bluuebunny/crossref_metadata_2025 huggingface dataset:
Three-Spike Insole Can Substitute the Total Contact Insole (TCI) in Refractory Plantar Fasciitis: Randomized Control Trial
Authors: Shim Dong Woo
Published: November 2020

Category:

Hindfoot

Introduction/Purpose:

Plantar fasciitis is one of the common foot complaints that is chronic and can induce dysfunction. Approximately 80% of patients improve with conservative management such as stretching exercise, ice bag massage, and splint. Refractory plantar fasciitis, unresponsive to conservative care for more than 6months, can be treated with insole, extracorporeal shockwave therapy, injection, and surgery etc. Total contact insole (TCI) is effective in reducing pain with just putting it in the shoes but quite expensive and time consuming for the custom production. Therefore, we produced alternative three-spike insole that can press about half of patient’s plantar fascia using 3-dimensional (D) printing and compared the clinical outcomes with it and TCI.

Methods:

A pragmatic, participant-blinded randomized trial was carried out from February 2019 to January 2020. Inclusion criteria was refractory plantar fasciitis and the duration of follow-up for each patient was 6 months. Three-dimensional printing used thermoplastic polyurethane (TPU) for the material of insole and the hardness was 58 +- 5 Shore-A. Twenty-eight patients were randomly allocated to use a three-spike insole or a TCI (Figure 1). The following assessment tools were used; visual analog scale for pain, American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Outcome Score (FAOS), Karlsson- Peterson (KP) score, Medical Outcomes Study Short Form-36 (SF-36) for quality of life, and Foot Function Index (FFI). The groups were evaluated by a blinded assessor at baseline and after 6, 12, and 24 weeks.

Results:

The groups were homogenous for the majority of variables at baseline. Overall patient reported satisfaction showed improvement from mean 5.2 (range, 1 - 12) weeks of wearing and patient’s wearing time in a day was mean 2.4 (range, 0.5 - 3.0) hours. All the subscales except for sports in FAOS and mental component summary in SF-36 showed significant improvement from 6 weeks in both groups. There was no significant difference in all parameters between both groups at 6 weeks but AOFAS score, some of FAOS subscales, KP score, SF-36, and FFI showed significantly better outcome in three-spike insole group at 12 weeks. Those significant differences in outcome parameters tended to diminish at 24 weeks.

Conclusion:

We reaffirmed that insole is effective in plantar fasciitis and showed the three-spike insole restores function rapidly comparing to TCI. Three-spike design that supports not the whole longitudinal arch but about half of it was efficient enough. We can manufacture the three-spike insole for the popularization that can lower the price and producing time.
Calcaneal Stress Reaction with Distal Anchor Fixation for Mid-Substance Achilles Ruptures
Authors: Shoap Seth C. , Freibott Christina , Polzer Hans , Vosseller J. Turner
Published: November 2020

Category:

Sports; Other

Introduction/Purpose:

Minimally invasive Achilles rupture treatment has been purported to lead to superior outcomes relative to open treatment. Various forms of minimally invasive treatment exist. One newer technique involves the use of suture proximally that anchors into interference screws distally in the calcaneus. This treatment paradigm potentially addresses some deficiencies of other techniques. However, the authors have noted calcaneal stress reactions in some patients with this technique and here we report our experience.

Methods:

We conducted a retrospective chart review of patients that had minimally invasive Achilles tendon repair performed by the senior author. Patient demographics, medical history, social history, surgical details, and additional surgeries were recorded. The presence of a calcaneal stress reaction, as evidenced by pain near the calcaneal anchor insertion and confirmed via MRI was reviewed. A comparison was made between those patients that did and did not have a stress reaction.

Results:

Of the 30 included patients, the average age was 36.93 (+-13.17) and 63.3% were male. The mean BMI in this cohort was 28.76 (+-7.62). 66.7% injured themselves while played a sport. 4 patients (13.3%) had a stress reaction from suture anchors. When comparing those who had a stress reaction to those who did not, independent samples t-test revealed that age (p=0.168) and BMI (p=0.568) were not significantly different between the groups. Chi square noted that gender (p=0.87), ASA score (p=0.449), and mechanism of injury (p=0.486) were not significantly associated. All of the patients that sustained a stress reaction were very fit and active.

Conclusion:

This case series notes the presence of calcaneal stress reaction in 4/30 patients treated for an Achilles tendon rupture with distal anchor fixation. This stress reaction has not been previously reported. It should be noted that the stress reaction was self-limited in all patients. It typically became symptomatic around the 3-4 month after surgery mark and resolved by 5-6 months.
A Comparison of Microvasculature of Normal versus Torn Lesser Toe Metatarsophalangeal Joint Plantar Plates Using Nano-CT Imaging
Authors: Singer Natalie , Walton David M. , Holmes James R. , Talusan Paul G.
Published: November 2020

Category:

Lesser Toes

Introduction/Purpose:

Recent surgical techniques have focused on anatomic repair of lesser toe metatarsophalangeal (MTP) plantar plate tears. MTP instability has been implicated in a number of common toe deformities as well as metatarsalgia. Recently, a study demonstrated that the microvasculature of the normal plantar plate is densest at the proximal and distal attachments. The purpose of this study was to compare the intact plantar plate microvasculature network to the microvasculature network of plantar plates in the presence of toe deformity using similar perfusion and nano-CT imaging methods.

