scores postoperatively compared to preperatively, indicating an improvement in physical function and pain outcomes in each of the operative groups. However, there were no differences in physical function and pain outcomes between the groups. [Table: see text]
Is it Safe to Offer Total Ankle Replacement (TAR) Surgery in Patients with Type II Diabetes?
Authors: Hutt Nicholas , Allport Jack , Shahid Zuhaib , Ramaskandhan Jayasree Ramas , Siddique Malik S.
Published: November 2020

Category:

Ankle; Ankle Arthritis; Diabetes; Midfoot/Forefoot

Introduction/Purpose:

The indications for Total Ankle Replacement (TAR) in patients with Type II Diabetes mellitus is poorly defined and there is paucity of literature reporting clinical, radiological and patient reported outcomes for TAR in this patient group. We aimed to explore the ideal pre-operative criteria for TAR in patients with Type II DM based on results from our center.

Methods:

We studied the x-rays, clinical findings and patient reported outcomes of surgery at pre-op and 5 years for patients who underwent a total ankle replacement at our center between 2006 and 2014 who had Type II DM. This was a retrospective study. The above findings were also compared between patients who had Type II DM vs. who were not diabetic. Pre-operative screening for diabetic patients included Hb1Ac levels, clinical reporting of swelling, warmth, erythema findings, neurovascular status including proprioception, vibration and neuro filament tests. Statistical analysis of WOMAC and SF-36 scores and differences between diabetic and non-diabetic patients were calculated using General Linear Model - repeated measures ANOVA. Patient satisfaction was analyzed using chi-square test. Rates of superficial and deep infection as well as revision were recorded.

Results:

Of 230 patients, 9 (3.9%) were diabetic. Pre-op radiographic analysis showed features confining to OA; x-ray, CT scan showed no signs of bone debris, fragmentation per articular fractures. Talus was not translated, no evidence of OA in Subtalar or Talonavicular joint. At 5 years, there was no implant subsidence, loosening, migration or peri-prosthetic cysts; hind and midfoot joints had no features of diabetic arthropathy/collapse. Comparing outcomes to Non-diabetic TAR patients, WOMAC & SF-36 scores showed significant (p<0.05) improvement and no significant difference between groups from pre-op to 5 years. In the diabetic group there was 1 superficial infection (11%) 1 deep infection that required revision (11%) compared to 30 superficial infections (13.6%), 1 deep infection (0.5%) and 12 revisions (5.4%) in the non-diabetic group.

Conclusion:

Painful end stage OA in Type II DM can be treated by TAR, taking into consideration the inclusion and exclusion criteria that we have used in our series.
Efficacy of Bilateral Simultaneous Hallux Valgus Correction in the Elderly Aged 70 to 79 Compared to Middle Age
Authors: Jang Chul-Young , Lee Ho-Jin , Park Eui Hyun , Chu In Tak
Published: November 2020

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

Due to the increase in life expectancy, the frequency of elderly patients with moderate to severe hallux valgus deformity is expected to increase. The aim of this study was to evaluate the clinical and radiological efficacy of bilateral simultaneous correction of hallux valgus in elderly patients aged 70s and to compare the results with those of middle age.

Methods:

From August 2014 to July 2017, 92 women (184 feet) patients, who underwent bilateral simultaneous correction surgery (proximal chevron metatarsal osteotomy, Akin osteotomy, and distal soft tissue procedure) due to moderate to severe hallux valgus deformity, were retrospectively analyzed. Based on the age at the time of surgery, elderly patients in their 70’s (70˜79 years) were defined as the ‘elderly’ group and middle aged patients in the 45˜50 years as the ‘middle age’ group. The VAS score, AOFAS-Hallux Metatarsophalangeal-Interphalangeal score, hallux valgus angle, 1-2 intermetatarsal angle, and post-operative complications were compared and analyzed between the two groups. The mean follow-up period was 30.6(24˜57) months. There was no significant difference in improvement of VAS scores after surgery between the middle age and elderly group (p=0.710).