Methods:

Eight fresh frozen human cadaveric lower extremities with lesser toe deformities including hammertoe or crossover toe were perfused using a barium solution. The soft tissues of each foot were counterstained with phosphomolybdic acid (PMA). Then using nano-CT imaging the second through fourth toe metatarsophalangeal joints of 8 feet were imaged. These images were then reconstructed, plantar plate tears were identified, and eleven toes remained. The plantar plate microvasculature for these eleven toes was analyzed and calculation of vascular density along the plantar plate was performed. Using ANOVA analysis this experimental group was compared to a control group of 35 toes from cadaveric feet without deformity and the vascular density compared between quartiles of plantar plate length proximal to distal.

Results:

Demonstrated in Figure 1, of the torn plantar plates the average percent vascular density (vascular volume/tissue volume) in the first quartile of length (proximal to distal) is 0.365 (SD 0.058) compared to 0.281 (SD 0.036) for intact plantar plates; in the second quartile it is 0.300 (SD 0.044) vs 0.175 (SD 0.025); third quartile it is 0.326 (SD 0.051) vs 0.117 (SD 0.015); and fourth (most distal) quartile is 0.600 (SD 0.183) vs 0.319 (SD 0.082) respectively. Using ANOVA testing all differences were found to be significant to p<0.001.

Conclusion:

Torn plantar plates demonstrate increased vascular density throughout the length of the plantar plate with an increase in density most notable in the region at or just proximal to the attachment to the proximal phalanx. The clinical significance of the increased vascularity of torn plantar plates is unknown at this time. However, the increase in vasculature may suggest that the plantar plate is a structure that is attempting to heal.
Trends in Foot and Ankle Publications
Authors: Sleasman Brian T. , Caughman Alexander , Gross Christopher E.
Published: November 2020

Category:

Ankle; Other

Introduction/Purpose:

Scientific publication and original articles remain the primary method of sharing scientific findings and thus advancing the knowledge base of that subject. These articles have the potential to reinforce or change current practice. Despite the value of these publications, little research has gone into surveying what topics are being published. Our goal was to identify and characterize the most common topics of publication in current foot and ankle literature.

Methods:

To determine the rate of publications in the literature, we reviewed all published articles in a 3.5-year period (January 2016 - June 2019) in three foot and ankle specific journals: Foot and Ankle International, Foot and Ankle Orthopaedics, and Foot and Ankle Surgery. We then sorted these articles into the topic of the article to identify the four most common domains of publication. These domains were further characterized by level of evidence as well as citations/year.

Results:

A total of 845 articles were published in the 3.5-year study period. During this time, the four most published topics in foot and ankle literature were hallux valgus (10%), arthroplasty (9%), ankle fracture (7.5%), and achilles pathology (6.4%). These four subjects accounted for 280/845 articles (33%). The average level of evidence for articles on hallux valgus, arthroplasty, ankle fracture, and Achilles pathology were 3.3 (3.1, 3.4, 3.4, and 3.4 respectively), and the average number of citations/year for these articles was 2.6 (2.3, 3.0, 2.3, and 3.1 respectively). Based on our study there is no correlation between level of evidence and number of citations.

Conclusion:

Despite the wide variety of cases (176 unique CPT codes) performed by an orthopedically trained foot and ankle surgeons, a small subset of publications represent a significant portion of scientific publication within the field.
Predictive Variables for Patient Compliance with Physician Prescribed Orthotics
Authors: Stevens Trenton T. , Bettin Clayton C. , Murphy G. Andrew , Richardson David R. , Grear Benjamin J. , Hartline Jacob T.
Published: November 2020

Category:

Other; Midfoot/Forefoot

Introduction/Purpose:

Custom and off-the-shelf orthotics frequently are prescribed by foot and ankle orthpaedic surgeons. This study aimed to quantify the rate at which patients receive their prescribed orthotic and explore the variables that could be predictive of patients’ receiving and using orthotics.

Methods:

We analyzed the demographics of 382 patients who received an orthotic prescription from a group of foot and ankle surgeons to assess variables predictive of patients receiving their prescribed orthotic. Of these 382 patients, 186 (49%) completed a survey regarding insurance status, cost of the orthotic, education, income, and satisfaction with the orthotic. This information was used to identify variables that may help identify patients who are at an increased risk of failing to receive their prescribed orthotic.

Results:

Patients received their orthotic at an overall rate of 61.2% (235/382). Patients with commercial insurance were more likely to receive their orthotic (67%) than patients with Medicaid (40%). Of the 186 patients who completed the survey, those whose insurance covered all or part of their orthotic were more likely to receive their orthotic (100% and 96%, respectively) compared to those whose insurance did not cover the orthotic (81.5%). Overall 86.5% reported being ‘better’ or ‘completely relieved’ with orthotic use, and 13.4% reported ‘no difference’ or ‘worse.’ There were no differences in receive rates according to age or gender, but there was a disparity in race, with 71% (155/219) of white and only 48% (72/151) of black patients receiving their orthotics.

Conclusion:

A substantial number of patients (38.8%) do not receive their physician-prescribed orthotic. Patients who do receive and use their orthotic report positive results. Insurance status, race, and coverage of costs by the insurance company play important roles in predicting which patients are at risk for failing to receive their orthotic.
The Lateral Trans-Malleolar approach for Posterior Malleolar Fracture of the Ankle: A Clinical and Computed Tomography Evaluation
Authors: Taki Masanori , Hio Naohiro
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

Posterior malleolar fracture reduction including the articular surface of trimalleolar ankle fracture has been reported to be an important prognostic factor. The lateral trans-malleolar approach (LTA) is a surgical approach that provides direct visualization of the articular surface of the posterior malleolus. We herein report the clinical results and computed tomography (CT) findings for the articular reduction status after LTA for posterior malleolar fracture of the ankle.

Methods:

Sixteen patients (9 men, 7 women, mean age 52.6+-18.1 years old) who underwent the LTA for posterior malleolar fracture of the ankle and were followed for at least 1 year were evaluated retrospectively. The types of ankle malleolar fracture according to the Lauge-Hansen classification were Supination-External rotation (SER) in 13 patients and Pronation-External rotation (PER) in 3 patients. The CT classifications of posterior malleolus fracture by Haraguchi were Type 1 in 6 cases, Type 2 in 10 cases and Type 3 in 0 cases. The AOFAS score, post-surgical complications and reduction status of the posterior malleolus on CT were investigated.

Results:

The mean follow-up period was 15.5 months. The AOFAS score was 93.0+-5.2 points. Postoperative complications were seen in one case of superficial infection; however, delayed union, nonunion and fibular necrosis were not observed. The articular step-off in CT improved significantly after surgery (5.9+-2.9 mm preoperatively vs. 0.6+-0.8 mm postoperatively). The 2 patients who showed an articular step-off exceeding 1 mm were both Haraguchi type 2 posterior malleolar fracture.

Conclusion:

Several approaches for managing posterior malleolus of the ankle have been reported. However, few provide direct visualization to the articular surface. The LTA requires relatively substantial invasion, but it can facilitate surgery in the supine position and thereby reduce the articular surface directly. In our experience, the LTA provided favorable clinical results and fracture reductions. Even when utilizing the LTA, it remains difficult to confirm the fracture reduction of medial articular surface for Haraguchi type 2 medial extension fractures. Therefore, it remains important to also perform appropriate intraoperative X-ray controls.
Fresh Cadaveric Study of the Distances between the Deep Plantar Arch and the Lesser Metatarsals at Risk During Osteotomy of the Lesser Metatarsals
Authors: Tonogai Ichiro , Tonogai Ichiro
Published: November 2020

Category:

Midfoot/Forefoot

Introduction/Purpose:

Osteotomy of the lesser metatarsals is useful to treat forefoot deformity. Although there is the possibility that some arteries supplying the lesser metatarsals are injured during osteotomy, there are few informations about the distances from the deep plantar arch to the lesser metatarsals. This study aimed to identify the distances from the deep plantar arch to the lesser metatarsals and to reveal how osteotomy of the lesser metatarsals might injure the deep plantar arch.

Methods:

Twenty fresh cadaveric feet were injected with barium through the external iliac artery, and enhanced computed tomography images were assessed. The distance between the deep plantar arch and each lesser metatarsal was measured on both axial and sagittal images.

Results:

The distances between the deep plantar arch and the second, third, and fourth metatarsals on the axial plane were 0.5, 2.2, and 2.8 mm, respectively. The distances from the distal epiphysis to the line passing through the deep plantar arch perpendicular to the longitudinal axis of the lesser metatarsal on the sagittal plane were 47.0, 45.7, and 46.4 mm, respectively, and those from the proximal epiphysis were 23.0, 21.0, and 18.6 mm, respectively. The deep plantar arch coursed at the level of the middle third, proximal to this third in 11/20 (55.0%), 7/20 (35.0%), and 5/16 (31.2%) feet, respectively.

Conclusion:

This study suggested that overpenetration into the medial-plantar direction of the second metatarsal or the proximal-plantar direction of the fourth metatarsal during the shaft or proximal osteotomy might injure the deep plantar arch easily. This study also suggested that on the plantar aspect, the shaft or proximal osteotomy about 45-47 mm proximal to the distal epiphysis of the lesser metatarsal or 18-23 mm distal to the proximal epiphysis might damage blood flow of the deep plantar arch.
Influence of Platelet Rich Plasma on the Skeletal Muscle Fibrosis after Limb Lengthening in Mice
Authors: Tonogai Ichiro , Tonogai Ichiro
Published: November 2020

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Skeletal muscle fibrosis induced by the increase of collagen occurs after limb lengthening which is also called distraction osteogenesis. Although there are studies about influence of platelet rich plasma (PRP) on tissues healing process, its effectiveness is still controversial. The aim of this study was to examine whether PRP decreased the skeletal muscle fibrosis induced by limb lengthening.

Methods:

Tibial osteotomy was done to 8-week-old wild type mice. Tibia was lengthened at a rate of 0.42 mm/day during 2 weeks, launching 1 week after tibial osteotomy. Just after lengthening completed (3 weeks after tibial osteotomy), PRP was injected into the gastrocnemius muscle (PRP group). As a sham group, phosphate buffered saline (PBS) was injected into the gastrocnemius muscle (non-PRP group). The gastrocnemius (GC) muscles were taken and analyzed at 4, 6, 8 and 10 weeks after tibial osteotomy.