Results:

Although the final AOFAS scores were significantly different between two groups, there was no significant difference in AOFAS score improvement after surgery between two groups (p=0.129) (Table 1). At the last follow up after surgery, the HV angles and 1-2 IM angles were all significantly improved compared to the preoperation (Table2). Complications occurred in 16 cases, 5 in middle age (11.1%) and 9 in the elderly (19.1%). In the middle age group, 1 case (2.2%) of HV recurrence (> 15 degrees), 1 case of medial incision site paresthesia, 2 plantar pain, and 1 MTP joint stiffness occurred. In the elderly group, 3 case (6.4%) HV recurrence, 2 cased of displacement after metatarsal bone fixation, 2 cases of medial incision site paresthesia, and 2 plantar pain.

Conclusion:

In patients aged 70s, bilateral simultaneous correction of moderate to severe hallux valgus showed good improvement of clinical and radiologic outcome without any significant difference compared to the middle age group. However, the attention should be paid to the fixation failure after correction in the simultaneous treatment of hallux valgus in elderly patients aged 70s. [Table: see text][Table: see text]
Socioeconomic Distressed Communities Index Associated with Higher Burden of Amputation in Diabetic Peripheral Arterial Disease
Authors: Jensen Katherine J.
Published: November 2020

Category:

Diabetes; Other

Introduction/Purpose:

The prevalence of diabetes and one of its complications, peripheral arterial disease (PAD), is increasing. Diabetic PAD is known to lead to high rates of lower extremity amputations. Diabetes disproportionately affects people of low socioeconomic status. The Distressed Community Index (DCI) is a proxy social risk factor, calculated at the zip code level as a function of seven metrics of community economic well-being: no high school diploma, housing vacancy rate, unemployment rate, poverty rate, median income ratio, change in employment, and change in establishments. Higher DCI has been linked to longer operative times, longer hospital length of stay, and increased incidence of postoperative complications. This analysis sought to analyze the impact of a socioeconomic risk factor, DCI, on amputation rate in patients with diabetic PAD.

Methods:

Data from a regional hospital abstract reporting system was obtained from the State Department of Health. It was sorted to include patient records with a diagnosis of peripheral arterial disease (ICD-10-CM diagnostic codes). Data was further stratified by diagnosis of diabetic PAD and DCI score. DCI scores were obtained from the Economic Innovation Group. Procedure codes were used to identify amputations starting with ‘detachment at [R/L] foot, complete, open approach’ and including all progressively distal amputations (ICD-10-PCS codes). Statistical analysis was performed using XLSTAT, significance was assigned at alpha of 0.05.

Results:

From 2016 to 2018, there were 33664 patients requiring inpatient treatment with a diagnosis of PAD. 13261 patients (39.4%) had diabetic PAD, 3078 patients (9.1%) originated from a zip code with a DCI score greater than or equal to 75 (top quartile) and 1394 patients (4.1%) had diabetic PAD and DCI greater than 75. While patients with diabetic PAD and a DCI less than 75 had approximately the same rate of amputations as all patients with diabetic PAD (15.3% and 15.7%, respectively), patients with diabetic PAD and a DCI greater than 75 were 1.30 times more likely (p=0.0003) to require amputation than all patients with diabetic PAD (19.1% and 15.7% overall amputation rates, respectively). The relationship with DCI was not significant in non- diabetic PAD patients.

Conclusion:

Approximately one in five patients presenting for inpatient treatment with a diagnosis of diabetic PAD originating from a zip code with a DCI score greater than or equal to 75 required a lower extremity amputation. Though diabetes by itself was a stronger risk factor for amputation (OR 8.24, p<0.0001) than DCI in the comprehensive PAD patient population, a patient with a high DCI score in the diabetic PAD population was significantly more likely to require amputation. DCI is a proxy social risk factor providers can use to preemptively identify patients at increased risk of lower extremity amputation secondary to PAD. [Table: see text]
The 3D Printed Total Talus Replacement: A Novel Treatment Option for Avascular Necrosis of the Talus
Authors: Kadakia Rishin J. , Akoh Craig C. , Chen Jie , Sharma Akhil , Parekh Selene G.
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

Talus avascular necrosis (AVN) is a challenging entity to treat. Management options depend upon disease stage and severity. Total talus replacement (TTR) is a treatment option that maintains joint range of motion. The literature on TTR is limited with variability in implant design and material. The purpose of this study is to evaluate outcomes following total talus replacement with a custom 3D printed metal implant.