Results:

The fibrotic area of the GC muscles in the both groups increased at 4 weeks after tibial osteotomy in histological analysis (Figure). Then, it gradually decreased at 6, 8, and 10 weeks after tibial osteotomy. There were no significant differences between the both groups at 6, 8, and 10 weeks after tibial osteotomy. Hydroxyproline, which was a major constituent of collagen, increased in the non-PRP and PRP groups by limb lengthening as well. However, significant changes were not found between the both groups at all any points.

Conclusion:

At first, we anticipated that PRP should reduce the skeletal muscle fibrosis after limb lengthening significantly. But our results implied that PRP did not decrease the skeletal muscle fibrosis induced by limb lengthening.
Medial Displacement Calcaneal Osteotomy: Loss of Correction with Varying Drilling Techniques
Authors: Umbel Benjamin D. , Sharpe B. Dale , Halverson Adam L. , Prissel Mark A.
Published: November 2020

Category:

Hindfoot

Introduction/Purpose:

Surgical correction of Stage 2 posterior tibial tendon dysfunction typically involves a combination of soft tissue and bony corrections, often including a medial displacement calcaneal osteotomy (MDCO). This osteotomy is often fixated utilizing two parallel screws; however, it remains unknown how much correction is lost based on various accepted drilling techniques for common fixation of this osteotomy. Our cadaveric study compares three different surgical drilling techniques, using two parallel cannulated screws for fixation, to best maintain desired translation of the MDCO.

Methods:

Fifteen above knee, fresh-frozen, matched pair cadaveric specimens (30 limbs) were randomized equally into three groups. Calcanealosteotomies were performed, followed by manual 10 mm medial translation of the tuberosity. Two parallel 2.5mm guide wires were advanced across the osteotomy site under fluoroscopy. The first group involved a ‘staggered’ drilling technique in which one guide wire was over drilled to the osteotomy site with a 4.5mm cannulated drill and then a 7.0 mm cannulated screw was placed across the osteotomy, followed by a second screw in similar fashion. The second, ‘simultaneous’ group consisted of over drilling both guide wires sequentially followed by placement of both screws. The third control group involved simultaneously over drilling only the near cortex, followed by placement of the 2 screws. Following screw fixation, the calcaneal tuberosity was manually translated in a lateral direction. The loss of correction was then marked and measured in millimeters.

Results:

All thirty cadaveric specimens underwent standard medializing calcaneal displacement osteotomy without significant variation, or complication. Loss of medialization was measured in millimeters following a manual lateral displacing force after the screw fixation of the osteotomy. The ‘simultaneous’ drilling group experienced the greatest loss of medial displacement with the mean loss of correction being 2.6 mm (range 1.37 - 3.48 mm) following manual lateral translation. The ‘staggered’ group showed an average loss of 1.16 mm (range 0.36 - 2.67 mm). The control group, that simply involved drilling of the near cortex, demonstrated the greatest maintenance of medial displacement with a mean loss of only 0.036 mm (range 0.01 - 0.06 mm).

Conclusion:

Our cadaveric study comparing three different drilling techniques for maintaining the intended correction following MDCO demonstrates that simultaneous over drilling of only the tuberosity near cortex prior to screw fixation was the most resistant to loss of medial displacement; whereas mean loss of correction with simultaneous drilling of both wires to the osteotomy resulted in the greatest loss of correction at an average of 26%.
Development of an Anatomic Landmark-Based Measurement of the Achilles Tendon
Authors: Urness Daniel , Thompson Austin R. , Ensrud Erik , Meeker James E.
Published: November 2020

Category:

Ankle; Sports

Introduction/Purpose:

Achilles tendon ruptures (ATRs) occurred with an incidence of 2.5 per 100,000 person-years in 2016. This rate has been increasing over the last decade and it has been postulated that this is due to the increasing activity level of older people. With a high and increasing incidence of such a significant injury, further investigation must be done to optimize the treatment of ATRs. The degree of tendon lengthening has been correlated with clinical outcomes, with greater elongation being associated with worse outcomes. MRI and ultrasound techniques have been validated in measurement of Achilles tendon. We sought to develop a reliable, reproducible, and accurate measurement technique utilizing the manual palpation of anatomic landmarks that will be cost effective as well as convenient to perform, particularly intraoperatively.

Methods:

Both lower legs of 10 healthy subjects without history of Achilles tendon injury were examined using ultrasound and anatomic landmark-based measurement techniques. Subjects sat upright on the exam table and legs were held in flexion at the knee with slight external rotation with the ankle held at 90o, allowing the lower leg to rest flat on the exam table. The length from the medial head of the gastrocnemius to the bottom of the non-compressed heal pad was measured by three raters using the ultrasound and anatomic landmark-based techniques for inter-rater reliability. The measurements were repeated one week later for intra-rater reliability. Ultrasound measurements had excellent inter-rater (0.93) and intra-rater (0.82) correlation coefficients, while good inter-rater (0.76) and intra-rater (0.86) correlation coefficients were observed among anatomic landmark-based measurements. Achilles tendon length measured with ultrasound and anatomic landmark-based techniques were compared using a paired t-test.