Methods:

Patients that underwent TTR were retrospectively reviewed over a three year period. Basic demographic data and comorbidities were collected. Medical records were reviewed to obtain postoperative and preoperative visual analog (VAS) scores, Foot and Ankle Outcomes Scores, (FAOS), ankle range of motion, and postoperative complications. Statistical analysis was conducted to compare clinical and patient-reported outcomes pre and postoperatively.

Results:

Twenty-eight patients underwent TTR for talar AVN with a mean follow-up of 16.4 months. Ankle range of motion remained unchanged statistically pre and postoperatively. VAS pain scores improved significantly pre and postoperative from 6.6 to 3.9 (p < 0.001). FAOS scores significantly improved postoperatively with regards to pain (p = 0.002), symptoms (p=0.03), quality of life (p < 0.001), and activities of daily living (P < 0.001). There were three complications requiring reoperation in this cohort.

Conclusion::

3D printed total talus replacements represent a unique surgical option for patients with talar collapse secondary to AVN. Patients in this cohort demonstrated significant improvements in pain scores and patient-reported outcomes while maintaining preoperative joint range of motion. TTR allows for symptomatic improvement with the preservation of motion in individuals with talar collapse and end-stage AVN.
The Difference of In-Shoe Plantar Pressure between Level Walking and Stair Walking
Authors: Kang Ho Won , Kim Dae-Yoo , Cho Yun Jae , Kyung Min Gyu , Hwang Il-ung , Cao Linying , Lee Dong Yeon
Published: November 2020

Category:

Basic Sciences/Biologics; Other

Introduction/Purpose:

Stair walking is one of common activities of daily living. It is more demanding than level walking and can aggravate discomfort of the foot, such as Morton’s neuroma, plantar fasciitis, Achilles tendinitis, pressure related-ulcer, and etc. Therefore, analysis of increased pressure in specific plantar area at stair walking can be used as a risk assessment of foot discomfort and basic data in the clinical field. The purpose of this study is to analyze plantar pressure distribution and pressure patterns during gait cycle at stair walking compared to level walking.

Methods:

Fourty healthy male adults were recruited. Radiologic measurements and gait analysis were performed to check participants’ normality, and 35 healthy males with 20-28 years old were included. They performed level walking (18 meters walkway), stair (26 steps stair, height:16.7cm, depth:29.8cm) ascending, and descending in same type of running shoes. Measurements of in-shoe plantar pressure including peak pressure, pressure-time integral (PTI) were done by Pedar-X system. The sole was masked in 7 segments (hallux, 2nd-5th toes, medial forefoot, central forefoot, lateral forefoot, midfoot, heel region) to analyze properly. Percentages were assigned in relation to the size for each mask segment. Statistical analysis was performed using repeated measure ANOVA, and Bonferroni post hoc test was done.

Results:

PP in all regions except for the midfoot were higher during level walking than stair walking. During stair descent, PP in all the regions except for the midfoot were generally lower than other types of walking, but it was the highest in the midfoot region. PTI in the medial and central forefoot was higher during stair descent than level walking. PTI in the central and lateral forefoot, and the midfoot was higher when stair ascending than level walking. PTI in the heel region was the highest during level walking, followed by stair ascent, stair descent.

Conclusion:

The risk of aggravation of discomfort in the midfoot area increases when stair descending. The medial region of forefoot bear high pressure load during stair descent, and the lateral region of forefoot and the midfoot region bear high pressure load during stair ascent. This is the first study to show plantar pressure patterns during level and stair walking in the large healthy gender-controlled population. We recommend that patients with pressure related foot lesions in the forefoot or midfoot avoid stair walking.
Predicting Syndesmotic Injury in Weber B Ankle Fractures
Authors: Kellam Patrick , DeKeyser Graham J. , Higgins Thomas F. , Rothberg David , Haller Justin , Marchand Lucas S.
Published: November 2020

Category:

Trauma; Ankle

Introduction/Purpose:

Accurate pre-operative diagnosis of syndesmotic injuries can be difficult in the setting of AO 44-B1 fractures. Ankle fractures with syndesmotic injuries have worse reported outcomes. No study has investigated the relative fracture height in determining potential syndesmotic injury. The goal of this study was to establish if pre-operative radiographs could accurately predict syndesmotic injury.