Results:

The anatomic landmark-based technique produces longer measurements of the Achilles tendon (23.2 cm (sd 2.6 cm)) compared to measurements made using ultrasound (22.4 cm (sd 2.6)) (p<0.001). On average, the anatomic landmark-based technique measures 0.8 cm (95% Confidence Interval: 0.4, 1.2) longer than the ultrasound technique. The intraclass correlation coefficient between the anatomic landmark-based and ultrasound measurements is 0.90.

Conclusion:

While the anatomic landmark-based technique produces a longer measurement of the Achilles tendon, it may still be a reproducible measurement tool. If the change in tendon length is of interest, this technique may be a valid and simple way to monitor that variable. Comparison with MRI may be warranted to better determine the accuracy of the anatomic landmark-based Achilles tendon measure. These results compared with MRI may set the stage for further evaluation of this measurement technique in the operating room in subjects undergoing ATR repair.
Reduction of Foot Width with Triplanar Tarsometatarsal Arthrodesis for Hallux Valgus Deformity: A Multicenter Study
Authors: Vaida Justin , Ray Justin J. , Shackleford Taylor L. , DeCarbo William T. , Hatch Daniel J. , Dayton Paul , Smith Brett L. , Santrock Robert D. , McAleer Jody
Published: November 2020

Category:

Bunion; Hindfoot

Introduction/Purpose:

Foot width reduction is a desirable cosmetic and functional outcome for patients with hallux valgus. Triplanar tarsometatarsal (TMT) arthrodesis achieves this by three-dimensional correction of the deformity. The aim of this study was to evaluate changes in bony and soft tissue width in patients undergoing triplanar TMT arthrodesis.

Methods:

After receiving IRB approval, charts were retrospectively reviewed for patients undergoing triplanar TMT arthrodesis for hallux valgus deformity at four institutions between 2016 and 2019. Patients who underwent concomitant first metatarsal head osteotomies (e.g., Silver or Chevron) or fifth metatarsal osteotomies were excluded. Preoperative and postoperative anteroposterior weightbearing radiographs were compared to evaluate for changes in bony and soft tissue width. Bony width was defined as the distance from the most medial aspect of the first metatarsal head to the most lateral aspect of the fifth metatarsal head. Soft tissue width was defined as the distance from the most medial soft tissue overlying the first metatarsal head to the most lateral soft tissue overlying the fifth metatarsal head.

Results:

148 feet from 144 patients (48.1 +- 15.7 years, 92.5% male) met inclusion criteria. Preoperative osseous foot width was 96.2 mm, compared to 85.8 mm postoperative (p < 0.001). Preoperative soft tissue width was 106.6 mm, compared to 99.3 mm postoperative (p < 0.001). Postoperatively, patients had an average 10.4 +- 0.33 mm reduction (10.8% reduction) in osseous width and average 7.3 +- 0.33 mm reduction (6.8% reduction) in soft tissue width.

Conclusion:

Triplanar TMT arthrodesis reduces both osseous and soft tissue foot width providing a desirable cosmetic and functional outcome for patients with hallux valgus. Future studies are needed to determine if patient satisfaction and outcome measures correlate with reductions in foot width.
Syndesmosis Screw Breakage: An Analysis of Current Literature
Authors: Maten Josh W. Vander , Roebke Logan , Liu Jiayong
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

Syndesmosis screw fracture is a common occurrence post syndesmosis screw fixation. The purpose of this study is to analyze all studies that include syndesmosis injury fixed with syndesmosis screws based on patient, screw, and surgical/rehabilitation characteristics. An emphasis will be placed on patients who suffered syndesmosis screw fracture following fixation. To date, no review has examined patient, screw, and surgical/rehabilitation characteristics with an emphasis on screw fractures in this patient population.

Methods:

Of the 482 articles assessed for eligibility, a total 52 articles were selected for full-text review. Following further inclusion criteria requirement 21 articles were included in the study. Each study was analyzed based on patient, screw, and surgical/rehabilitation characteristics. Patient demographics and comorbidities of gender, age, BMI, smoking, alcohol abuse, diabetes, soft tissue conditions were included. Screw characteristics that were included were screw material, number of screws, screw width, number of cortices, and number of patients with screw fracture (screw fracture rate). Surgical/rehabilitation characteristics included ankle position, screw placement above tibial plafond, screw angle, routine removal, rehabilitation process, and time to full weight bearing.

Results:

A total of 1,196 patients, 761 men and 440 females, were included in the analysis. The average number of patients in each study was 59.80±39.41(12-161). Comprehensive screw, surgical, and rehabilitation + outcome data can be seen in Table 1, 2, and 3, respectively. Nine studies reported on ankle position during surgery; dorsiflexion was the most common. Fourteen reported on placement of the screw above the tibial plafond, with 2 cm being the most common. Five reported on screw angle. 141 patients had a fractured screw(s). The average fracture rate was 11.41%. Five of the 21 studies reported BMI. Three studies stratified data comparing broken screw versus intact screw patients. Five reported on diabetes, one on alcohol abuse, and one study reported on comorbidities.

Conclusion:

In conclusion, analysis of syndesmosis screw fracture patients versus those with no fracture was difficult due to lack of differentiation in almost all the studies. Notably, syndesmosis screw fracture studies under report patient characteristics, specifically BMI. Comorbidities, especially BMI, are potential cofounding variables within this patient population and could contribute to screw failure. Future studies should include both BMI and comorbidities when analyzing patients whose syndesmosis fixation resulted in screw breakage.
Antibiotic Loaded Calcium Sulphate/Hydroxy Apatite Bio Composite in Diabetic Foot Surgery
Authors: Vasukutty Nijil L. , Mordecai Simon , Subramaniam Murali , Tarik A , Srinivasan Bala
Published: November 2020

Category:

Diabetes

Introduction/Purpose:

Antibiotic loaded bio composites help in eradication of infection and obliteration of dead space created by debridement in diabetic foot disease.

Methods:

We present early results of 54 feet in 51 patients from 2 centres in the UK, where we used local antibiotic carrier. Of these 51 had osteomyelitis and in 3 cases we used this agent prophylactically for Charcot reconstruction. All patients were managed by a multidisciplinary team. Our protocol involved, pre op assessment, debridement, culture specific systemic antibiotics and dead space obliteration with antibiotic loaded bio composite (CERAMENT G Bone Support, Lund, Sweden). The wound was managed with negative pressure wound therapy where applicable and all patients were off loaded. Skin cover where required was undertaken by our plastic surgeons.

Results:

Nine patients were Cierny-Mader type 1, 7 were defined as type 2, 16 were type 3 and 19 were type 4. 26 patients were type B hosts and 25 were type A hosts. 38 patients had forefoot pathology, 7 had midfoot and 9 had hindfoot disease. 6 patients had pre-operative reperfusion procedures. At a mean follow up of 72 weeks (12-136) 44 feet were infection free and 41 patients (80%) were mobilizing full weight bearing with or without surgical footwear. 15 wounds healed by secondary intention, 3 had plastic surgical procedures and 23 had primary closure. 5 patients required revision procedures. 6 patients had below knee amputation, 2 due to significant vascular disease and 2 at patient request.

Conclusion:

A multidisciplinary approach and a strict protocol including augmented debridement and Cerament G are effective for treatment of chronic osteomyelitis in diabetic foot disease.
Novel Hallux Valgus Cadaveric Model: Role of Ligament Damage and Tendon Pull in Recreating the Deformity
Authors: Wagner Emilio , Wagner Pablo , Pacheco Florencia J. , Villarroel Carlos , Palma Felipe H. , Venegas Rodrigo Guzman-
Published: November 2020

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

Hallux valgus (HV) is of uncertain origin, which explains the plethora of treatment options available. In the last few years it has been shown that it is not a one plane deformity, but a multiplanar one. It is the authors belief that Hallux Valgus originates from instabilities located at medial ray joints. To be able to further understand this frequent pathology, a cadaveric model should be developed. Through specific and limited medial column ligament damage, a model was developed trying to obtain similar deformities to the ones observed in real life, i.e. first ray varus and pronation.

Methods:

7 fresh frozen lower leg specimens were used without evident foot and ankle pathology. Tibio-talar and talo-navicular joints were fixed. Luminous markers were attached to the medial and middle foot ray bones, including talus. A constant tibial axial load of 25 kg was used. Cyclic tibial rotation (to simulate gait phases) and 5 kg pull on the extensor and flexor hallucis tendons (EHL and FHL) were applied to every specimen. Limited and sequential medial and middle column ligamentous sectioning were performed, including the naviculocuneiform, intercuneiform, metatarsocuneiform, metatarsophalangeal medial capsule and intermetatarsal ligaments. After each ligament damage, 3D bony alignment was registered using high speed high definition infrared cameras.

Results:

After ligament sectioning, an increase in intermetatarsal angle was observed of 2.5 degrees (range 0.8-5) (p=0.001), with 1 degree (0-3) (p=0.02) of further increase when Hallucis tendons pull was applied. Intercuneiform angle increased 2.3 degrees (0- 6) (p=0.01), with no change with tendons pull. Regarding bone rotation, the metatarsal pronated in relation to the navicular (metatarso-navicular angle) 6.3 degrees (3-20) (p=0.015) and the cuneiform pronated in relation to the navicular (naviculo- cuneiform angle) 3.3 degrees (0.5-6) (p=0.005). At the metatarso-cuneiform joint, a non-significant rotation was identified (1 degree (p=0.39). Hallucis tendons pull did not significantly affect any rotation angle. An evident hallux valgus deformity could be created, which further deformed with hallucis tendons pull.

Conclusion:

After sequential medial and middle ray ligament sectioning, a progressive and simultaneous increase in medial column varus and pronation were observed. Hallucis tendons pull, increased the medial column varus, but appeared not to play a role in bone rotation. Bone rotation occurs along the medial column joints, not isolated to the tarsometatarsal joint. Progressive medial ray ligamentous sectioning was able to recreate a Hallux valgus deformity, including medial ray varus and pronation.
Low Risk of Wound Complications with Sinus Tarsi Approach for Treatment of Calcaneus Fractures
Authors: Wallace S. Blake , O’Neill David , Narayanan Anish , Liu George T. , Chhabra Avneesh , Wukich Dane K. , Lalli Trapper
Published: November 2020

Category:

Trauma; Hindfoot

Introduction/Purpose:

Fractures of the calcaneus are life-changing events with a major socioeconomic impact from lost productivity. Traditional operative treatment with the extensile lateral approach has shown relatively high rates of wound complications. Less invasive approaches can improve fracture alignment and decrease wound healing complications. The purpose of this study is to report our experience with the sinus tarsi approach in treating calcaneus fractures.