Methods:

Patients treated for an isolated AO 44-B1 fracture over a ten-year period (2007-2017) were reviewed. Anteroposterior and mortise views of the ankle were used to determine the zone of distal extent of the proximal fracture fragment (Figure 1). Syndesmotic injury was defined as positive intraoperative stress exam that required syndesmotic fixation. Relative risks were determined between zones with a statistical significance set at 0.05. Ten randomly selected radiographs were reviewed by two authors and assessed by intra-class correlation (ICC) for inter- and intra-observer reliability.

Results:

There were 548 AO 44-B1 fractures that were reviewed; and 287 patients were included in the study. There were 191 zone 1 injuries, 57 zone 2 injuries, and 39 zone 3 injuries. Of these, 17% (33 patients) of zone 1, 42% (24) of zone 2, and 74% (29) of zone 3 fractures had syndesmotic injuries. The relative risk of syndesmotic injury of Zone 1 compared to Zone 2 was 2.4 (p<0.001), Zone 1 to Zone 3 was 4.3 (p<0.001), Zone 2 to Zone 3 was 1.8 (p=0.002). The ICC for inter- and intra-observer reliability was perfect (ICC=1).

Conclusion:

AO 44-B1 fractures have a varying rate of syndesmotic injury. Weber B fractures that end between the level of the plafond and the physeal scar (Zone 2) are 2.6 times more likely to have a syndesmotic injury compared to those that end below the plafond (Zone 1). This is magnified in those injuries ending above the scar (Zone 3). This simple classification of AO 44-B1 fractures is predictive of syndesmotic injury and may aid in preoperative counseling and planning.
Predictors of Malreduction in Zone II and III 5th Metatarsal Fractures Fixed with an Intramedullary Screw: A Retrospective Analysis
Authors: Khurana Ankit , Pitts Charles C. , Alexander Bradley , Patel Akshar , Sutherland Charles R. , Greco Elise M. , Cage Benjamin B. , Shah Ashish
Published: November 2020

Category:

Midfoot/Forefoot; Sports

Introduction/Purpose:

Percutaneous fixation of 5th metatarsal fractures may lead to malreduction due to improper implant selection and placement. Our aim was to test the effects of screw entry, length, and diameter on malreduction, delayed union, non-union, or refracture.

Methods:

We retrospectively reviewed zone II and proximal zone III 5th metatarsal fractures managed with intramedullary screw fixation. Comparisons were made between plantar cortex distraction/lateral cortex distraction and ratios of screw length, diameter, and entry point using multiple regression analysis. A further analysis was carried out between time to union and distraction in the lateral and plantar cortices.

Results:

Plantar and lateral gap were both correlated with entry point ratio on lateral and AP view respectively (p<0.001 for both views). We did not see an association between plantar and lateral gap with screw diameter ratio (p=0.393 for AP and p=0.981 for lateral) or screw length ratio (p=0.966 for AP and p=0.740 for Lateral). Ratio of postop/preop apex height on AP and lateral showed correlation to presence of lateral and plantar fracture gap respectively (p<0.0001). Presence of a plantar gap did have a slight influence on time to union (p=0.044). Most fractures showed radiographic union at 12 weeks (38/44 that were followed until union). There were no refractures or nonunions as per available records.

Conclusion:

Our study shows that screw length and diameter did not lead to significant plantar or lateral fracture site distraction. However, entry point had a significant effect on plantar and lateral gap on post-operative x-ray. Patients with a plantar gap did have an increased risk of delayed union. Entry point should be given more significance rather than screw diameter and length in managing zone 2/3 fifth metatarsal base fractures. This is contradictory to existing radiologic studies. [Table: see text]
An Update of Foot and Ankle Fellowship Website Content and Accessibility
Authors: Khwaja Ansab M. , Du Peter Z. , Sherman Nathan , Truchan Lisa
Published: November 2020

Category:

Other; Ankle

Introduction/Purpose:

The internet is one of the first resources for prospective fellowship applicants, and a previous study evaluated the presence of information present on foot and ankle websites. This study aims to evaluate the accessibility provided via the American Orthopaedic Foot & Ankle Society (AOFAS) websites and individual websites.

Methods:

The AOFAS website was used to identify the list of foot and ankle fellowship programs. The database information was used to review links to fellowship program websites and corroborate it with accessibility through a Google search. Information from fellowship program websites and the AOFAS was used to analyze the presence of previously described recruitment and educational content, and this analysis was compared to previously reported metrics.