Methods:

We retrospectively identified patients at our institution treated with a limited sinus tarsi approach for calcaneus fractures from 2009-2018. Demographic and radiographic data were collected including: age, sex, mechanism of injury, occupation, presence of diabetes, smoking status, Sanders classification, Bohler and Gissane angles. Postoperatively, we recorded the presence of complications, return-to-work time, and radiographic measurements.

Results:

Our analysis included 105 fractures in 100 patients: 86% males, 42% smokers, 4% diabetics, with an average body mass index of 26.5. The fractures were: Sanders type 2 (32%), type 3 (48%), type 4 (18%), and 2% were a tongue-type variant. Preoperatively 38% of fractures displayed a negative angle, 50% had an angle 0-20 degrees, and 12% over 20 degrees; postoperatively 13% had an angle 0-20 degrees, and 87% had an angle over 20 degrees. Of patients working prior to the injury, 72% had returned to work by 6 months, and 89% by 12 months. The wound complication rate was 12% (12/100), with only 2% (2/100) requiring additional procedures. There was no significant difference in wound complication rates in smokers versus nonsmokers (11.9% vs 12.2%, p=0.55).

Conclusion:

The limited sinus tarsi approach for depressed calcaneus fractures allows radiographic restoration of calcaneal height with a low rate of wound complications, even amongst active smokers. To the authors’ best knowledge, this is the largest published case series of calcaneus fractures treated with the sinus tarsi approach. Further follow up is needed to determine the success of this approach in mitigating long term complications.
Patient Perceptions of Patient Reported Outcome Measures in Orthopedic Surgery (PROMOS): A Snapshot of Data for Foot and Ankle Patients
Authors: Walley Kempland C. , Vannatta Emily , Stauch Chris M. , Fritsche Madelaine W. , Dunleavy Mark , Juliano Paul J. , Aynardi Michael C.
Published: November 2020

Category:

Other

Introduction/Purpose:

Used intimately to qualify the use of new surgical devices, advance new surgical techniques and evaluate faculty performance with regard to patient satisfaction and outcomes, patient reported outcome measures (PROMs) are commonplace across all sub-specialties in orthopaedics. Despite their theorized utility, these interactive tools are burdensome in clinic and their true utility is anecdotally in question. No prior study to the best of our knowledge has investigated the degree at which patients find them useful or even appropriate measures to objectify their injuries or state of recovery. The purpose of this study is to ascertain patient perceptions of the utility of commonly used patient reported outcome measures (PROMs) in foot and ankle surgery.

Methods:

After IRB approval, consecutive patients visiting a foot and ankle surgery outpatient clinic (either new or return) will be asked to complete a survey assessing their attitudes toward commonly used PROMs relevant to foot and ankle surgery. Upon verbal consent, patients will be asked a short series of demographic questions including: age, whether they are a new patient, sex, education level, disability status, current region of residence, and history of opiate use. After completion, patients will be shown the Visual Analog Scale (VAS) tool to quantify pain and asked two questions: 1) concerning effectiveness and 2) concerning their personal perceptions. Next, patients will be shown a single PROM used pertaining to their injury (eg, Foot & Ankle Disability Index (FADI)). All patient will comment on their perceptions of the VAS and one additional PROM specific to the sub-specialty in which there are seeking treatment.

Results:

We report a total of 39 patients in this preliminary data set (49% males, 51% females) with a mean age of 51 (range, 19 - 83). A majority of patients reported that both VAS and FADI are effective PROMs in foot and ankle surgery. Additionally, patients reported that there is no benefit to artificially inflating their PROMs to receive better/more-prompt patient care. These findings were independent of history of opiate use, disability, gender, or age cohort (Figure 1).

Conclusion:

The results of this study show that the majority of patients visiting a foot and ankle surgeon in the outpatient setting perceive both VAS and FADI are effective tools to describe their respective foot/ankle condition. Patients report, in this preliminary sample, do not ‘game’ these PROMs to receive better care though these study findings are subject to the Hawthorne Effect.
Pediatric Calcaneus Fractures and Associated Injuries
Authors: Ward Norman H. , Roper Brennan P. , Munz John W. , McGarvey William C. , Mansour Alfred
Published: November 2020

Category:

Trauma; Hindfoot

Introduction/Purpose:

The objective of the study was to determine the injuries associated with calcaneus fractures in pediatric patients and to determine if the skeletally immature sustain different injury patterns than the skeletally mature. In the adult population, these concurrent injuries are well-defined and consistent with a large axial load; however in the pediatric population, we anticipate that the differences in the mechanism of injury and developmental anatomy will alter the types of injuries observed with calcaneus fractures. Additionally, given the plasticity of immature bone, the skeletally immature patients may sustain different fracture patterns than the skeletally mature.

Methods:

A retrospective chart review was performed of pediatric patients presenting with a calcaneus fracture from 2008 to 2017. Patients under the age of 18 with an ICD code consistent with a calcaneus fracture were included. Patients who sustained penetrating trauma were excluded along with medical records with incomplete data. Demographics, injury information, associated injuries, skeletal maturity, fracture characteristics, and treatment were recorded. As defined by calcaneal apophyseal closure, the cohort was divided into the skeletally mature and immature for analysis. Student’s t-test and Fisher’s exact tests were used to determine significance.

Results:

199 records were reviewed resulting in a sample of 81 pediatric patients with 91 calcaneus fractures. 37(40.7%) patients were immature at the time of injury. The most common mechanism witnessed was a fall in 52(64.2%) patients, with an average age of 12.8 years-old (range 0-17). There were 50(54.9%) intra-articular fractures and 15(16.5%) who underwent reduction and fixation. In the immature, open reduction internal fixation was performed on 6(14.3%) fractures which demonstrated a significantly decreased average Bohler’s angle than the conservatively treated, 14 degrees(p= 0.048). Fractures of the spine were the most commonly associated injury in 10(12.3%) pediatric patients however tibia fractures were the most commonly observed injury in the skeletally immature cohort, 7(18.9%). There were no associated injuries significantly unique to the skeletally immature.

Conclusion:

The present study provides one of the largest published cohorts to date of pediatric calcaneus fractures. They were most commonly associated with fractures of the spine however in the skeletally immature group as defined by apophyseal staging, tibia fractures were most often observed. No injuries were found to be significantly associated with immature patients. The skeletally immature calcanei produce fracture patterns which may be difficult to observe on radiographs and often require advanced imaging to delineate. While the majority may be treated with conservative therapy, there are no current concrete operative indications for the closed skeletally immature calcaneus fracture.
Functional Analysis of Distraction Arthroplasty in the Treatment of Ankle Osteoarthritis
Authors: Xiaojun Liang , Hong-Mou Zhao
Published: November 2020

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle joint distraction arthroplasty (AJDA) is an alternative surgical procedure for the management of moderate to severe ankle osteoarthritis. However, the benefit of this procedure and failure relative factors are still in debate. The purpose of current study was to evaluate the functional outcomes of AJDA in treatment of moderate to severe ankle OA; and to evaluate the relative factors correlated with treatment failure.

Methods:

Forty-six van Dijk stage II and III ankle osteoarthritis patients were included. Fifteen males and 31 females with a mean age of 54.8 (range, 42-71) years were followed with a mean of 42.8 (range, 24-68) months. The Ankle Osteoarthritis Scale (AOS) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score were used for functional outcomes evaluation. The talar tilt (TT) angle and ankle joint space distance (AJSD) were evaluated. The risk ratio (RR) was calculated for each potential failure relative factor.

Results:

The AOS and AOFAS scores were significantly improved at the last followup time (P＜0.01). The AJSD was improved in 61% of patients, and with a significant improvement compared with the preoperative conditions (P＜0.01). The TT angle and range of motion reached no significant difference. The failure rate was 21.7%. Patients with large TT (>=5°) angle (RR=3.81, 95%CI: 1.28-11.33, P=0.02) and obesity (RR=3.58, 95%CI: 1.30-9.89, P=0.01) were found have positive correlation with failure. No correlation was found between failure and gender, or overweight, or side, or age, or type and stage of OA, or pin infection.

Conclusion:

Current study confirmed the early functional outcomes of ankle distraction arthroplasty. However, this procedure still has a relatively high failure rate, especially for those obesity patients and the patients with large TT angles.
Short-Term Effect of the INBONE II Total Ankle Arthroplasty in the Treatment of End-Stage Ankle Arthritis
Authors: Xiaojun Liang , Hong-Mou Zhao
Published: November 2020

Category:

Ankle Arthritis

Introduction/Purpose:

To study the short-term effect of the INBONE II total ankle arthroplasty in the treatment of end-stage ankle arthritis, and to analyze the main operation points and complications.

Methods:

A total of 10 patients who used INBONE II for total ankle replacement in my Center from March 2016 to June 2017 were retrospective analyzed, including 2 patients who have a subtalar joint fusion at the same time. The VAS pain score and the American Orthopaedic Foot & Ankle Society (AOFAS) scores were used to evaluate the clinical efficacy.

Results:

All the patients were followed up, the average follow-up time was (12.80+-4.11) months (5-15 months), The AOFAS of preoperation was significantly higher (44.00+-4.06) vs (82.50+-3.17) score than that of the final follow-up, and VAS score was lower (6.80+-0.63) vs (1.60+-0.70) than that of the final follow-up (all P<0.01). There were 1 medial malleolus fracture, 1 lateral malleolus fracture intraoperation, 1 with symptomatic lateral malleolus osteophytes and lateral instability, which needs debridement, no superficial or deep infection was found,no prosthesis subsidence or malalignment and other complications was found.

Conclusion:

The short-term effect of total ankle arthroplasty using INBONE II prostheses for ankle end-stage arthritis is satisfactory, and further analysis was needed for its long-term efficacy and prosthetic survival rate.