Results:

Forty-eight orthopaedic foot and ankle fellowship programs were identified. The AOFAS database featured direct links to 19 (40%) fellowship websites with the Google search providing direct links to 35 (73%) websites. From the available program websites, the most common recruitment content was salary/benefits, faculty listing, program contact information (48, 100%), and program description (47, 98%). The most common educational content was presence of research component (44, 92%) and description of rotations/curriculum (43, 90%). Foot and ankle fellowship information markedly improved in domains of salary/benefits, program description, faculty listing meetings/courses, rotations/curriculum, and had less information in the domains of office/clinic information and operative experience.

Conclusion:

There continues to be substantial variability between foot and ankle fellowship websites and the AOFAS website regarding program content and descriptions. Some information is more readily available, but other domains have less information now than in previously reported research.
Foot and Ankle Fellowship Faculty Research Productivity
Authors: Khwaja Ansab M. , Bridge Nathaniel , Sherman Nathan , Du Peter Z.
Published: November 2020

Category:

Other

Introduction/Purpose:

Academic productivity within orthopaedic subspecialties is important in developing generalizable knowledge, challenging biases, and evolving practice management. Productivity is linked to academic status and can affect compensation. This study evaluated the research activity of faculty at foot and ankle surgery fellowship programs in the United States and associated Canadian programs. The primary objective was to describe the publishing productivity of American Orthopaedic Foot & Ankle Society (AOFAS) fellowship faculty.

Methods:

Program characteristics from orthopaedic foot and ankle fellowship programs across the United States and Canada were collected from AOFAS and each program’s respective websites. The studied faculty characteristics consisted of years in practice, academic rank, extent of training, and gender. Specific program characteristics were recorded, including Accreditation Council for Graduate Medical Education approval, academic affiliation, fellow research requirement, number of fellows, number of associated faculty members. Data analysis of faculty productivity (Publications, number of publications in specific journals, number of citations, and Hirsch index [h index]) was gathered using the Scopus database.

Results:

A total of 48 AOFAS foot and ankle surgery fellowship programs were identified with an associated 185 faculty members. The mean number of publications per faculty member was 44.9 (sd 53.0; range 0-323) with a mean h-index of 11.9 (sd 10.6; range 0-54). One-hundred and forty-four (77.8%) academic-affiliated faculty had a significantly greater number of publications (p<0.01), total citations (p<0.05), and publications in FAI (p<0.05), JBJS (p<0.05), CORR (p<0.05), and JAAOS (p<0.05) compared to the 41 (22.2%) nonacademic faculty. Nonacademic faculty maintained a h-index of 9.5 (95% CI 7-12), while academic faculty had a h-index of 12.6 (95% CI 11-14), which did not meet statistical significance (p=0.062). There were no significant differences between measures of publication productivity in male and female faculty, except for maximum citations in a single paper (67.1 vs 142.3; p<0.05)

Conclusion:

Academic-affiliated foot and ankle fellowship faculty have higher research productivity than non-academic surgeons. The mean h-index of foot and ankle fellowship faculty was 11.9, which is lower than that reported in sports, joints, and spine fellowship faculty but higher than that reported for hand fellowship faculty. The analyses presented can aid foot and ankle surgeons in assessing their academic productivity. [Table: see text]
Talar-Tarsal Stabilization: Rationale and Preliminary Outcomes
Authors: Khwaja Ansab M. , Stevens Peter , Lancaster Alex
Published: November 2020

Category:

Ankle; Hindfoot

Introduction/Purpose:

While surgical stabilization of the subtalar joint (arthroeresis) in children remains controversial in the USA, it is practiced worldwide, with reportedly good outcomes. Our purpose is to present a series of patients who met our criteria for calcaneal lengthening, but who opted instead for the less invasive option of talo-tarsal stabilization (TTS). In particular we wanted to assess the incidence of untoward outcomes that may manifest within the first year postoperatively, namely peroneal spasm or painful loosening of the implant, and discuss the management of these problems.

Methods:

With IRB approval, we conducted this retrospective review of 32 patients (60 feet) who underwent talo-tarsal stabilization (TTS) for flexible planovalgus deformity and had a minimum of 1 year follow-up. The etiology was idiopathic for the majority, with a few being neurogenic or syndromic. The age range at insertion was 6-15 years, with the younger patients having neuromuscular etiology or underlying syndromes. Concomitant procedures, included percutaneous Achilles lengthening (33 feet), Kidner (9), supramalleolar rotational osteotomy (1), and guided growth for ankle valgus (2). We assessed hindfoot flexibility and alignment, obvserved the gait pattern and compared weightbearing AP and lateral radiographs taken preoperatively and at least one year postoperatively.

Results:

At a minimum of 1 year follow-up, 50 implants (85%) were retained and the patients reported satisfactory outcomes. Henceforth, those patients will be monitored on a prn basis. In the early post-immobilization phase, peroneal spasm occurred in 3 patients (5 feet). This resolved with Botox injection in the peroneus brevis in 3 patients and required transfer of the peroneus brevis to the peroneus longus in one. One patient experienced early migration of hte implants, and these were repositioned with a good outcome. Due to lingering discomfort, Implants were removed in five patients (10 feet = 15 %). None of these patients have collapsed and required salvage hindfoot osteotomy or calcaneal lengthening.

Conclusion:

For the child with flat feet and unremitting pain talar-tarsal stabilization, combined with other procedures as indicated, offers advantages over the accepted methods of medial shift osteotomy or calcaneal lengthening. It is less invasive, well tolerated and may prove to be definitive. The outcome at 1 year is a good forecast of whether or not further treatment will be required. Osteotomy may be obviated.
Establishing a New Bony Landmark for Safe Screw Insertion in Medial Displacement Calcaneal Osteotomy: A Simulation-Based Approach
Authors: Kim Jaeyoung , Day Jonathan
Published: November 2020

Category:

Hindfoot; Other

Introduction/Purpose:

Medial displacement calcaneal osteotomy (MDCO) is a commonly performed procedure in flatfoot reconstruction. Fixation is often achieved with screws due to its ability to compress across the osteotomy site. Screws are placed via a free-handed technique without direct fluoroscopic visualization, due to difficulty attaining a simultaneous axial calcaneal view. In addition, the posterior calcaneal tuber translates medially after displacement, resulting in altered anatomical geometry. It is therefore important to establish a reliable external bony landmark when performing free-handed interfragmentary fixation in order to avoid potential screw-related complications and to provide better surgical technique and fixation. The purposes of this study are to validate a new external bony landmark and to establish the appropriate trajectory and screw length for free-hand screw fixation in MDCO.

Methods:

A total of 84 postoperative computed tomography (CT) scans of MDCO in 70 patients were analyzed. The images were reconstructed using a 3-dimensional simulation program (Vworks 4.0, Cybermed). Virtual screw insertion was simulated by aiming towards two bony landmarks: the base of the 5th metatarsal in the axial plane, and the sinus tarsi in the sagittal plane (Figure 1). A grading system was also utilized to classify scenarios in which the screw breached the distal cortical wall: Grade 1 was defined as contact between the virtual screw and the cortex, Grade 2 as the screw approaching the outer margin of the cortex, and Grade 3 as the screw penetrating the outer cortex. The trajectory angle between the screw and the osteotomy, as well as the screw size, were also measured.

Results:

The average age of patients was 24.5 (range, 19 to 53), and 100% were males. The average displacement of the posterior calcaneal fragment was 7.3+-1.5 mm (range, 3.9 to 13.8). Among the 84 virtual screws, only five (6.0%) breached the medial cortical wall of the osteotomized calcaneus. All medial breaches were Grade 1. None of the virtual screws breached the lateral cortical wall. Mean trajectory angle between the virtual screw and the osteotomy site was 74.9+-6.7˚ (range, 60.0 to 89.8˚). In the perioperative data, estimated maximum screw length by simulation was 55.6+-4.4 mm (range, 50 to 65).

Conclusion:

Our results suggest that the optimal trajectory of free-handed screw placement can be determined through simulation of calcaneal interfragmentary screw insertion using postoperative CT imaging. Using this simulation technology, we determined a trajectory towards the sinus tarsi on the sagittal plane and the base of the 5th metatarsal on the axial plane to be a reliable external bony landmark for placement of screws in MDCO. These promising results have potential implications in achieving better fixation as well as improving union rates and operative outcomes.